Lifetime prevalence of mental disorders among first and second generation individuals with Turkish migration backgrounds in Germany.

BACKGROUND: This paper focuses on the lifetime prevalence of mental disorders in individuals with Turkish migration backgrounds in Germany, as there is a lack of reliable epidemiological data on this subject. METHODS: In total, 662 adults with Turkish migration backgrounds were interviewed in Hamburg and Berlin by trained, bilingual interviewers using the computerized Composite International Diagnostic Interview (CIDI DIA-X Version 2.8) to assess diagnoses according to the DSM-IVTR. RESULTS: The analyses showed a weighted lifetime prevalence of 78.8% for any mental disorder, 21.6% for more than one and 7.3% for five or more disorders. Any mood disorder (41.9%), any anxiety disorder (35.7%) and any somatoform disorder/syndrome (33.7%) had the highest prevalences. Despite the sociodemographic differences between the first and second generations, there were no significant differences in the lifetime prevalence between generations, with the exception of any bipolar disorder. Female gender, older age and no current partnership were significantly associated with the occurrence of any mood disorder. CONCLUSIONS: Overall, the results indicate a high lifetime prevalence in individuals with Turkish migration backgrounds in Germany. These initial data are highly relevant to the German clinical and psychosocial healthcare system; however, the methodological limitations and potential biases should be considered when interpreting the results.

Effectiveness of a Web-based tailored interactive health communication application for patients with type 2 diabetes or chronic low back pain: randomized controlled trial.

BACKGROUND: The prevalence of chronic diseases such as type 2 diabetes and chronic low back pain is rising. Patient empowerment is a key strategy in the management of chronic diseases. Patient empowerment can be fostered by Web-based interactive health communication applications (IHCAs) that combine health information with decision support, social support, and/or behavioral change support. Tailoring the content and tone of IHCAs to the needs of individual patients might improve their effectiveness. OBJECTIVE: The main objective was to test the effectiveness of a Web-based, tailored, fully automated IHCA for patients with type 2 diabetes or chronic low back pain against a standard website with identical content without tailoring (control condition) on patients' knowledge and empowerment. METHODS: We performed a blinded randomized trial with a parallel design. In the intervention group, the content was delivered in dialogue form, tailored to relevant patient characteristics. In the control group, the sections of the text were presented in a content tree without any tailoring. Participants were recruited online and offline and were blinded to their group assignments. Measurements were taken at baseline (t0), directly after the first visit (t1), and at 3-month follow-up (t2). The primary hypothesis was that the tailored IHCA would have larger effects on knowledge and patient empowerment (primary outcomes) than the control website. The secondary outcomes were decisional conflict and preparation for decision making. All measurements were conducted by online self-report questionnaires. Intention-to-treat (ITT) and available cases (AC) analyses were performed for all outcomes. RESULTS: A total of 561 users agreed to participate in the study. Of these, 179 (31.9%) had type 2 diabetes and 382 (68.1%) had chronic low back pain. Usage was significantly higher in the tailored system (mean 51.2 minutes) than in the control system (mean 37.6 minutes; P<.001). Three months after system use, 52.4% of the sample was retained. There was no significant intervention effect in the ITT analysis. In the AC analysis, participants using the tailored system displayed significantly more knowledge at t1 (P=.02) and more emotional well-being (subscale of empowerment) at t2 (P=.009). The estimated mean difference between the groups was 3.9 (95% CI 0.5-7.3) points for knowledge and 25.4 (95% CI 6.3-44.5) points for emotional well-being on a 0-100 points scale. CONCLUSIONS: The primary analysis did not support the study hypothesis. However, content tailoring and interactivity may increase knowledge and reduce health-related negative effects in persons who use IHCAs. There were no main effects of the intervention on other dimensions of patient empowerment or decision-related outcomes. This might be due to our tailored IHCA being, at its core, an educational intervention offering health information in a personalized, empathic fashion that merely additionally provides decision support. Tailoring and interactivity may not make a difference with regard to these outcomes. TRIAL REGISTRATION: International Clinical Trials Registry: DRKS00003322; http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00003322 (Archived by WebCite at http://www.webcitation.org/6WPO0lJwE).

Efficacy and acceptability of acute treatments for persistent depressive disorder: a network meta-analysis.

