Reductions in inpatient and outpatient mental health care in germany during the first year of the COVID-19 pandemic - What can we learn for a better crisis preparedness?

BACKGROUND: During the COVID-19 pandemic, reports from several European mental health care systems hinted at important changes in utilization. So far, no study examined changes in utilization in the German mental health care inpatient and outpatient mental health care system comprehensively. METHODS: This longitudinal observational study used claims data from two major German statutory health insurances, AOK PLUS and BKK, covering 162,905 inpatients and 2,131,186 outpatients with mental disorders nationwide. We analyzed changes in inpatient and outpatient mental health service utilization over the course of the first two lockdown phases (LDPs) of the pandemic in 2020 compared to a pre-COVID-19 reference period dating from March 2019 to February 2020 using a time series forecast model. RESULTS: We observed significant decreases in the number of inpatient hospital admissions by 24-28% compared to the reference period. Day clinic admissions were even further reduced by 44-61%. Length of stay was significantly decreased for day clinic care but not for inpatient care. In the outpatient sector, the data showed a significant reduction in the number of incident outpatient diagnoses. CONCLUSION: Indirect evidence regarding the consequences of the reductions in both the inpatient and outpatient sector of care described in this study is ambiguous and direct evidence on treatment outcomes and quality of trans-sectoral mental healthcare is sparse. In line with WHO and OECD we propose a comprehensive mental health system surveillance to prepare for a better oversight and thereby a better resilience during future global major disruptions.

[Recommendations for the Utilization of Claims Data During a Pandemic: Lessons Learned from the Project EgePan-Unimed of the Netzwerk Universitätsmedizin (NUM)]. / Potentiale von und Empfehlungen zur Nutzung von GKV Routinedaten in einer pandemischen Versorgungslage ­ Erfahrungen aus dem Projekt egePan-Unimed des Netzwerk Universitätsmedizin (NUM).

For appropriate response to the COVID-19 pandemic, and for obtaining answers to various relevant research questions, empirical data are required. Claims data of health insurances are a valid data source in such a situation. Within the project egePan-Unimed of the Netzwerk Universitätsmedizin (NUM) we investigated five COVID-19-related research questions using German claims data of statutory health insurances. We studied the prevalence and relevance of risk factors for a severe course of COVID-19, the background incidence of cerebral venous sinus thrombosis and myocarditis, the frequency and symptoms of post-COVID as well as the care of people with a psychiatric condition during the COVID-19 pandemic. Based on these cases, context-specific recommendations regarding the use of German claims data for future pandemics or other public health emergencies were derived, namely that the utilization of established and interdisciplinary project teams enables a timely project start and furthermore, meta-analytic methods are a valuable way to pool aggregated results of claims data analyses when data protection regulations do not allow a consolidation of data sets from different statutory health insurances. Under these circumstances, claims data are a readily available and valid data source of empirical evidence base necessary for public health measures during a pandemic.

[COVID-19 vaccination for people with severe mental diseases : Results of the COVID Ψ outpatient survey and recommendations for psychiatry]. / COVID-19-Impfung für Menschen mit schweren psychischen Erkrankungen : Ergebnisse des COVID-Ψ-Ambulant-Surveys und Empfehlungen für die Psychiatrie.

BACKGROUND: Severe mental illnesses are risk factors for SARS-CoV-2-related morbidity and mortality. Vaccination is an effective protection; therefore, high vaccination rates should be a major priority for people with mental illnesses. OBJECTIVES: (1) Identification of at-risk groups for non-vaccination and structures and interventions needed for widespread vaccination among people with mental illnesses from the perspective of outpatient psychiatrists and neurologists, (2) discussion of the results in the context of the international literature and (3) recommendations derived from them. MATERIAL AND METHODS: Qualitative content analysis of COVID-19 vaccination-related questions from the COVID Ψ online survey of n = 85 psychiatrists and neurologists in Germany. RESULTS: In the survey, people with schizophrenia, severe lack of drive, low socioeconomic status and homelessness were seen as risk groups for non-vaccination. Increased and targeted information, education, addressing and motivation and easily accessible vaccination offers by general practitioners, psychiatrists, and neurologists as well as complementary institutions were considered as important interventions. DISCUSSION: COVID-19 vaccinations as well as information, motivation and access support should be systematically offered by as many institutions of the psychiatric, psychotherapeutic and complementary care systems in Germany as possible.

[Willingness to get vaccinated among hospital staff in Germany: What is the role of COVID-19 conspiracy assumptions?] / Impfbereitschaft von Krankenhauspersonal in Deutschland: Welche Rolle spielen Verschwörungsannahmen zu COVID-19?

