Establishing a Mental Health Surveillance in Germany: Development of a framework concept and indicator set.

In the course of the recognition of mental health as an essential component of population health, the Robert Koch Institute has begun developing a Mental Health Surveillance (MHS) system for Germany. MHS aims to continuously report data for relevant mental health indicators, thus creating a basis for evidence-based planning and evaluation of public health measures. In order to develop a set of indicators for the adult population, potential indicators were identified through a systematic literature review and selected in a consensus process by international and national experts and stakeholders. The final set comprises 60 indicators which, together, represent a multidimensional public health framework for mental health across four fields of action. For the fifth field of action 'Mental health promotion and prevention' indicators still need to be developed. The methodology piloted proved to be practicable. Strengths and limitations will be discussed regarding the search and definition of indicators, the scope of the indicator set as well as the participatory decision-making process. Next steps in setting up the MHS will be the operationalisation of the single indicators and their extension to also cover children and adolescents. Given assured data availability, the MHS will contribute to broadening our knowledge on population mental health, supporting a targeted promotion of mental health and reducing the disease burden in persons with mental disorders.

[Medical Rehabilitation in MS: Barriers to and Facilitators of its Utilization from the Patients' Perspective]. / Medizinische Rehabilitation bei MS: Barrieren und Facilitatoren der Inanspruchnahme aus Patientensicht.

PURPOSE: Although there is evidence on the efficacy of multi-disciplinary rehabilitation in the case of MS, use of inpatient rehabilitation by patients with MS in Germany is comparatively low. Therefore, it was the aim of this study to determine potential barriers and facilitators of inpatient rehabilitation use as perceived by patients with MS. METHODS: Based on an extensive preliminary qualitative study a questionnaire was developed that addressed potential determinants of inpatient rehabilitation use by means of 45 items. Data were obtained mainly online from 590 patients with MS. Data analysis primarily included descriptive statistics. RESULTS: Patients' expectations regarding rehabilitation in the case of MS strongly focus on structural components of a rehabilitation clinic's quality and on participating in treatment decisions in the rehab setting. Barriers to MS-rehabilitation use are perceived to exist in terms of insufficient information on the scope and process of rehabilitation, insufficient support from physicians with respect to applying for rehabilitation and a lack of clarity with respect to the criteria upon which applications will be decided. A smaller proportion of respondents also consider family- and vocation-related factors as barriers to making use of MS-rehabilitation. CONCLUSION: Based on these findings, recommendations may be derived that may help reduce barriers to the use of inpatient rehabilitation by patients with MS. These include providing and improving information on the aims, interventions and effects of MS rehabilitation, information on how to apply for medical rehabilitation and the criteria on which applications are decided upon, as well as strengthening the role of the outpatient medical specialist.

Rehabilitation use in multiple sclerosis: Do illness representations matter?

OBJECTIVES: Multidisciplinary rehabilitation improves illness outcomes and is recommended in clinical guidelines for multiple sclerosis (MS). However, many people with MS do not make use of rehabilitation. We do not know much about the barriers to the use of rehabilitation in MS, but in other patient groups, illness representations have proven to be predictors of service utilization. Therefore, the aim of our study was to explore whether, in patients with MS, illness representations are associated with self-reports of rehabilitation use in the past and the intention to use rehabilitation in the future, beyond sociodemographic and illness-related factors. MATERIALS AND METHODS: Patients were recruited in a cross-sectional nationwide online survey in Germany. Hierarchical binary logistic regression analysis was used to analyze whether illness representations are associated with the use of rehabilitation in the past and the intention to use rehabilitation in the future, over and above socio-demographic and illness-related variables. RESULTS: There were 590 patients, who had MS, participating in the study. Illness representations were correlated to both outcome variables beyond sociodemographic and illness-related factors: The probabilities of having the intention to use rehabilitation and of making using of rehabilitation were higher in patients who believed that their MS was controllable by treatment and perceived that their MS would have severe consequences. CONCLUSIONS: Our data suggest that addressing patients' illness representations may facilitate the intention to use and the use of multimodal rehabilitation, contributing to better illness outcomes.