BACKGROUND: We aimed to synthesize the available evidence on the relative efficacy and acceptability of specific treatments for persistent depressive disorder. METHODS: We searched several databases up to January 2013 and included randomized controlled trials that compared acute pharmacological, psychotherapeutic, and combined interventions with each other or placebo. The outcome measures were the proportion of patients who responded to (efficacy) or dropped out from (acceptability) the allocated treatment. Data synthesis was performed with network meta-analysis. RESULTS: A network of 45 trials that tested 28 drugs included data from 5,806 and 5,348 patients concerning efficacy and acceptability, respectively. A second network of 15 trials that tested five psychotherapeutic and five combined interventions included data from 2,657 and 2,719 patients concerning efficacy and acceptability, respectively. Among sufficiently tested treatments, fluoxetine (odds ratio (OR) 2.94), paroxetine (3.79), sertraline (4.47), moclobemide (6.98), imipramine (4.53), ritanserin (2.35), amisulpride (5.63), and acetyl-l-carnitine (5.67) were significantly more effective than placebo. Pairwise comparisons showed advantages of moclobemide (2.38) and amisulpride (1.92) over fluoxetine. Sertraline (0.57) and amisulpride (0.53) showed a lower dropout rate than imipramine. Interpersonal psychotherapy with medication outperformed medication alone in chronic major depression but not in dysthymia. Evidence on cognitive behavioral analysis system of psychotherapy plus medication was partly inconclusive. Interpersonal psychotherapy was less effective than medication (0.48) and cognitive behavioral analysis system of psychotherapy (0.45). Several other treatments were tested in single studies. CONCLUSIONS: Several evidence-based acute pharmacological, psychotherapeutic, and combined treatments for persistent depressive disorder are available with significant differences between them.

Medication complexity, prescription behaviour and patient adherence at the interface between ambulatory and stationary medical care.

PURPOSE: A hospital stay is often accompanied by changes in medication therapy. The purpose of this study was to investigate the impact of a transfer across the interfaces on the complexity of therapeutic regimens and patient adherence as well as the attitudes of patients and general practitioners (GPs) towards pharmacotherapies. METHODS: This was a prospective observational study that analysed the complexity of medication therapies and the adherence and attitudes of internal medicine and urology patients towards their medication(s) at three time points (hospital admission, discharge and 6 weeks after discharge). GPs of the patients recruited to the study were questioned about the follow-up medication therapy and their opinion on the medication prescribed in hospital. RESULTS: At the time of hospital admission, 60.2 % of the study population were nonadherent. During hospitalization, the number decreased to 37.6 %, but increased to 61.2 % 6 weeks after discharge. Changes in the overall complexity of the therapy regimens were marginal and not statistically significant. Of the long-term medication regimens, 48.6 % were modified during hospital stay. The patients preferred regimens with a minimum of drug administrations. GPs stated to be willing to continue hospital prescriptions but were restricted by financial budgets. CONCLUSION: The results of this study confirm that an increase in adherence during a hospital stay is only transient, underlining the need for interventions to ameliorate medication adherence. They also suggest that patients prefer simple regimens. Although GPs are willing to consider their patient's preferences on pharmacotherapy, they state limitations due to financial budgets. Further studies are needed that investigate the extent to which medication therapies can be simplified and the effect of simplification on adherence.

Combination of pharmacotherapy and psychotherapy in the treatment of chronic depression: a systematic review and meta-analysis.

BACKGROUND: Chronic depression represents a substantial portion of depressive disorders and is associated with severe consequences. This review examined whether the combination of pharmacological treatments and psychotherapy is associated with higher effectiveness than pharmacotherapy alone via meta-analysis; and identified possible treatment effect modifiers via meta-regression-analysis. METHODS: A systematic search was conducted in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ISI Web of Science, BIOSIS, PsycINFO, and CINAHL. Primary efficacy outcome was a response to treatment; primary acceptance outcome was dropping out of the study. Only randomized controlled trials were considered. RESULTS: We identified 8 studies with a total of 9 relevant comparisons. Our analysis revealed small, but statistically not significant effects of combined therapies on outcomes directly related to depression (BR = 1.20) with substantial heterogeneity between studies (I² = 67%). Three treatment effect modifiers were identified: target disorders, the type of psychotherapy and the type of pharmacotherapy. Small but statistically significant effects of combined therapies on quality of life (SMD = 0.18) were revealed. No differences in acceptance rates and the long-term effects between combined treatments and pure pharmacological interventions were observed. CONCLUSIONS: This systematic review could not provide clear evidence for the combination of pharmacotherapy and psychotherapy. However, due to the small amount of primary studies further research is needed for a conclusive decision.

