[Implementing a Global Treatment Budget for Psychiatric Hospital Services - What are Incentives, Requirements, and Challenges?] / Implementierung eines globalen Behandlungsbudgets in der Psychiatrie ­ Welche Anreize, Voraussetzungen und Herausforderungen gibt es?

OBJECTIVE: Since 2013, flexible and integrative psychiatric treatment models (FIT64b) have been set up in 22 German hospitals. FIT64b is based on a global treatment budget (GTB) covering costs for all psychiatric hospital services and is related to the number of patients treated. As part of the "PsychCare"-study we are examining incentives, requirements and challenges which relate to the introduction of FIT64b. METHODS: Expert interviews and focus groups (n = 29) were led with management and controlling staff from 7 FIT64b adopting hospitals and 3 statutory health insurance funds (SHI). A thematic analysis was conducted. RESULTS: A central component for the introduction of a GTB is a cooperative relation based on mutual trust between hospitals and SHI. Challenging are, above all, performance documentation and performance control of cross-sectoral treatment as well as the parallel structure of FIT64b and standard care. CONCLUSION: Apart from several surmountable obstacles to implementation, the GTB seems to be a strong driver for the future-oriented transformation of psychiatric hospital services in Germany. In the further development of GTB, the obligation to contract with all SHI should be considered.

Prevention of Psychosis: Advances in Detection, Prognosis, and Intervention.

Importance: Detection, prognosis, and indicated interventions in individuals at clinical high risk for psychosis (CHR-P) are key components of preventive psychiatry. Objective: To provide a comprehensive, evidence-based systematic appraisal of the advancements and limitations of detection, prognosis, and interventions for CHR-P individuals and to formulate updated recommendations. Evidence Review: Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO were searched for articles published from January 1, 2013, to June 30, 2019, to identify meta-analyses conducted in CHR-P individuals. MEDLINE was used to search the reference lists of retrieved articles. Data obtained from each article included first author, year of publication, topic investigated, type of publication, study design and number, sample size of CHR-P population and comparison group, type of comparison group, age and sex of CHR-P individuals, type of prognostic assessment, interventions, quality assessment (using AMSTAR [Assessing the Methodological Quality of Systematic Reviews]), and key findings with their effect sizes. Findings: In total, 42 meta-analyses published in the past 6 years and encompassing 81 outcomes were included. For the detection component, CHR-P individuals were young (mean [SD] age, 20.6 [3.2] years), were more frequently male (58%), and predominantly presented with attenuated psychotic symptoms lasting for more than 1 year before their presentation at specialized services. CHR-P individuals accumulated several sociodemographic risk factors compared with control participants. Substance use (33% tobacco use and 27% cannabis use), comorbid mental disorders (41% with depressive disorders and 15% with anxiety disorders), suicidal ideation (66%), and self-harm (49%) were also frequently seen in CHR-P individuals. CHR-P individuals showed impairments in work (Cohen d = 0.57) or educational functioning (Cohen d = 0.21), social functioning (Cohen d = 1.25), and quality of life (Cohen d = 1.75). Several neurobiological and neurocognitive alterations were confirmed in this study. For the prognosis component, the prognostic accuracy of CHR-P instruments was good, provided they were used in clinical samples. Overall, risk of psychosis was 22% at 3 years, and the risk was the highest in the brief and limited intermittent psychotic symptoms subgroup (38%). Baseline severity of attenuated psychotic (Cohen d = 0.35) and negative symptoms (Cohen d = 0.39) as well as low functioning (Cohen d = 0.29) were associated with an increased risk of psychosis. Controlling risk enrichment and implementing sequential risk assessments can optimize prognostic accuracy. For the intervention component, no robust evidence yet exists to favor any indicated intervention over another (including needs-based interventions and control conditions) for preventing psychosis or ameliorating any other outcome in CHR-P individuals. However, because the uncertainty of this evidence is high, needs-based and psychological interventions should still be offered. Conclusions and Relevance: This review confirmed recent substantial advancements in the detection and prognosis of CHR-P individuals while suggesting that effective indicated interventions need to be identified. This evidence suggests a need for specialized services to detect CHR-P individuals in primary and secondary care settings, to formulate a prognosis with validated psychometric instruments, and to offer needs-based and psychological interventions.

Gene set enrichment analysis and expression pattern exploration implicate an involvement of neurodevelopmental processes in bipolar disorder.

