[Guideline-conform inpatient psychiatric psychotherapeutic treatment of chronic depression: Normative personnel requirements]. / Leitlinienentsprechende stationäre psychiatrisch-psychotherapeutische Behandlung der chronischen Depression : Normative Personalbedarfsermittlung.

BACKGROUND: Chronic depression is a frequent mental disorder representing a significant subjective and economic burden. Effective disorder-specific treatment of chronic depression presupposes sufficient funding of treatment resources. OBJECTIVE: Definition of normative needs of personnel resources for guideline-compliant and evidence-based inpatient treatment of chronic depression based on treatment duration and intensity. The personnel resources determined were compared to the resources provided on the basis of the existing reimbursement system (Psych-PV) in Germany. MATERIAL AND METHODS: Resources determined according to national treatment guidelines and empirical evidence were compared to personnel resources dictated by the German Psych-PV reimbursement algorithm. RESULTS: The current funding algorithm greatly underestimates the resources needed for a guideline-compliant and evidence-based treatment program, even if healthcare providers received 100 % reimbursement of the sum determined by the Psych-PV algorithm. DISCUSSION: The results clearly show that even in the case of a full coverage of the current German reimbursement algorithm, funding allocation for evidence-based inpatient treatment of chronic depression is insufficient. In addition, the difficulties of specific coding of chronic depression in the ICD-10 system generates a major problem in the attempt to measure the current resources needed for sufficient treatment.

[Resource use and financing of guideline-adherent psychotherapeutic inpatient care]. / Aufwand und Finanzierung leitliniengerechter, psychotherapeutischer Behandlung im Krankenhaus.

BACKGROUND: The financing of psychiatric psychotherapeutic care in Germany is determined by the German psychiatric staffing regulations which are unchanged since 1991. Psychotherapy was established after 1991 as an effective and indispensable treatment of mental and behavioral disorders. AIMS AND OBJECTIVES: The aim of this study was to empirically investigate the use of psychiatrists' and psychologists' working time for psychotherapy in guideline-adherent hospital care. A further aim was to compare these results to the resources defined by the German psychiatric staffing regulations and in the new prospective payment system for psychiatry and psychosomatics in Germany. MATERIAL AND METHODS: University hospitals for psychiatry and psychotherapy were asked to retrospectively provide data of patients for which guideline-adherent care was possible. Participating institutions provided both data describing the staff time utilization of psychotherapeutic services provided by psychiatrists and psychologists and patient classifications according to the German psychiatric staffing regulations and the new prospective payment system for psychiatry and psychosomatics. RESULTS: Resources defined by the German psychiatric staffing regulations covered a mean of only 71 min of psychotherapy per patient and week while the actual mean intensity of psychotherapeutic care provided by the participating hospitals was 194 min per patient and week. The associated use of staff time was 102 min per patient and week. Both figures increased during an inpatient episode. The resources defined by the German psychiatric staffing regulations covered only 70 % of medical and psychological personnel. The current configuration of the new prospective payment system for psychiatry and psychosomatics covered only 59 % of staff time. CONCLUSION: The results of this study provide another unambiguous recommendation to adjust the out-dated German psychiatric staffing regulations to the current evidence and S3 guidelines for psychiatric psychotherapeutic hospital care. In particular, more resources are required for the provision of psychotherapeutic care.

[Metabolic syndrome and depression]. / Metabolisches Syndrom und Depression.

The metabolic syndrome is defined as a constellation of metabolic abnormalities, including glucose intolerance, obesity, dyslipidaemia, and hypertension. It is associated with an elevated risk for cardiovascular disease and type 2 diabetes. Over the past 20 years, a worldwide increase of the metabolic syndrome has taken place. In the USA, 21% to 39% of the general population suffer from metabolic syndrome; in Europe prevalence rates are lower. At the same time, depressive disorders, which are associated with a 1.5 to 2.5 fold risk for cardiovascular events, are increasing. The combination of metabolic syndrome and depression multiplies the risk for severe complications: Due to behavioural, physiological, genetic, and treatment-induced factors, depression stimulates the development of a metabolic syndrome. In reverse, the metabolic syndrome favours development and maintenance of the metabolic syndrome. Consequently, in patients suffering from metabolic syndrome and depression, both disorders must be treated simultaneously. The treatment plan includes weight reduction, physical activity, psychoeducation, family interventions, the patient's subjective explanatory and treatment models, cognitive techniques, and problem solving techniques. Weight, blood pressure, fastening glucose, haemoglobin A1c, and lipids must be controlled in order to monitor treatment progress. Additional drug treatment can be appropriate for hypertension, dyslipidaemia, hyperglycaemia, and depression. Under these conditions, sustained improvements of individual well-being, psychosocial risk-factors, functional limitations, glycemic control, hypertension, and obesity are possible.