The latent factor structure of Young's early maladaptive schemas: are schemas organized into domains?

OBJECTIVE: In previous research it has not been clarified whether the first-order schema factors of the Young Schema Questionnaire (YSQ) can be structured into higher order domains. We examined whether investigators' subjective choices between complex models of the YSQ or chance as opposed to clinical diversity of the samples may be responsible for the heterogeneity of results reported in the literature. METHOD: We used confirmatory factor analysis to compare several a priori defined domain models in a sample of 542 undergraduate students (82.8% female; mean age 24.1 years) and 590 nonstudent adults (73.9% female; mean age 34.5 years) form an Internet survey. An additional Monte Carlo simulation study was performed to gain further insights on model selection. RESULTS: The analyses did not provide unequivocal support for the presence of a second-order domain structure. However, study findings suggested that the structure of the YSQ could be represented by a bifactor model including a first-order generic factor on which all items load and correlated first-order specific schema factors on which only the items load that were meant to measure the respective schemas. CONCLUSION: In the YSQ either several second-order domain structures are present that cannot be ranked by statistical measures alone or a first-order generic factor is present making second-order domains dispensable. Future research should include theoretical arguments and incorporate the clinical experience of practitioners.

Effectiveness of psychotherapeutic, pharmacological, and combined treatments for chronic depression: a systematic review (METACHRON).

BACKGROUND: Chronic depressions represent a substantial part of depressive disorders and are associated with severe consequences. Several studies were performed addressing the effectiveness of psychotherapeutic, pharmacological, and combined treatments for chronic depressions. Yet, a systematic review comparing the effectiveness of multiple treatment options and considering all subtypes of chronic depressions is still missing. METHODS/DESIGN: Aim of this project is to summarize empirical evidence on efficacy and effectiveness of treatments for chronic depression by means of a systematic review. The primary objectives of the study are to examine, which interventions are effective; to examine, if any differences in effectiveness between active treatment options exist; and to find possible treatment effect modifiers. Psychotherapeutic, pharmacological, and combined treatments will be considered as experimental interventions and no treatment, wait-list, psychological/pharmacological placebo, treatment as usual, and other active treatments will be seen as comparators. The population of patients will include adults with chronic major depression, dysthymia, double depression, or recurrent depression without complete remission between episodes. Outcomes of the analyses are depressive symptoms, associated consequences, adverse events, and study discontinuation. Only randomized controlled trials will be considered. DISCUSSION: Given the high prevalence and serious consequences of chronic depression and a considerable amount of existing primary studies addressing the effectiveness of different treatments the present systematic review may be of high relevance. Special attention will be given to the use of current methodological standards. Findings are likely to provide crucial information that may help clinicians to choose the appropriate treatment for chronically depressed patients.

Development and feasibility of the computerized Turkish edition of the Composite International Diagnostic Interview [DIA-X/CIDI version 2.8(TR)].

The Composite International Diagnostic Interview (CIDI), which has been widely applied in epidemiological research, is a standardized, clinically structured interview that enables the diagnosis of mental disorders based on DSM and ICD criteria. The computerized DIA-X CIDI Version 2.8 investigated in this study is an adaptation of the German DIA-X/Munich CIDI, which was translated in a multi-step process into Turkish and used to survey the prevalence of mental disorders in individuals with Turkish migration backgrounds in Germany (N = 662). The bilingual lay interviewers were intensively trained and supervised during the data collection. The survey was accompanied by further quality measures, including editing and documenting. To investigate the instrument's feasibility, quality criteria were used based on the following data sources: (1) socio-demographic sample characteristics; (2) interviewer assessments and (3) quantitative measures (interview duration, non-response items, error items). The results indicated that quality differences between the German and Turkish DIA-X/CIDI are associated with age, educational level and socio-economic status and not with the CIDI version itself. In short, the Turkish DIA-X/CIDI Version 2.8 has comparatively good quality and feasibility relative to its German counterpart.

Treatment patterns in inpatient depression care.