BACKGROUND: Bipolar disorder (BD) is a common and highly heritable disorder of mood. Genome-wide association studies (GWAS) have identified several independent susceptibility loci. In order to extract more biological information from GWAS data, multi-locus approaches represent powerful tools since they utilize knowledge about biological processes to integrate functional sets of genes at strongly to moderately associated loci. METHODS: We conducted gene set enrichment analyses (GSEA) using 2.3 million single-nucleotide polymorphisms, 397 Reactome pathways and 24,025 patients with BD and controls. RNA expression of implicated individual genes and gene sets were examined in post-mortem brains across lifespan. RESULTS: Two pathways showed a significant enrichment after correction for multiple comparisons in the GSEA: GRB2 events in ERBB2 signaling, for which 6 of 21 genes were BD associated (PFDR = 0.0377), and NCAM signaling for neurite out-growth, for which 11 out of 62 genes were BD associated (PFDR = 0.0451). Most pathway genes showed peaks of RNA co-expression during fetal development and infancy and mapped to neocortical areas and parts of the limbic system. LIMITATIONS: Pathway associations were technically reproduced by two methods, although they were not formally replicated in independent samples. Gene expression was explored in controls but not in patients. CONCLUSIONS: Pathway analysis in large GWAS data of BD and follow-up of gene expression patterns in healthy brains provide support for an involvement of neurodevelopmental processes in the etiology of this neuropsychiatric disease. Future studies are required to further evaluate the relevance of the implicated genes on pathway functioning and clinical aspects of BD.

[How frequently are depressive disorders recognized in primary care patients? : A cross-sectional epidemiological study in Germany]. / Wie häufig werden Patienten mit depressiven Störungen in der hausärztlichen Praxis erkannt? : Eine epidemiologische Querschnittsstudie.

BACKGROUND: Primary care physicians (PCPs) play a crucial role for guideline-oriented intervention in patients with depression. OBJECTIVES: Based on a diagnostic screening questionnaire, this study investigates the sensitivity of PCPs to recognize patients with depression as well as the factors facilitating recognition and concordant diagnostic decisions. METHOD: In a cross-sectional epidemiological study in six regions of Germany, 3563 unselected patients filled in questionnaires on mental and physical complaints and were diagnostically evaluated by their PCP (N = 253). The patient reports on an established Depression-Screening-Questionnaire (DSQ), which allows the approximate derivation of an ICD-10 depression diagnosis, were compared with the physician diagnosis (N = 3211). In a subsample of discordant cases a comprehensive standardized clinical-diagnostic interview (DIA-X/CIDI) was applied. RESULTS: On the study day, the prevalence of ICD-10 depression was 14.3% according to the DSQ and 10.7% according to the physician diagnosis. Half of the patients identified by DSQ were diagnosed with depression by their physician and two thirds were recognized as mental disorder cases. More severe depression symptomatology and the persistent presence of main depression symptoms were related to better recognition and concordant diagnostic decisions. Diagnostic validation interviews confirmed the DSQ diagnosis in the majority of the false-negative cases. Indications for at least a previous history of depression were found in up to 70% of false-positive cases. CONCLUSION: Given the high prevalence of depression in primary care patients, there is continued need to improve the recognition and diagnosis of these patients to assure guideline-oriented treatment.

Disturbed sleep in bipolar disorder is related to an elevation of IL-6 in peripheral monocytes.

Bipolar disorder is a severe psychiatric disorder that is associated with persistent changes in the quality, duration and architecture of sleep. Currently there is no unifying hypothesis explaining the alterations in sleep observable in patients with bipolar disorder and management is often difficult though vital. Sleep is modified by various cytokines including IL-6. Elevated levels of IL-6 are associated with a poorer quality of sleep and changes in the architecture of sleep similar to those observed in bipolar disorder. Therapeutic administration of Interferon causes elevations of intrathecal IL-6 concentrations and appears to provoke a deteriorating quality of sleep. The blockade of IL-6 with tocilizumab in rheumatoid arthritis is associated with improvements in the quality of sleep. Bipolar disorder is associated with elevated levels of IL-6 and in particular elevated levels of mRNA coding for IL-6 in peripheral monocytes. We propose that the changes observed in the sleep of patients with bipolar disorder are related to the elevation of IL-6 and that this correlates with an elevated expression of mRNA coding for IL-6 expression in peripheral monocytes.