BACKGROUND: A critical factor in achieving widespread immunity against COVID-19 is the willingness of previously unvaccinated individuals to get vaccinated. Medical staff play a key role in this, as they ensure healthcare during the pandemic and for many serve as a source of information about vaccinations. Among the factors that negatively influence the general willingness to get vaccinated are conspiracy assumptions and the spread of misinformation. OBJECTIVE: The willingness of hospital staff in Germany to get vaccinated and various influencing variables were examined to obtain indicators that could help increase the general willingness to get vaccinated. METHODS: Between January and June 2021, a voluntary and anonymous online survey conducted as part of the egePan joint project of the national network for university medicine (funded by the Federal Ministry of Education and Research) was used to assess the willingness to be vaccinated, individual social characteristics, the belief in conspiracy assumptions, and communication items in German hospitals. RESULTS: In comparison with the general population, physicians and scientific staff in particular indicated an increased willingness to get vaccinated. Conspiracy assumptions were not very widespread but most frequent among administrative and nursing staff. Conspiracy assumptions were negatively associated with the willingness to get vaccinated. Predictors for a higher willingness to get vaccinated were the perceived safety and effectiveness of vaccinations and a higher age. DISCUSSION: Since the perceived safety and effectiveness of vaccinations have a positive effect on the willingness to get vaccinated, educational work and transparent information transfer could counteract the spread of conspiracy assumptions and increase vaccination rates among hospital staff.

[Impact of the COVID-19 pandemic on the care situation in psychiatric hospitals in Germany]. / Auswirkungen der COVID-19-Pandemie auf die Versorgungssituation in psychiatrischen Kliniken in Deutschland.

AIM: To assess the structural performance of psychiatric hospitals in Germany during the COVID(coronavirus disease)-19 pandemic, a nationwide survey was launched in March 2020, in which the corona-related changes in care structures during the first wave of the pandemic were collated. METHODS: Data on the care situation were collected by means of a survey in 38 out of 388 contacted psychiatric and psychotherapy hospitals in Germany over the course of 1 month. The changes and adaptations of the care structures, the type of therapy measures applied and care options for people with mental disorders and a COVID-19 infection as well as the legal basis underlying the care for patients unable to consent were documented. RESULTS: On average, the inpatient treatment capacity of psychiatric hospitals in Germany decreased by approximately 40% compared with prepandemic periods. Day clinic and outpatient services were also only available in a limited form or were even discontinued completely. Specialized wards for patients with COVID-19 infections were available in most of the surveyed clinics (84%). CONCLUSION: Psychiatric hospitals were already able to respond quickly and adequately to the crisis situation in the first wave of the pandemic, e.g. by setting up COVID wards; however, the reduction in treatment capacity to 60% has significantly worsened the care situation for people with mental illnesses. Therefore, further efforts should urgently be made to adapt mental health care to the requirements of the pandemic in the long term.

[The Dawn of Modernity: Giovanni Boccaccio's "The Decameron" and the Tradition of Genetic Understanding]. / Die Dämmerung der Neuzeit: Giovanni Boccaccios "Das Dekameron" und die Tradition des genetischen Verstehens.

"The Decameron" by Giovanni Boccaccio is a work which stands between the Middle Ages and Modernity. There are theories which postulate that concepts of identity and individuality, which arose with the dawn of Modernity, have an influence on mental illness. We chose a hermeneutic approach towards "The Decameron" to analyse the depiction of a changing society, of love, mental suffering and the role of therapeutic interventions. We conclude that Boccaccio showed an interest in intrapsychic mechanisms, an idea pertaining to Modernity, and discuss this idea in light of today's psychiatry and Karl Jaspers' concept of "genetic understanding".

Counseling and support services for healthcare workers in German university hospitals during the pandemic-descriptive results of a Germany-wide cross-sectional survey.

Background: Due to the SARS-CoV-2 pandemic, healthcare workers (HCWs) are experiencing tremendous levels of emotional and physical stress. Hospitals are trying to help personnel cope with work-related pressure. The aim of this study was to assess HCWs' awareness and utilization of counseling and support services during the pandemic, HCWs' unmet counseling and support needs, and the type and content of these services. Methods: A cross-sectional online survey was conducted from January to June 2021 through the German national research organization Network University Medicine (NUM). All participating hospitals (6 in total) were asked to inform their employees about the study. Results: A total of 1,495 HCWs were included in the analysis. Of these, 42.8% (n = 637) were frontline HCWs (who had contact with COVID-19 patients), 23.1% (n = 344) were second-line HCWs (who only had contact with non-COVID-19 patients) and 34.1% (n = 508) had no contact with any patients. Participating hospitals offer various counseling and support services for their staff. The percentage of respondents who were unaware of available counseling and support services ranged from 5.0 to 42.0%. Depending on the type of counseling and support services, 23.0-53.6% of the respondents indicated that counseling and support services were provided but not used, while 1.7-11.6% indicated that, despite the need for them, such services were not available. HCWs' overall satisfaction with the provided counseling and support services and their unmet support needs differed by patient contact: Frontline HCWs reported more unmet needs for counseling and support than second-line HCWs, while second-line HCWs reported more unmet needs than HCWs without patient contact. Conclusion: The results indicate that hospitals should make more efforts to inform HCWs about available counseling and support services. Hospitals could also create networks where HCWs could share information about the type and content of services and their experiences with various counseling and support services. These steps would enable hospitals to respond more quickly and effectively to the problems facing HCWs during pandemics.