This study aimed to identify latent patterns of treatment combinations in inpatient depression care. A secondary analysis of routinely collected data on inpatient depression treatment from 2133 patients was conducted. Exploratory latent class modeling was used to identify distinct classes of treatment combinations based on antidepressant medication, psychotherapeutic interventions, and additional treatments. The classes were compared with regard to patient characteristics and treatment outcomes. Eight different classes of inpatient treatment combinations could be identified: 22.8% of the patients were treated with a combination labelled "standard modern antidepressants", 14.6% with "standard tricyclic antidepressants", 12.2% with "high intensity innovative strategies", 12.1% with "standard selective-reuptake-inhibitors", and 11.6% with "low intensity", 9.6% with "somatic", 8.8% with "high intensity traditional", and 8.3% with "high intensity psychosocial" care, respectively. Patients treated with different patterns of interventions differed statistically significantly regarding demographic and clinical characteristics. Responder rates ranged from 68.4% to 86.6% across treatment classes. The presented attempt of empirical modeling of a complex multifactorial intervention by means of latent class analysis proved to be a promising way of capturing the complexity of routine inpatient depression treatment. The identified classes of treatment combinations may provide relevant information for a re-evaluation and improvement of inpatient depression treatment strategies.

Comparative Safety of Pharmacologic Treatments for Persistent Depressive Disorder: A Systematic Review and Network Meta-Analysis.

We aimed to compare the safety of antidepressants for the treatment of persistent depressive disorder (PDD) with each other and with placebo. We conducted a systematic electronic search and included randomized controlled trials that investigated antidepressants for the treatment of PDD in adults. Outcomes were the incidence of experiencing any adverse event, specific adverse events and related treatment discontinuations. We analyzed the data using traditional and network meta-analyses. Thirty-four studies that comprised 4,769 patients and examined 20 individual agents in nine substance classes were included. Almost all analyzed substance classes were associated with higher discontinuation rates than placebo including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), antipsychotics, and the serotonin antagonist and reuptake inhibitor (SARI) trazodone. The odds of experiencing any adverse event were significantly higher for TCAs and serotonin noradrenaline reuptake inhibitors (SNRIs) compared to placebo. Pairwise comparisons among the substance classes revealed that more patients receiving TCAs or SNRIs experienced any adverse event and that more patients receiving TCAs or the SARI trazodone discontinued treatment. The complementary treatment with acetyl-l-carnitine showed lower rates of experiencing any adverse event and related discontinuations than all other comparators. TCAs were primarily associated with (anti-)cholinergic and sedating adverse events. SSRIs primarily showed gastrointestinal adverse events. Patients treated with the antipsychotic amisulpride were more likely to manifest weight gain and endocrine adverse events. The comparative evidence for further agents was insufficient or lacking. The identified safety differences may be used to inform the selection among the antidepressants.

Adverse event methods were heterogeneous and insufficiently reported in randomized trials on persistent depressive disorder.

OBJECTIVES: To investigate adverse event (AE) reporting practices in a systematic review of randomized controlled trials for persistent depressive disorder (PDD). STUDY DESIGN AND SETTING: A systematic electronic database search was conducted up to October 2014 to identify randomized controlled trials investigating pharmacologic, psychotherapeutic, and combined treatments for PDD in adults. We calculated the number and percentage of studies that reported predefined AE information. All calculations were carried out including all studies and stratified for study type (pharmacologic, psychotherapeutic, and mixed) and publication year [before and after the publication of the Consolidated Standards of Reporting Trials (CONSORT) extension for harms in 2004], respectively. RESULTS: Sixty studies, reported in 126 publications, were included. Across all studies, reporting of AE information was insufficient. Substantial differences between studies that investigated different treatments emerged. Most pharmacologic studies (39/42) and mixed studies (7/9) reported any AE information, although the amount of information varied and the reported methods to assess and analyze AEs were heterogeneous. We found no substantial change in reporting practices after the publication of the CONSORT extension. Psychotherapeutic studies, although almost entirely published after the CONSORT extension, largely neglected reporting of any AE information (1/9). CONCLUSIONS: There is a strong need to improve the current practice of assessing, analyzing, and reporting AEs, especially for psychotherapeutic studies.

Odds ratios of treatment response were well approximated from continuous rating scale scores for meta-analysis.