Nonmotor fluctuations in Parkinson disease: severity and correlation with motor complications.

OBJECTIVE: To evaluate frequency, severity, and correlation of nonmotor symptoms (NMS) with motor complications in fluctuating Parkinson disease (PD). METHODS: The Multicenter NonMotor Fluctuations in PD cross-sectional study used clinical examination of 10 NMS (dysphagia, anxiety, depression, fatigue, excessive sweating, inner restlessness, pain, concentration/attention, dizziness, bladder urgency) quantified using a visual analogue scale (VAS) in motor-defined on (NMS(On)) and off state (NMS(Off)) combined with motor assessments and self-ratings at home in 100 patients with advanced PD. RESULTS: All NMS except dysphagia, excessive sweating, and bladder urgency fluctuated in conjunction to motor fluctuations with more frequent and severe symptoms in off compared to on state. The proportions of patients experiencing autonomic/sensory NMS in both motor states were similar to those with these NMS exclusively in off state (ratios 0.4-1.3), while for mental/psychic NMS the proportions with exclusive manifestation in off state were higher (ratios 1.8-3.1). Demographic and clinical characteristics correlated neither with NMS frequency patterns and severities nor with ΔNMS(On/Off) severities (defined as the differences of VAS scores between on and off). Severities of NMS(on), NMS(Off), and ΔNMS(On/Off) did not correlate with motor function. Presence of anxiety, depression, fatigue, and pain had negative impact on health-related quality of life (HRQOL) measured by Parkinson's Disease Questionnaire-8 scoring independent of their occurrence with respect to motor state. Fluctuations of these NMS but not of fatigue deteriorated HRQOL. CONCLUSION: Patterns of NMS fluctuations are heterogeneous and complex, but psychic NMS fluctuate more frequently and severely. Demographic parameters and motor function do not correlate with NMS or nonmotor fluctuation severities in fluctuating PD.

Pain intensity on and off levodopa in patients with Parkinson's disease.

Pain is frequently reported by patients with Parkinson's disease (PD). In this study, intensity of pain as measured by a visual analogue scale (VAS) was assessed on and off levodopa in 15 patients with PD. All patients had motor fluctuations and suffered from pain of various types. Description of pain was assessed with the McGill pain questionnaire. Ratings for pain intensity on the VAS were increased during off period for all patients but one (P = 0.001). There was a correlation (P = 0.04) between changes in motor performance (Unified Parkinson's Disease Rating Scale part III) and pain intensity (VAS). Compared with a historical sample of subjects with different pain syndromes without PD, terms related to fear and punishment were used more frequently by patients with PD in this study. In two patients, pain was exclusively limited to the off period. The majority of subjects suffered from secondary pain possibly related to lumbar osteoarticular degeneration. Secondary pain was relieved but not completely abolished by levodopa. The results of this study suggest that aggravation of secondary pain should be considered as a part of the spectrum of nonmotor off symptoms. Analgesics should not be given as first line drugs when pain occurs or increases in off conditions, and pain can be significantly alleviated or abolished by adjustments of dopaminergic medication.

Selective diplopia in Parkinson's disease: a special subtype of visual hallucination?

Diplopia is sometimes reported by patients with Parkinson's disease (PD) without apparent oculomotor disorders. We assessed clinical features and associated oculomotor and perceptual performance in 14 patients (6 male, 8 female) with PD with a peculiar type of selective diplopia. Duplication of images was confined to single objects or persons, occurred repetitively, and lasted few seconds in all subjects. Frequency of episodes ranged from several episodes per day to three episodes per year. In six of seven subjects undergoing comprehensive ophtalmological examination, subtle ocular disorders (heterophoria, strabism, etc.) were found. Nine of 14 patients were suffering from current or previous visual hallucinations and 3 more patients developed hallucinations within 3 years of diplopia onset. Selective diplopia of isolated single objects and persons in PD is possibly related to hallucinosis and minor ocular disturbances seem to be a triggering factor for this peculiar type of misperception.