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.

Substance Abuse-Related Self-Stigma in Women with Substance Use Disorder and Comorbid Posttraumatic Stress Disorder.

BACKGROUND: Self-stigma is a result of internalizing negative stereotypes by the affected person. Research on self-stigma in substance use disorders (SUD) is still scarce, especially regarding the role of childhood trauma and subsequent posttraumatic disorders. OBJECTIVES: The present study investigated the progressive model of self-stigma in women with SUD and posttraumatic stress disorder (PTSD), and the predictive value of PTSD severity and childhood trauma experiences on self-stigma. METHOD: In a cross-sectional study with 343 women with SUD and PTSD, we used the Self-Stigma in Alcohol Dependency Scale, the Childhood Trauma Questionnaire (CTQ), the PTSD Symptom Scale Interview (PSS-I), and to control for SUD severity and depression, the Addiction Severity Index Lite and the Beck Depression Inventory-II. Hierarchical regression analyses were conducted for each stage of self-stigma (aware-agree-apply-harm). RESULTS: The interrelated successive stages of self-stigma were largely confirmed. In the regression models, no significant effects of the PSS-I- and the CTQ-scores were observed at any stage of self-stigma. Agreeing with negative stereotypes was solely predicted by younger age, applying these stereotypes to oneself was higher in women with younger age, higher depression and SUD severity, and suffering from the application (harm) was only predicted by depression. CONCLUSIONS: The progressive model of self-stigma could be confirmed in women with SUD and PTSD, but PTSD severity and childhood trauma did not directly affect this process. Self-stigma appears to be related to depression in a stronger way than PTSD is related to women with SUD and PTSD.

Collaborative mental health care program versus a general practitioner program and usual care for treatment of patients with mental or neurological disorders in Germany: protocol of a multiperspective evaluation study.

BACKGROUND: German statutory health insurances are pursuing the goal of improving treatment of chronically ill people by promoting networks of health care providers and supporting treatments that reflect the current medical knowledge. The so-called PNP program is a collaborative care program developed by a German statutory health insurance, which defines specific rules on psychiatric, neurological, psychosomatic, and psychotherapeutic treatment. It aims to strengthen provision of guideline-based outpatient treatment and collaboration between different health care providers. It includes the general practitioners' program, which aims to strengthen the coordinating role of GPs. This study aims to evaluate the PNP program. METHODS: To evaluate the effectiveness of the PNP program, we will conduct a prospective non-randomized controlled trial with primary data comparing patients enrolled in the PNP program and in the general practitioner program (intervention group) to patients enrolled only in the general practitioner program and patients who receive usual care (control groups). To evaluate costs and level of detail of diagnoses in care of patients with PNP program, we will use routinely collected secondary administrative health data in a retrospective quasi-experimental design. Patients who are at least 18 years old, insured by the statutory health insurance AOK, and on sick leave due to one of the mental or neurological diagnoses (affective, anxiety, somatoform or adjustment disorders, alcohol use disorders, schizophrenia, multiple sclerosis) will be included. We will collect data at baseline and at 12-months follow-up. Health-related quality of life (primary data) and direct costs (secondary data) caused by outpatient and inpatient service utilization and medication will be the primary outcomes. We will analyze data using (generalized) linear mixed models and exploratory analyses. We will use entropy balancing to control for possible differences between the groups. We will use an exploratory sequential design including qualitative and descriptive statistical analyses to assess the structure and process quality of the PNP program among health care providers. DISCUSSION: The results will help to develop a comprehensive picture of collaborative care programs for mental and neurological health care from the perspective of patients, health care providers, and health insurance companies. TRIAL REGISTRATION: German Clinical Trial Register DRKS00013114.

Choosing the appropriate treatment setting: which information and decision-making needs do adult inpatients with mental disorders have? A qualitative interview study.