OBJECTIVES: To empirically evaluate the performance of methods for estimating odds ratios and their corresponding standard errors from continuous end point data for meta-analysis. STUDY DESIGN AND SETTING: A database of randomized controlled trials of chronic depression treatments was used. Trials that reported both continuous and dichotomous end points for symptom improvement were considered. Odds ratios and standard errors were calculated from the dichotomous data and estimated from the continuous data using currently available methods: Hasselblad and Hedges (HH), Cox and Snell (CS), Furukawa (F), Suissa (S), and Kraemer and Kupfer (KK). Single and meta-analytically pooled observed and estimated values were compared. RESULTS: A total of 26 trials were included. At the trial level, four of five (HH, CS, F, and S) and three of four (HH, F, and S) methods for estimating odds ratios and standard errors performed well, respectively. We found considerable differences in the performance of all methods across trials with more accurate estimates for smaller treatment effects. At the level of meta-analysis, three of four methods (CS, F, and S) performed acceptably. CONCLUSION: Odds ratios and standard errors can be approximated from continuous end points, but we recommend sensitivity and subgroup analyses to test robustness of the findings.

[Which factors predict treatment duration and outcome of psychotherapeutic hospital treatment?]. / Welche Merkmale sagen die Behandlungsdauer und das Behandlungsergebnis von psychotherapeutischer Krankenhausbehandlung voraus?

OBJECTIVE: Several studies document the effectiveness of psychotherapeutic hospital treatment in German speaking countries, although results show a considerable heterogeneity. METHODS: Based on data from a comprehensive meta-analysis, we investigated the impact of potential study-level predictors on average treatment duration and average symptom severity at discharge using meta-regression. RESULTS: Selected predictors explain 55 and 78 percent of between-study variance of mean treatment duration and mean symptom severity at discharge, respectively. Samples of younger patients, samples including more patients with personality disorders, samples treated in specialist centers and samples from older investigations showed longer average treatment durations. Studies in patient populations with less severe symptoms at intake and a lower proportion of personality disorders showed lower impairment at discharge. We found a statistically significant positive association between severity of symptoms at discharge and treatment duration. CONCLUSION: Regarding the higher symptom load at discharge in patients with higher impairment at intake and personality disorders, treatment concepts for these groups require improvement, for example through flexible treatment durations.

Development and Psychometric Evaluation of an Instrument to Assess Cross-Cultural Competence of Healthcare Professionals (CCCHP).

BACKGROUND: Cultural competence of healthcare professionals (HCPs) is recognized as a strategy to reduce cultural disparities in healthcare. However, standardised, valid and reliable instruments to assess HCPs' cultural competence are notably lacking. The present study aims to 1) identify the core components of cultural competence from a healthcare perspective, 2) to develop a self-report instrument to assess cultural competence of HCPs and 3) to evaluate the psychometric properties of the new instrument. METHODS: The conceptual model and initial item pool, which were applied to the cross-cultural competence instrument for the healthcare profession (CCCHP), were derived from an expert survey (n = 23), interviews with HCPs (n = 12), and a broad narrative review on assessment instruments and conceptual models of cultural competence. The item pool was reduced systematically, which resulted in a 59-item instrument. A sample of 336 psychologists, in advanced psychotherapeutic training, and 409 medical students participated, in order to evaluate the construct validity and reliability of the CCCHP. RESULTS: Construct validity was supported by principal component analysis, which led to a 32-item six-component solution with 50% of the total variance explained. The different dimensions of HCPs' cultural competence are: Cross-Cultural Motivation/Curiosity, Cross-Cultural Attitudes, Cross-Cultural Skills, Cross-Cultural Knowledge/Awareness and Cross-Cultural Emotions/Empathy. For the total instrument, the internal consistency reliability was .87 and the dimension's Cronbach's α ranged from .54 to .84. The discriminating power of the CCCHP was indicated by statistically significant mean differences in CCCHP subscale scores between predefined groups. CONCLUSIONS: The 32-item CCCHP exhibits acceptable psychometric properties, particularly content and construct validity to examine HCPs' cultural competence. The CCCHP with its five dimensions offers a comprehensive assessment of HCPs' cultural competence, and has the ability to distinguish between groups that are expected to differ in cultural competence. This instrument can foster professional development through systematic self-assessment and thus contributes to improve the quality of patient care.

Efficiency and contribution of strategies for finding randomized controlled trials: a case study from a systematic review on therapeutic interventions of chronic depression.

