[Telephone coaching for depression]. / Telefoncoaching bei Depression.

BACKGROUND: Depression is associated with a substantial utilization of resources in the German healthcare system. A typical symptom in depression is loss of drive, which possibly contributes to non-adherence and increased costs. OBJECTIVE: The study is based on routine healthcare data and tested the hypothesis that telephone coaching in cases of depression leads to a reduction in total healthcare costs. MATERIAL AND METHODS: Based on approximately 80 covariates and using propensity score matching, a total of 1586 persons who had received telephone coaching for depression and covered by a German statutory health insurance fund were matched to a comparable cohort of patients with depression to whom telephone coaching had not been provided. RESULTS: Within the study period of 12 months (3rd quarter 2012-4th quarter 2013) a positive program effect was observed for the intervention group by a significant reduction of total healthcare costs (2332 € vs. 2626 €, p = 0.0015) resulting in total savings to the statutory health insurance fund of 415,532 €. Investment costs amounted to 256,683.42 € leading to a return on investment of 1.62 € (total savings/total investment). The coaching program was well accepted by patients. CONCLUSION: Telephone coaching for depression was able to significantly reduce total healthcare expenditure and the intervention was well accepted by patients.

[Preoperative anemia in orthopedic surgery: clinical impact, diagnostics and treatment]. / Präoperative Anämie in der Orthopädie: Klinische Relevanz, Diagnostik und Therapie.

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels < 13 g/dl at preadmission testing. Preoperative anemia has been associated with increased mortality and morbidity after surgery, increased allogeneic blood transfusion therapy and increased rates of postoperative infection leading to a longer length of hospital stay. Because of the risks associated with allogeneic blood transfusions according to German law patients have to be offered the option of autologous transfusion if the risk associated with allogeneic blood transfusion is > 10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28 days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ≥ 120 g/l, normal male ≥ 130 g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.

[Do individuals with substance use disorders find information for crisis intervention and suicide prevention resources on the Internet?]. / Finden suizidale Suchtkranke Hilfsangebote im Internet?

BACKGROUND AND OBJECTIVE: Suicidality is an important issue for substance-dependent people. The few studies about Internet searches have provided ambiguous results regarding help and support using suicide-related terms. MATERIAL AND METHODS: Five popular search engines and several substance use- and suicide-related German search terms were used; the search results were classified as being pro-suicide, anti-suicide, suicide-neutral, websites not associated with suicide or "page could not be loaded". RESULTS: The majority of identified websites was not associated with suicide at all, whereas websites offering help and support were less frequent. Using suicide-associated search terms (such as "Selbsttötung") almost half of all web pages were help sites. Websites with instructions for committing suicide were very rarely found. CONCLUSIONS: In view of the difficulties for substance abusers to get immediate and adequate information about help and support in a suicidal crisis via the Internet, it is urgently necessary to extend fast available help sites on the Internet.

Neuropeptide S receptor gene -- converging evidence for a role in panic disorder.

Animal studies have suggested neuropeptide S (NPS) and its receptor (NPSR) to be involved in the pathogenesis of anxiety-related behavior. In this study, a multilevel approach was applied to further elucidate the role of NPS in the etiology of human anxiety. The functional NPSR A/T (Asn¹°7Ile) variant (rs324981) was investigated for association with (1) panic disorder with and without agoraphobia in two large, independent case-control studies, (2) dimensional anxiety traits, (3) autonomic arousal level during a behavioral avoidance test and (4) brain activation correlates of anxiety-related emotional processing in panic disorder. The more active NPSR rs324981 T allele was found to be associated with panic disorder in the female subgroup of patients in both samples as well as in a meta-analytic approach. The T risk allele was further related to elevated anxiety sensitivity, increased heart rate and higher symptom reports during a behavioral avoidance test as well as decreased activity in the dorsolateral prefrontal, lateral orbitofrontal and anterior cingulate cortex during processing of fearful faces in patients with panic disorder. The present results provide converging evidence for a female-dominant role of NPSR gene variation in panic disorder potentially through heightened autonomic arousal and distorted processing of anxiety-relevant emotional stimuli.