BACKGROUND: Decisions on medical treatment setting are perceived as important but often difficult to make for patients with mental disorders. Shared decision-making as a strategy to decrease decisional conflict has been recommended, but is not yet widely implemented. This study aimed to investigate the information needs and the decision-making preferences of patients with mental disorders prior to the decision for a certain treatment setting. The results will serve as a prerequisite for the development of a high-quality patient decision aid (PtDA) regarding the treatment setting decision. METHODS: We conducted retrospective individual semi-structured interviews with n=24 patients with mental disorders in three psychotherapeutic inpatient care units. The interviews were audiotaped, transcribed, coded, and content-analyzed. RESULTS: The majority of the patients wanted to be involved in the decision-making process. They reported high information needs regarding treatment options in order to feel empowered to participate adequately in the decision for a certain treatment setting. However, some patients did not want to participate or receive information, for example, because of their high burden of mental disorder. Whereas the majority were satisfied with the extent they were involved in the decision, few participants felt sufficiently informed about treatment options. Most patients reported that a decision aid regarding an appropriate treatment setting would have been helpful for them. Important information that should be included in a PtDA was general information about mental illness, effective treatment options, specific information about the different treatment settings, and access to treatment. DISCUSSION: The identified information and decision-making needs provide a valuable basis for the development of a PtDA aiming to support patients and caregivers regarding the decision for an adequate treatment setting. As preferences for participation vary among patients and also depend on the current mental state, a flexible approach is needed to meet patients' individual wishes and needs.

Effectiveness of telephone-based aftercare case management for adult patients with unipolar depression compared to usual care: A randomized controlled trial.

BACKGROUND: Patients with depression often have limited access to outpatient psychotherapy following inpatient treatment. The objective of the study was to evaluate the long-term effectiveness of a telephone-based aftercare case management (ACM) intervention for patients with depression. METHODS: We performed a prospective randomized controlled trial in four psychotherapeutic inpatient care units with N = 199 patients with major depression or dysthymia (F32.x, F33.x, F34.1, according to the ICD-10). The ACM consisted of six phone contacts at two-week intervals performed by trained and certified psychotherapists. The control group received usual care (UC). The primary outcome was depressive symptom severity (BDI-II) at 9-month follow-up, and secondary outcomes were health-related quality of life (SF-8, EQ-5D), self-efficacy (SWE), and the proportion of patients initiating outpatient psychotherapy. Mixed model analyses were conducted to compare improvements between treatment groups. RESULTS: Regarding the primary outcome of symptom severity, the groups did not significantly differ after 3 months (p = .132; ES = -0.23) or at the 9-month follow-up (p = .284; ES = -0.20). No significant differences in health-related quality of life or self-efficacy were found between groups. Patients receiving ACM were more likely to be in outpatient psychotherapy after 3 months (OR: 3.00[1.12-8.07]; p = .029) and 9 months (OR: 4.78 [1.55-14.74]; p = .006) than those receiving UC. CONCLUSIONS: Although telephone-based ACM did not significantly improve symptom severity, it seems to be a valuable approach for overcoming treatment barriers to the clinical pathways of patients with depression regarding their access to outpatient psychotherapy.

Predicting the preferences for involvement in medical decision making among patients with mental disorders.

BACKGROUND: The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders. OBJECTIVE: This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients' self-efficacy. METHOD: Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients' perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference. RESULTS: Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model. CONCLUSION: Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome.

The Prevalence of Gestational Diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) is defined as a glucose tolerance disorder that arises during pregnancy. Estimates of its prevalence vary widely because of varying threshold values. Screening of all pregnant women with a two-step test has been available in Germany since 2012. This study is the first population-based, nationwide analysis of the screening coverage and the resulting one-year prevalence. METHODS: Billing data from the outpatient sector were analyzed for all persons covered by statutory health insurance in the two-year period 2014-2015. A cohort of pregnant women, constructed by using pregnancy care billing data, was studied with respect to the screening coverage. The prevalence of GDM was determined from the use of the corresponding ICD-10-GM codes. RESULTS: 80.8% of 567 191 pregnant women were screened for GDM. Most of them (63.3%) received only the pre-test, and 12.7% received both the pre-test and the diagnostic test. 4.8% received only the diagnostic test. The overall prevalence of GDM was 13.2%. The prevalence rose with age, from 8% to 26% in women aged 45 or older. Younger women more commonly received only the pre-test; the frequency of receiving both tests rose with age. CONCLUSION: Screening for GDM is comprehensively implemented. The analysis of billing data reveals a relatively high prevalence that accords with estimates in other countries, implying that earlier prevalence figures for Germany were probably underestimates.