Changes and Challenges in Inpatient Mental Health Care During the First Two High Incidence Phases of the COVID-19 Pandemic in Germany - Results From the COVID Ψ Psychiatry Survey.

Psychiatric inpatient treatment, an important pillar of mental health care, is often of longer duration in Germany than in other countries. The COVID-19 pandemic called for infection prevention and control measures and thereby led to shifts in demand and inpatient capacities. The Germany-wide COVID Ψ Psychiatry Survey surveyed department heads of German psychiatric inpatient institutions. It assessed changes in utilization during the first two high incidence phases of the pandemic (spring 2020 and winter 2020/21) and also consequences for care, telemedicine experiences, hygiene measures, treatment of patients with mental illness and co-occuring SARS-CoV-2, and coercive measures in such patients. A total of n = 71 psychiatric departments (of 346 contacted) participated in the survey. The results showed a median decrease of inpatient treatment to 80% of 2019 levels and of day hospital treatment to 50% (first phase) and 70% (second phase). Reductions were mainly due to decreases in elective admissions, and emergency admissions remained unchanged or increased in 87% of departments. Utilization was reduced for affective, anxiety, personality, and addiction disorders but appeared roughly unaffected for psychotic disorders. A lack of integration of patients into their living environment, disease exacerbations, loss of contact, and suicide attempts were reported as problems resulting from reduced capacities and insufficient outpatient treatment alternatives. Almost all departments (96%) treated patients with severe mental illness and co-occurring SARS-CoV-2 infection. The majority established special wards and separate areas for (potentially) infectious patients. Telephone and video consultations were found to provide benefits in affective and anxiety disorders. Involuntary admissions of persons without mental illness because of infection protection law violations were reported by 6% of the hospitals. The survey showed high adaptability of psychiatric departments, which managed large capacity shifts and introduced new services for infectious patients, which include telemedicine services. However, the pandemic exacerbated some of the shortcomings of the German mental health system: Avoidable complications resulted from the lack of cooperation and integrated care sequences between in- and outpatient sectors and limited options for psychiatric hospitals to provide outpatient services. Preventive approaches to handle comparable pandemic situations in the future should focus on addressing these shortcomings.

Challenges in the Transition from In-Patient to Out-Patient Treatment in Depression.

BACKGROUND: Few data are available on the characteristics of inpatient treatment and subsequent outpatient treatment for depression in Germany. In this study, we aimed to characterize the inpatient and outpatient treatment phases, to determine the rates of readmission and mortality, and to identify risk factors. METHODS: We carried out a descriptive statistical analysis of routine administrative data from a large health-insurance carrier (BARMER). All insurees aged 18 to 65 who were treated in 2015 as inpatients on a psychiatry and psychotherapy service or on a psychosomatic medicine and psychotherapy service with a main diagnosis of depression were included in the analysis. Risk factors for readmission and death were determined with the aid of mixed logistic regression. RESULTS: Of the 22 893 patients whose data were analyzed, 78% had been hospitalized on a psychiatry and psychotherapy service and 22% on a psychosomatic medicine and psychotherapy service. The median length of hospital stay was 42 days. Follow-up care in the outpatient setting failed to conform with the recommendations of the pertinent guidelines in 92% of the patients with a main diagnosis of severe depression during hospitalization, and in 50% of those with moderate depression. 21% of the patients were readmitted within a year. The mortality at one year was 961 per 100 000 individuals (adjusted for the age and sex structure of the German population), or 3.4 times the mortality of the population at large. In the regression model, more treatment units during hospitalization and subsequent treatment with psychotherapy were associated with a lower probability of readmission, while longer hospitalization with subsequent pharmacotherapy or psychotherapy was associated with lower mortality. CONCLUSION: The recommendations of the national (German) S3 guidelines for the further care of patients who have been hospitalized for depression are inadequately implemented at present in the sectored structures of in- and outpatient care in the German health care system. This patient group has marked excess mortality.

Major depression treatment in Germany-descriptive analysis of health insurance fund routine data and assessment of guideline-adherence.