[Shared decision making (SDM) with chronic pain patients. The patient as a partner in the medical decision making process]. / Partizipative Entscheidungsfindung (PEF) mit chronischen Schmerzpatienten. Der Patient als Partner im medizinischen Entscheidungsprozess.

Fibromyalgia syndrome (FMS) is an exemplary condition of chronic widespread pain that is difficult to control and often leads to frustration and resignation on the part of both the patient and the doctor. Shared decision making (SDM) could be a means to facilitate doctor-patient interaction and might therefore influence therapeutic decisions taken. We conducted a prospective study to evaluate the effects of SDM with FMS patients. We developed a communication train-ing program for physicians and a computer-based information tool on FMS for patients. The study included 133 FMS patients. Intervention group I (IG I) was treated by communication-trained doctors and had access to a computer-based information tool on FMS,intervention group II (IG II) was treated by standard doctors and received the information tool, and the control group (CG) was treated by standard doctors and got no additional information. All three groups we-re offered the same evidence-based treatment options for FMS. Patients of the IGs were more willing to become involved in exercise, to enroll in integrated group therapy for FMS patients (IGTF), and to take analgesics. Patients of the CG preferred anti-depressants. More patients from IG II and CG opted for relaxation techniques. Patients in IG I and IG II choose significantly more therapeutic options than patients in the CG. SDM is one means to increase FMS patients' readiness for treatment. Especially the element of providing sufficient medical information seems to account for this effect. The readiness to enroll in physical activities, to take analgesics, and to participate in psychotherapeutic elements was most likely to be raised through SDM.

Presenting XML-based medical discharge letters according to CDA.

UNLABELLED: The HL7 Clinical Document Architecture (CDA) is an important XML-based standard for the representation of clinical documents. OBJECTIVES: The use of Markup Languages could satisfy the demands of involved healthcare staff as well as the needs of patients, to receive an overview of the patient's treatment during the hospital stay. The standardization efforts of different groups dealing with this problem have demonstrated progress, but have not, as yet, achieved a routinely usable result. In particular, differentiating information according to a hierarchical order has not been published to date. METHODS: A retrospective analysis of 60 discharge letters from a cardiology ward (ward A) as well as 60 discharge letters from a gastroenterology ward (ward B) were extracted from the central hospital information system, by taking every fifth discharge letter issued over a one year period. RESULTS: An XML-based prototype for medical discharge letters has been put in place representing the required information units and information elements. By means of an XSL-stylesheet, a detailed representation of the conventional discharge letter has been produced that is platform independent and permits the recurrent use of information units. CONCLUSIONS: Through the introduction of definitions like information elements and information units, progress in the development of CDA level two and three might be realized. We present a method by which discharge letters can be used by an Internal Medicine Department. This concept is implemented in a XML-based prototype allowing a special view on XML data to generate this document type.

Impairment of intestinal glutathione synthesis in patients with inflammatory bowel disease.

BACKGROUND: Reactive oxygen species contribute to tissue injury in inflammatory bowel disease (IBD). The tripeptide glutathione (GSH) is the most important intracellular antioxidant. AIMS: To investigate constituent amino acid plasma levels and the GSH redox status in different compartments in IBD with emphasis on intestinal GSH synthesis in Crohn's disease. METHODS: Precursor amino acid levels were analysed in plasma and intestinal mucosa. Reduced (rGSH) and oxidised glutathione (GSSG) were determined enzymatically in peripheral blood mononuclear cells (PBMC), red blood cells (RBC), muscle, and in non-inflamed and inflamed ileum mucosa. Mucosal enzyme activity of gamma-glutamylcysteine synthetase (gamma GCS) and gamma-glutamyl transferase (gamma GT) was analysed. Blood of healthy subjects and normal mucosa from a bowel segment resected for tumor growth were used as controls. RESULTS: Abnormally low plasma cysteine and cystine levels were associated with inflammation in IBD (p < 10(-4)). Decreased rGSH levels were demonstrated in non-inflamed mucosa (p < 0.01) and inflamed mucosa (p = 10(-6)) in patients with IBD, while GSSG increased with inflammation (p = 0.007) compared with controls. Enzyme activity of gamma GCS was reduced in non-inflamed mucosa (p < 0.01) and, along with gamma GT, in inflamed mucosa (p < 10(-4)). The GSH content was unchanged in PBMC, RBC, and muscle. CONCLUSIONS: Decreased activity of key enzymes involved in GSH synthesis accompanied by a decreased availability of cyst(e)ine for GSH synthesis contribute to mucosal GSH deficiency in IBD. As the impaired mucosal antioxidative capacity may further promote oxidative damage, GSH deficiency might be a target for therapeutic intervention in IBD.