BACKGROUND: Identifying all existing evidence is a crucial aspect in conducting systematic reviews. Since the retrieval of electronic database searches alone is limited, guidelines recommend the use of additional search strategies. The aim of this investigation was to assess the efficiency and contribution of additional search strategies for identifying randomized controlled trials in conducting a systematic review on interventions after performing a sensitive electronic database search. DESIGN AND METHODS: Seven electronic databases, 3 journals and 11 systematic reviews were searched. All first authors of the included studies were contacted; citation tracking and a search in clinical trial registers were performed. A priori defined evaluation criteria were calculated for each search strategy. RESULTS: A total of 358 full-text articles were identified; 50 studies were included in the systematic review, wherefrom 84.0% (42) were acquired by the sensitive electronic database search and 16.0% (8) through additional search strategies. Screening reference lists of related systematic reviews was the most beneficial additional search strategy, with an efficiency of 31.3% (5) and a contribution of 10.0% (5/50), whereas hand-searching and author contacts contributed two and one additional studies, respectively. Citation tracking and searching clinical trial registers did not lead to any further inclusion of primary studies. CONCLUSIONS: Based on our findings, hand-searching contents of relevant journals and screening reference lists of related systematic reviews may be helpful additional strategies to identify an extensive body of evidence. In case of limited resources, a sensitive electronic database search may constitute an appropriate alternative for identifying relevant trials. Significance for public healthSystematic reviews provide the strongest form of evidence synthesis for therapeutic interventions and are of high relevance for decision makers in public health. Preparing high quality systematic reviews can be very time-consuming since all existing evidence should be identified, but the retrieval of electronic database searches is limited and therefore additional search strategies are recommended. However, the time needed for conducting full systematic reviews does often not address the need for urgent evidence. Thus, priorities of summarizing all available evidence and providing fast evidence-based recommendations may conflict. So far, no consensus exists regarding which additional search strategies are beneficial and sparsely time-consuming for conducting systematic reviews. We examined the efficiency and contribution of additional search strategies performed after a sensitive electronic database search. Our results provide highly relevant information for researchers conducting systematic reviews in various fields of public health research and for establishing guidelines for conducting rapid reviews.

Generalizability of findings from efficacy trials for chronic depression: an analysis of eligibility criteria.

OBJECTIVES: Concerns have been raised that the rigorous eligibility criteria used to select patients for randomized controlled trials (RCTs) limit the generalizability of trial findings. The objectives of this study were to identify commonly used eligibility criteria in RCTs for chronic depression, to examine whether these criteria are met by patients with chronic depression who are in routine care, and to identify differences between patients who would and would not meet RCT criteria. METHODS: Thirteen eligibility criteria were extracted from eight RCTs of combined psychotherapeutic and pharmacological interventions for patients with chronic depression. These criteria were then applied to a sample of patients with chronic depression receiving care in one of ten German hospitals (N=231). Demographic, clinical, and treatment characteristics of those who met the RCT criteria and those who did not were compared in univariate and multivariate analyses. RESULTS: Only 25% of the 231 inpatients met all RCT eligibility criteria. Patients were ineligible mainly because of suicide risk, low severity of depression at admission, and concurrent psychiatric or somatic disorders. No statistically significant differences were found between those who met the criteria and those who did not in demographic characteristics, length of inpatient stay, treatment outcome, and efficacy of certain antidepressants, except that slightly more patients meeting RCT criteria received selective serotonin reuptake inhibitors. CONCLUSIONS: Findings suggest that the generalizability of RCT findings to routine health care is less limited than frequently supposed.

Reducing cardiovascular medication complexity in a German university hospital: effects of a structured pharmaceutical management intervention on adherence.