[Equal access to medical services over the lifespan]. / Versorgungsgerechtigkeit in der Lebensspanne.

Demand for health services is in principle unlimited, in contrast to resources. People covered by public health funds in principle have equal access to treatment according to the highest level of medical evidence available. In order to restrict expenditure the legislator stipulates different instruments. These include reference pricing for generics as well as price capping. The legislator still shies from price fixing which is well established in other states. Instead, office-based physicians are confronted by law with rationing decisions concerning their own services as well as services prescribed where the mentally ill are at special risk of becoming victims of intransparency, as exemplified by the heterogeneity of the prescription of psychotropic drugs. A systematic prioritization approach following internationally available models might open new perspectives.

[Predictors of major mental disorders]. / Prädiktoren psychischer Krankheiten.

Predictors of several major mental disorders include strong genetic linkage that is modified by biological, psychological and social factors. Insight into the biological mechanisms underlying these interactions is growing. Several candidate genes have been identified but their predictive value is still limited for predictions in the single individual. Comorbidities are common, including combinations of different mental disorders and/or combinations of mental and physical disorders. The combination of a mental and physical disorder often indicates a worse outcome for the physical disorder.

[Extent and use of administrative hospital data in the German DRG system]. / Diagnose- und Prozedurendaten im deutschen DRG-System.

In 2003 the mandatory introduction of diagnosis related groups as an overall payment system started for all hospitals in Germany, except for departments of psychiatry and psychotherapy as well as psychosomatics and psychotherapy. All hospitals are legally obliged to deliver extensive data on hospital treatment, including demographic data, diagnoses, comorbidities, complications, and procedures, to the "Institute for the Hospital Remuneration System" which uses the data for yearly adaptation of the German DRG system (G-DRG). This article describes legal issues of data collection, parameters and content of hospital data. In principle, the data might additionally be used for epidemiological, quality and public health issues which is, however, not supported by federal law, as of this time (January 2007). Completion of hospital data by unique patient identifiers, extended legal possibilities of scientific use of the data and the combination of hospital data from the DRG system with the data collected by the federal statistical office of Germany are proposed.

Rgs 2 gene polymorphisms as modulators of anxiety in humans?

Rgs2 (regulator of G-protein signalling 2) gene recently was reported as a quantitative trait gene for anxious behaviour in mice and male Rgs2 knockout mice have been shown to be more anxious than wildtype mice. Therefore we investigated four non-coding single nucleotide polymorphisms in a sample of 173 patients with panic disorder and 173 matched controls of German descent. At the genotype level all four SNPs were associated with panic disorder (p = 0.02-0.05). At the haplotype level the strongest association was observed for a haplotype containing SNP3 and SNP 4 (subgroup men and men with agoraphobia: p = 0.01 and 0.03). This points towards a functional polymorphism at the 3' end of the gene. Our results support the hypothesis that variations of the Rgs2 gene play a role also for the development of anxiety in humans.

[Selective serotonin and noradrenaline reuptake inhibitors: a step forward in the treatment of depression?]. / Medikamentöse Behandlung von Depressionen und Angststörungen. Dem Therapieziel Remission wieder ein Schritt näher.

With the tricyclics, selective serotonin reuptake inhibitors (SSRIs) and other substances, we now have available a range of medications for the treatment of depression and other psychological disorders (e.g. anxiety, panic). Nevertheless, only some of the patients experience a remission of their depressive symptoms. The occurrence of side effects and the only modest level of effectiveness result in inadequate compliance on the part of the patient. With venlafaxine and duloxetine two representatives of the selective serotonin and noradrenaline reuptake inhibitor (SSNRI) class of antidepressants are now available. SSNRIs have a dual effect coupled with high selectivity. The present article the extent to which this particular action mechanism results in an improved clinical efficacy and tolerability profile of the SSNRIs, in particular in comparison with SSRIs.