Effectiveness of case management as a cross-sectoral healthcare provision for women with breast cancer.

OBJECTIVE: Case management (CM) programs are intended to improve care coordination for cancer patients. This quasi-experimental, controlled study evaluated whether such a program was effective in improving health-related quality of life and reducing the psychological distress of breast cancer patients. METHODS: For the study, 126 patients with CM and 118 patients with treatment as usual (TAU) were surveyed at baseline, a 6-month follow-up and a 12-month follow-up. Comparisons of the two groups with regard to quality of life (Short Form-8, European Organization for Research and Treatment of Cancer-11; primary outcome) and psychological distress (Hospital Anxiety and Depression Scale, distress thermometer; secondary outcome) were conducted. RESULTS: Univariate t-tests regarding the primary and secondary outcomes demonstrated improvements in the relevant outcomes at the 6-month and 12-month follow-ups for the intervention group as well as for the control group. An analysis of covariance revealed that the controls showed a higher level of physical quality of life at the 12-month follow-up than the other time points and no differences at 6 months after the baseline. CONCLUSIONS: The tested CM model did not improve the quality of life or psychological well-being of the patients beyond treatment as usual. Possible reasons include that the treatment was already of high standards in the control group or that there are possibly different impacts than found in the literature regarding different forms of organization in CM. The need for and the tailoring of this CM model as well as the transfer of CM to other oncological indications remain to be clarified. Copyright © 2016 John Wiley & Sons, Ltd.

Symptom change trajectories during inpatient psychotherapy in routine care and their associations with long-term outcomes.

This study examined symptom change trajectories during inpatient psychotherapy and the association of these changes with long-term outcomes. In an observational multicenter study, weekly measurements of symptom severity were performed during inpatient treatment and 6 months after discharge. The symptom severity was measured using the 18-item scale of the Hamburg Modules for the Assessment of Psychosocial Health. The sample included 576 inpatients (mean age: 43.9 years; 77.6% female; main diagnoses: depressive (57.2%), adjustment (15.8%), anxiety (7.4%), and eating disorders (7.2%); mean treatment duration: 42.0 days). With empirically and clinically informed growth mixture models four subgroups of symptom change were revealed: gradual response (71%), early response (9%), delayed response (5%), and nonresponse (11%). Particularly low educational level, non-employment and chronic disorders were associated with unfavorable symptom courses (non- and delayed response). Long-term outcomes differed systematically across subgroups (p<0.001; η(2)=0.165). The patients who responded early presented the highest rates of clinically significant improvement (43.9%) from admission to follow-up. Nearly all of these patients (92.7%) showed reliable improvement. Due to the high association of symptom change trajectories with long-term outcomes, results may contribute to interventions that are tailored to the needs of patients and may foster longer lasting therapeutic effectiveness.

Effectiveness of case management-based aftercare coordination by phone for patients with depressive and anxiety disorders: study protocol for a randomized controlled trial.