BACKGROUND: Patient adherence is necessary for successful medication therapy. However, highly complex medication regimens may lead to poor adherence, which decreases the effectiveness of treatment and often results in treatment failure, excessive morbidity and mortality, and higher costs.  OBJECTIVE: To examine whether patient adherence can be increased indirectly through reducing medication complexity by (a) pharmaceutical counseling of hospital medical staff and (b) additional information in the discharge letter for the primary care provider (PCP) about the simplified discharge medication.  METHODS: At the Medical Center Hamburg-Eppendorf, a tertiary care university hospital in Germany, 240 chronically ill inpatients with hypertension, diabetes, and/or dyslipidemia were enrolled in this prospective, semirandomized study. For the intervention group, hospital doctors were counseled by a clinical pharmacist on feasible simplifications of cardiovascular and antidiabetic medications. In 1 randomized subgroup, the PCP received additional explanatory information in the discharge letter. Adherence (self-reporting using the Medication Adherence Rating Scale [MARS-D]) and medication complexity (using the Medication Regimen Complexity Index [MRCI-D]) were recorded at admission to the hospital, discharge from the hospital, and 6 weeks after discharge. Patient quality of life (QoL) and satisfaction with information about medications were assessed at admission and after discharge.   RESULTS: At discharge, the medication regimen in the intervention group was significantly less complex than in the comparison group. Yet, 6 weeks  after discharge, the complexity of the outpatient medication had increased to values similar to the comparison group, unless the PCP received additional information in the discharge letter. Propensity adjusted complete adherence rates at discharge were slightly, but not significantly, higher in the intervention group than in the comparison group. Within the intervention group, complete adherence was more frequent in the subgroup with additional information for the PCP. Patient QoL and satisfaction with information were comparable in both groups.   CONCLUSION: The complexity of cardiovascular and antidiabetic hospital medications can be reduced by counseling the hospital doctors. However, for a sustainable simplification of outpatient medication, the PCPs must receive explicit information about the modifications. Patient adherence was not significantly influenced by this intervention. To verify these results, further research with objective measures of adherence and in patients with other diseases is needed. 

Incomplete medication adherence of chronically ill patients in German primary care.

BACKGROUND: Incomplete medication adherence is a major problem in health care worldwide. Patients who adhere to medical treatment have a better prognosis and create fewer costs. OBJECTIVE: To assess the degree of incomplete adherence of chronically ill routine primary care patients in a German setting and analyze the association between incomplete medication adherence, as well as clinical and sociodemographic patient characteristics. METHODS: In a cross-sectional survey, chronically ill patients were asked to assess their adherence in primary care retrospectively using the Medication Adherence Report Scale (MARS-D) questionnaire. To investigate the association of incomplete adherence with sociodemographic and clinical data, univariate and multivariate analyses were conducted. RESULTS: In total, 62.1% of 190 patients were categorized as incompletely adherent. The mean MARS-D score was 23.5 (standard deviation = 2.7). Analyses revealed no statistically significant associations at P < 0.05 between degree of adherence and patient characteristics. The total explained variance amounted to 11.8% (Nagelkerke's R(2) = 0.118) in the multivariate analysis. CONCLUSION: Previously reported results regarding associations of sociodemographic and clinical data with incomplete medication adherence could not be confirmed for this sample of chronically ill patients. In order to be able to provide guidelines for the reduction of incomplete medication adherence in German primary care, further research is needed.

Effectiveness of a web-based, individually tailored decision aid for depression or acute low back pain: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a web-based, individually tailored decision aid (Patient Dialogue) on depression or acute low back pain for insurees of a German sickness fund. METHODS: Patient Dialogue (PD) was compared to the non-tailored Static Patient Information (SPI) in an online randomized controlled trial (RCT). The primary outcome was decisional conflict; secondary outcomes included knowledge, preparation for decision-making, preference for participation, involvement in decision-making, decision regret, and adherence. RESULTS: Out of 2480 randomized participants, 657 (26.5%) provided analyzable data immediately after using the system. Three months later, data from 131 (5.3%) participants could be included in the analysis. The PD group reported a significantly lower overall decisional conflict than the SPI group (38.7 vs. 45.1; p=0.028 via multiple imputation estimator). The largest standardized effect (Cohen's d 0.56) resulted from the preparation for decision-making (PD 59.4 vs. SPI 46.8; p<0.001). CONCLUSION: PD may be an effective tool to reduce decisional conflict and prepare participants for treatment decision-making. However, the large dropout rate needs to be taken into account. PRACTICE IMPLICATIONS: This study shows how a health insurance fund can support shared decision-making and how a decision aid can be evaluated in a RCT under routine care conditions.

Not as golden as standards should be: interpretation of the Hamilton Rating Scale for Depression.

BACKGROUND: The Hamilton Rating Scale for Depression (HRSD) is one of the most frequently used instruments in antidepressant trials. METHODS: We examined different recommendations for classification of subjects according to depression severity by the HRSD. RESULTS: Several differences between recommendations were identified leading to the conclusion that a consensus on interpretation is largely missing. LIMITATIONS: Brief narrative review. CONCLUSIONS: Widely accepted standards for the interpretation of scores on the HRSD are needed.