BACKGROUND: Guideline oriented treatment strategies of Major depressive disorder (MDD) improve treatment outcomes and reduce risks of chronicity and recurrence. AIMS: Description of routine treatment reality and analysis of guideline fidelity in first episode MDD in Germany. Indicators: patients with severe or psychotic depression or severe psychiatric comorbidities' treatment by specialists, adequate antidepressant pharmacotherapy, permanent treatment with more than one antidepressant, long-term benzodiazepine treatment and provision of psychotherapy. METHOD: Descriptive analysis of routine data of the German statutory health insurance fund Barmer GEK in the index year 2011 that covers a population of 7,501,110. RESULTS: 236,843 patients were diagnosed a depressive episode. 53.0% of the patients with severe depression, 34.4% with psychotic depression and 50.9% with severe psychiatric comorbidities were treated by specialists; of the patients treated by a general practitioner 48.1% with severe and 47.3% with psychotic depression received an antidepressant; 9.7% of all patients with MDD got two antidepressants simultaneously; 8.3% received longterm benzodiazepine prescriptions; 26.1% got psychotherapy. LIMITATIONS: the analyses depends on the indicators definitions that cannot cope with the variety of individual treatment path; comparison with guidelines was complicated by a large fraction of patients with recurrent MDD that was wrongly diagnosed with first episode depression; due to the data structure, not all guideline recommendations could be examined CONCLUSIONS: Routine practice was oriented upon the guidelines recommendations. However some aspects could be identified that bear potential for improvements.

[Diagnosis of Metabolic Risk Factors in Psychiatric Inpatients]. / Diagnostik metabolischer Risikofaktoren bei stationär-psychiatrischen Patienten.

OBJECTIVE: Individuals suffering from mental illness have one to two decades reduced life expectancy. The increased morbidity and mortality is mainly due to cardiometabolic disorders. Despite these numbers, international studies give evidence that diagnoses and treatment of metabolic risk factors in psychiatric patients is insufficient. We assume that in Germany metabolic risk factors are also underdiagnosed and insufficiently treated. METHODS: We tested for the frequency of diagnoses of the metabolic risk factors obesity, nicotine dependence and abuse, disorders of lipid metabolism, hypertension and diabetes in 139 307 cases of residential treatment and semi-residential care in 47 psychiatric hospitals in Germany in the year 2012. Data were derived from the VIPP(indicators of treatment quality in psychiatry and psychosomatic medicine)-project, a project that comprises the routine data of psychiatric hospitals, that are sent to the InEK (institute for the lump sum payment system for hospitals). Frequencies were compared with prevalence of metabolic risk factors in the German population and prevalences of metabolic risk factors found in psychiatric patients in international studies. RESULTS: In particular obesity (2.8 %), disorders of lipid metabolism (2.8 %) and nicotin dependence (4.2 %) were underdiagnosed. We assume that also diabetes (6.8 %) and hypertension (17.7 %) were underdiagnosed. CONCLUSION: The results give evidence that metabolic risk factors are underdiagnosed and possibly insufficiently treated in German psychiatric hospitals. We cannot exclude that the results might also be due to poor documentation. It remains to be seen if the introduction of the PEPP (the new lump sum payment system in German psychiatry) will heighten the level of attention for metabolic risk factors and their treatment.

[Incidence and Costs of 1:1 Care in Psychiatric Hospitals in Germany - A Descriptive Analysis Based on the VIPP Project Data Set]. / Häufigkeit und Kosten der 1:1-Betreuung in der Erwachsenenpsychiatrie in Deutschland - Eine deskriptive Analyse anhand des VIPP-Datensatzes.

OBJECTIVE: 1:1 care is applied for patients requiring close psychiatric monitoring and care like patients with acute suicidality. The article describes the frequency of 1:1 care across different diagnoses and age groups in German psychiatric hospitals. METHODS: The analysis was based on the VIPP Project from the years 2011 and 2012. A total of 47 hospitals with more than 120,000 cases were included. Object of the analysis was the OPS code 9-640.0 1:1 care. The evaluation was performed on case level. RESULTS: Data of 47 hospitals were included. Of the 121,454 cases evaluated in 2011 3.8 % documented a 1:1 care within the meaning of OPS 9-640.0 additional code. Of the 66 245 male cases a 1:1 care was documented in 3.5 % and the 55 207 female cases was 4.1 %. Compared to 2011, the proportion of 1:1 care in 2012 rose to 4.8 %. CONCLUSION: The results show that 1:1 care is frequently applied in German psychiatric hospitals. The Data of the VIPP project have proven to be a useful tool to gain information on the frequency of cost-intensive interventions in German psychiatric hospitals. Further analyses should create the possibility of evaluation at the level of the individual codes.