BACKGROUND: Depressive and anxiety disorders are highly prevalent, but only a small percentage (approximately 50%) of patients receive appropriate treatment. Relevant barriers include communication and coordination gaps between different providers that result from the lack of integration between different care-giving systems. Aftercare following inpatient treatment represents one of these gaps because systematic follow-up care does not exist. Case management-based aftercare coordination by phone might be a promising approach to overcoming this gap and improving long-term treatment outcomes. Case management is a patient-centered and situation-based approach comprising systematic tracking and support of patients by a case manager. The aim of this study is to evaluate the effectiveness of aftercare coordination by phone for patients with depressive and anxiety disorders. METHODS/DESIGN: The effectiveness of aftercare coordination will be investigated in a prospective randomized controlled trial in four psychotherapeutic inpatient routine care units (St. Franziska-Stift Bad Kreuznach, MediClin Seepark Klinik Bad Bodenteich, Segeberger Kliniken Gruppe Bad Segeberg and Luisenklinik Bad Dürrheim). The patients receiving aftercare coordination (intervention group; IG) will be compared with those who receive treatment as usual (TAU control group; CG). Eligible patients will be required to have a diagnosis of an anxiety and/or depressive disorder and a recommendation for follow-up outpatient psychotherapy. The aftercare coordination consists of six phone contacts at intervals of two weeks that are performed by therapists in the inpatient units. The patients will complete questionnaires at discharge (t1), 3 months after discharge (i.e., at the end of the intervention (t2)) and 9 months after discharge (t3). The primary outcome will be change in symptom severity from t1 to t3, the secondary outcomes will be health-related quality of life and the proportion of patients who manage to begin outpatient psychotherapy by t3. DISCUSSION: This study will determine whether case management-based aftercare coordination by phone is an adequate approach for overcoming treatment barriers in the clinical pathways of patients with depressive and anxiety disorders. If proven effective, an accessible supplementary treatment approach that will help to maintain and even improve long-term treatment outcomes will be made available for patients following inpatient treatment. TRIAL REGISTRATION: ClinicalTrials.gov: ( NCT02044913 ).

[Health care barriers on the pathways of patients with anxiety and depressive disorders - a qualitative interview study]. / Versorgungsbarrieren auf den Behandlungswegen von Patienten mit Angst- und depressiven Erkrankungen - Eine qualitative Interviewstudie.

OBJECTIVE: Which health care barriers do patients with anxiety and depressive disorders experience on their clinical pathways? METHODS: Semi-structured interviews were conducted among 30 patients with anxiety and depressive disorders. Interviews were audio-taped, transcribed, coded and content-analysed. RESULTS: Following barriers perceived by patients were extracted: a lack of early diagnosis, communication and coordination problems between different services and providers, little information about their illness and its adequate treatment, as well as intrapersonal barriers. CONCLUSIONS: Patients perceive barriers on the individual, provider and system level. Especially barriers on the system and provider level indicate a need for more information, early recognition and support especially during the help-seeking process.

Self-efficacy and fear of cancer progression during the year following diagnosis of breast cancer.

OBJECTIVE: The aim of this study was to investigate fear of disease progression (FoP) during the year following diagnosis of breast cancer and its association with general self-efficacy (SE). METHODS: In a prospective study, 118 breast cancer patients were recruited shortly after diagnosis disclosure (response rate: 54%) and at 1-year follow-up (follow-up rate: 90%). Participants completed self-report measures of general self-efficacy (General Self-Efficacy Scale) and fear of progression (short form of the Fear of Progression Questionnaire). RESULTS: Cross-sectional regression analysis revealed that high FoP is significantly associated with low SE, even when controlling for demographic and medical characteristics (total R² = 0.17). Having children and a relatively short time since diagnosis also significantly predicted higher FoP. Longitudinal analyses showed that FoP decreased significantly over time (p = 0.001; d = 0.25), but a significant decrease was only observed for patients with high initial FoP (p < 0.001; d = 0.74) and not for those with low initial FoP (p = 0.688; d = 0.08). SE was not a significant predictor of FoP at follow-up when controlling for initial FoP and other patient characteristics (incremental R² = 0.001; p = 0.674; total R² = 0.47). Overall, only initial FoP significantly predicted FoP at follow-up (p < 0.001; ß = 0.671). CONCLUSION: Findings that low SE is associated with high FoP can help to improve the treatment of dysfunctional fears in breast cancer patients. As FoP changes only slightly over time, treatment to enhance SE and reduce FoP should be initiated soon after disease disclosure.

Class Evolution Tree: a graphical tool to support decisions on the number of classes in exploratory categorical latent variable modeling for rehabilitation research.

The aim of our study was to develop a graphical tool that can be used in addition to standard statistical criteria to support decisions on the number of classes in explorative categorical latent variable modeling for rehabilitation research. Data from two rehabilitation research projects were used. In the first study, a latent profile analysis was carried out in patients with cancer receiving an inpatient rehabilitation program to identify prototypical combinations of treatment elements. In the second study, growth mixture modeling was used to identify latent trajectory classes based on weekly symptom severity measurements during inpatient treatment of patients with mental disorders. A graphical tool, the Class Evolution Tree, was developed, and its central components were described. The Class Evolution Tree can be used in addition to statistical criteria to systematically address the issue of number of classes in explorative categorical latent variable modeling.