[Early recognition centers for mental disorders - a complementary supply in the german health system]. / Früherkennungszentren für psychische Erkrankungen - ein Komplementärangebot der psychiatrischen Regelversorgung in Deutschland.

OBJECTIVE: Mental disorders are identified and treated too late, because of stigma, deficient information in the population and lack of specific supply in the public health systems. Another problem is the deficient cooperation between psychiatry and child psychiatry. Therefore early recognition centers were founded, in Germany primarily with focus on psychosis and in research settings. METHODS: The early recognition center in Dresden offers a low-threshold and anonym service for young people independent of diagnosis. The multiprofessional team including psychologists, psychiatrists and child psychiatrists applies defined standards. In addition to standard history taking and formally assessing psychopathology, early recognition instruments for psychosis and bipolar disorders are used as appropriate. RESULTS: In 167 out of 192 individuals a structured diagnostic procedure was recommended, 149 persons (89 %) completed the procedure. Thereof 78 (52 %) persons fulfilled criteria for one, 21 (14 %) persons for two and 10 (7 %) persons for three mental disorders. 49 (33 %) persons fulfilled criteria for (Ultra)high risk for psychosis and/or bipolar disorders. CONCLUSIONS: In the majority of cases diagnostic criteria for at least one mental illness was already fulfilled. All diagnosis and stages from prodromal till chronic were represented. The high percentage of subjects fulfilling criteria for (ultra)high risk-constellations offers the chance for early interventions. The implementation of early detection centers for psychiatric disorders seems reasonable and necessary.

Epidemiology of bipolar disorders.

UNLABELLED: Bipolar, or manic-depressive, disorders are frequent and severe mental illnesses associated with considerable morbidity and mortality. Epilepsy and bipolar disorder could probably share some aspects of pathophysiology because manic as well as depressive symptoms are seen in patients with seizures, and a number of antiepileptic drugs are effectively used in the acute and prophylactic treatment of bipolar disorder. Epidemiologic research suggests a dimensional composition of bipolar illness at the population level. Apart from the DSM-IV diagnostic features of bipolar I (mania and depression) and bipolar II (hypomania and depression), the concept of bipolar spectrum disorders comprises a range of bipolar conditions with less obvious manifestations with estimated lifetime prevalence rates ranging from 2.8 to 6.5%. Expanding the definition of bipolar II disorders shows that half of the patients currently diagnosed with a unipolar depressive episode could suffer from unrecognized bipolar II disorder, and about the same number of mild depressive patients could be minor bipolars. Research efforts to refine the diagnostic criteria of bipolar disorder aim at an earlier and complete recognition of the disease to provide appropriate pharmacological and nonpharmacological treatment early in the course of the illness to anticipate individual suffering, suicidal behavior, and increased socioeconomic costs for society. This article also discusses risk factors, comorbid conditions, course of illness, as well as the individual and socioeconomic impact of bipolar disorders. CONCLUSIONS: The findings suggest reconceptualizing bipolar illnesses as highly recurrent, malignant disorders that occur far more frequently than previously thought. Interdisciplinary knowledge transfer could help to increase our understanding of the pathophysiology of these disorders as well as provide grounds for better recognition and treatment of patients with manic and/or depressive symptoms.

Ghrelin plasma levels during psychopharmacological treatment.

The mechanisms underlying weight gain induced by psychopharmacological agents are poorly understood. Because the recently discovered enteric hormone, ghrelin, stimulates food intake, we hypothesized that increases in circulating ghrelin levels might mediate the weight gain caused by certain antidepressants and atypical antipsychotic drugs. Fifty-two patients receiving psychopharmacological treatments were included in the study: 16 patients received antidepressants that are not known to induce weight gain, and 13 patients received mirtazapine or trimipramine, which are antidepressants known to lead to weight gain; 6 patients received clozapine and olanzapine, which have the highest liability among the antipsychotics to cause weight gain, and 17 patients received other antipsychotics. Fasting venous blood samples for the measurement of ghrelin were drawn in the morning between 06:00 and 08:00 a.m. in the second week of treatment. Although psychopharmacological treatment induced significant weight changes in the expected directions (most prominent in the clozapine or olanzapine treatment group), ghrelin levels did not differ significantly between groups. Psychotropic drugs with different propensities to induce body weight gain are associated with similar concentrations of plasma ghrelin in psychiatric patients after a short period of treatment.