Cholecystokinin- and cholecystokinin-B-receptor gene polymorphisms in panic disorder.

Panic disorder like other neuropsychiatric disorders is believed to be caused by multiple psychosocial and biological factors. Several lines of evidence point to a role for the peptide neurotransmitter cholecystokinin in the pathogenesis of panic disorder. We therefore determined the allele and genotype frequencies of a single nucleotide polymorphism in the CCK gene (-36C>T) and one CT repeat polymorphism in the CCK-B-receptor gene in a German panic disorder sample (n = 115 for CCK gene polymorphism, n = 111 for CCK-B-receptor polymorphism) and compared them with gender and age matched controls. The length of the polymorphic CT repeat alleles varies between 146 bp and 180 bp. We first analysed the results by a permutation test which provided evidence for heterogeneity between patients and controls (p=0.002). We then analysed the data as a di-allelic polymorphism with a short (146-162bp) and a long (164-180bp) allele and as a tetra-allelic polymorphism with 4 alleles (146-154bp, 156-162bp, 164-170bp, 172-180bp). In the di-allelic analysis as well as in the tetra-allelic analysis there was an excess of the longer allele (p = 0.001) or the two longer alleles (p = 0.041) respectively in patients with panic disorder. No difference between groups was observed for the -36C > T polymorphism. Our findings are consistent with the notion that genetic variation in the CCK neurotransmitter system contributes to the pathogenesis of panic disorder.

Association study of serotonin-2A receptor gene polymorphism and panic disorder in patients from Canada and Germany.

The T102C serotonin-2A (5-HT2A) receptor gene polymorphism has been studied extensively in a number of complex psychiatric conditions with mixed results. Recently a genetic association has been described between this polymorphism and panic disorder in a Japanese sample. To evaluate the impact of the T102C polymorphism in panic disorder we genotyped triad families (panic disorder patient and parents), and cases with controls in Canadian and German samples. No significant transmission disequilibrium was observed between the alleles of the T102C 5-HT2A receptor gene polymorphism and panic disorder, nor was a significant excess of either allele found in the case control analysis. Our data suggest thus that this polymorphism is unlikely to play a major role in the pathogenesis of panic disorder.

Reduction of clozapine-induced hypersalivation by pirenzepine is safe.

INTRODUCTION: Hypersalivation is known as a frequent, disturbing, and socially stigmatizing side effect of therapy with the atypical antipsychotic clozapine. It has been shown that the addition of the anticholinergic pirenzepine is able to reduce clozapine-induced hypersalivation, probably by blocking M4-receptors. Nevertheless, a pharmacokinetic interaction between both compounds cannot be excluded. METHODS: In this pilot study, 29 schizophrenic patients (ICD-10; 51.7 % female; age: 36.7 +/- 8.7 years [mean +/- SD]) were included. Serum concentrations of clozapine and its pharmacologically active metabolite N-desmethylclozapine were determined under steady-state conditions by automated HPLC with UV detection before and after addition of pirenzepine for 3 days. RESULTS: Significantly fewer patients reported hypersalivation after addition of pirenzepine (69 % vs. 34.5 %, P = 0.002). No significant differences of clozapine and N-desmethylclozapine serum levels before (329 +/- 181 ng/ml and 218.0 +/- 123.4 ng/ml, respectively) and 3 days after (336 +/- 215 ng/ml and 235.9 +/- 164.4 ng/ml, respectively) addition of pirenzepine were found. In three patients, however, clozapine serum levels increased; this was probably unrelated to pirenzepine. CONCLUSION: In conclusion, treatment of clozapine-induced hypersalivation with pirenzepine is a recommendable combination with low risk of additional side effects.