[Predictors of treatment duration for inpatients with mental disorders--a systematic literature review]. / Pradiktoren der stationaren Behandlungsdauer von Patienten mit psychischen storungen--Eine systematische Literaturanalyse.

OBJECTIVES: In a systematic literature review we examined patient-related predictors of inpatient treatment duration for mental disorders. METHODS: The databases Medline, Embase, Psyndex, PsycINFO and EBMR were systematically reviewed for studies in the years 1990-2009 regarding treatment duration of inpatients with ICD-10 diagnoses F3-F6. Also, their methodological quality was evaluated. RESULTS: Twenty-one studies examining 28 predictors (sociodemographic, clinical) were included. Longer treatment durations were found for patients living alone and with higher levels of initial symptom severity, duration of mental disorder, number of previous treatments, work absenteeism, and comorbidity. Obsessive-compulsive, eating and personality disorders were treated longer than depressive, anxiety, somatoform, and adjustment disorders. Results for age, gender, education, and profession were inconsistent. CONCLUSIONS: The studies included heterogeneous analyses, treatments, and patients. Despite their sufficient methodical quality, these results are only tentative.

Distinct mechanisms of altered brain activation in patients with multiple sclerosis.

Cerebral reorganization may limit the effects of central nervous system tissue damage on cognition in patients with multiple sclerosis (MS). This study investigated fMRI activation patterns in patients with relapsing-remitting MS and healthy control subjects during performance of a delayed recognition task. As intended, fMRI task performance was similar in the MS and the control group, whereas neuropsychological testing revealed reduced performance in the patient group on the Paced Serial Addition Test, a reference task for the assessment of cognitive function in MS. Patients overall showed more activation in left posterior parietal cortex than healthy control subjects. Global gray matter atrophy in the patient group was associated with low PASAT scores. In a multiple regression analysis including white matter lesion load and gray matter atrophy as covariates, PASAT performance correlated with activation in left posterior parietal cortex and right anterior midfrontal gyrus, indicating a reallocation of neuronal resources to help preserve function. Global gray matter atrophy correlated with activation in bilateral prefrontal cortex, dorsal ACC and left posterior parietal cortex and, furthermore, was associated with a low degree of deactivation in rostral ACC, suggesting neural inefficiency and consistent with a reduced capacity to modulate between frontoparietal task-associated activation and 'default network' activity. The current study provides evidence that altered brain activation in MS patients has two distinct components, one related to compensatory processes and one to neural inefficiency associated with tissue damage.

Evidence for a direct association between cortical atrophy and cognitive impairment in relapsing-remitting MS.

Cognitive deficits affecting memory, attention and speed of information processing are common in multiple sclerosis (MS). The mechanisms of cognitive impairment remain unclear. Here, we examined the association between neuropsychological test performance and brain atrophy in a group of mildly disabled patients with relapsing-remitting MS. We applied voxel-based morphometry (SPM2) to investigate the distribution of brain atrophy in relation to cognitive performance. Patients had lower scores than control subjects on tests of memory and executive function, including the PASAT, Digit Span Backward and a test of short-term verbal memory (Memo). Among patients, but not healthy controls, performance on the PASAT, a comprehensive measure of cognitive function and reference task for the cognitive evaluation of MS-patients, correlated with global grey matter volume as well as with grey matter volume in regions associated with working memory and executive function, including bilateral prefrontal cortex, precentral gyrus and superior parietal cortex as well as right cerebellum. Compared to healthy subjects, patients showed a volume reduction in left temporal and prefrontal cortex, recently identified as areas predominantly affected by diffuse brain atrophy in MS. A comparison of low performers in the patient group with their matched control subjects showed more extensive and bilateral temporal and frontal volume reductions as well as bilateral parietal volume loss, compatible with the progression of atrophy found in more advanced MS-patients. These findings indicate that MS-related deficits in cognition are closely associated with cortical atrophy.