Polymorphism of the brain-derived neurotrophic factor and dynamics of the seizure threshold of electroconvulsive therapy.

During a course of electroconvulsive therapy (ECT), the level of currency necessary to induce an epileptic seizure in a patient may either remain relatively stable or-more often-may require repeated upward adjustment over time due to a constantly increasing seizure threshold. We aimed to determine whether a common polymorphism of the brain-derived neurotrophic factor (BDNF), which constitutes an important and ubiquitously expressed neurotrophine in the brain, affects the stimulation threshold of ECTs required to induce an epileptic seizure over time. Twenty-seven adult patients who underwent at least 12 consecutive ECT sessions were analyzed for the stimulation intensities required during the course of the stimulation as well as their BDNF gene status. We could not find a relation between the Val/Met polymorphism of the BDNF and the development of the seizure threshold during the course of the ECT sessions. Mechanisms and predispositions other than the BDNF polymorphism investigated in this study are responsible for the change in seizure thresholds over the course of ECT.

[Guideline-adherent inpatient psychiatric psychotherapeutic treatment of behavioral and psychological symptoms of dementia : Normative definition of personnel requirements]. / Leitliniengerechte stationäre psychiatrisch-psychotherapeutische Behandlung psychischer und Verhaltenssymptome bei Demenz : Normative Personalbedarfsermittlung.

BACKGROUND: Dementia is of increasing medical and societal relevance. Hospitalization of dementia patients is mostly due to behavioral and psychological symptoms of dementia (BPSD). There is a need for sufficient qualified personnel in hospitals in order to be able to effectively treat these symptoms. OBJECTIVES: This study aims at identifying the personnel requirements for guideline-conform, evidence-based inpatient treatment concepts for patients with BPSD and to compare these with the resources defined by the German psychiatric personnel regulations (Psych-PV). Furthermore, it was the aim to identify how often patients with dementia received non-pharmacological therapy during inpatient treatment. METHODS: Based on the current scientific evidence for treatment of BPSD, a schedule for a multimodal non-pharmacological treatment was defined and based on this the corresponding personnel requirements were calculated. Using the treatment indicators in psychiatry and psychosomatics (VIPP) database as a reference, it was calculated on what proportion of treatment days patients were classified into G1 according to the German Psych-PV and at least once received more than two treatment units per week. RESULTS: For the implementation of a guideline-oriented and evidence-based treatment plan, a higher need for personnel resources than that provided by the Psych-PV was detected in all areas. Currently patients with dementia who received at least more than two treatment units per week during inpatient hospitalization, were classified into G1 according to German Psych-PV on 17.9 % of treatment days. CONCLUSION: Despite evidence for the efficacy of non-pharmacological treatment measures on BPSD, these forms of treatment cannot be sufficiently provided under the current conditions. The realization of a new quality controlled therapeutic concept is necessary to enable optimized treatment of patients with BPSD.

[Analysis and Assessment of Modifications of the PEPP System Introduced by the PEPP Catalogue 2015]. / Analyse und Beurteilung der Veränderungen des PEPP-Systems durch den Entgeltkatalog 2015.

PURPOSE: In 2015 the remuneration system for psychiatric and psychosomatic stationary treatments will be revised. The remuneration for a case is calculated by the product of base rate, a cost weight and the number of days of treatment. The cost weight varies depending on the number of days of treatment. This paper surveys the incentives, the casemix structure and the consistency of the modified PEPP system. METHODS: Under the assumption of a profit-maximising supplier it is possible to define the economically optimal length of stay by comparing marginal revenues and marginal costs. Therefore a revenue function is derived from the new structure of the PEPP system. Since the determination of the marginal revenues is not mathematically possible, the revenues per additional day of treatment are calculated. On that basis it is possible to determine the economically optimal length of stay and to assess the consistency of the system changes. RESULTS: In an early stage of treatment the revenues per additional day of treatment are degressive. After a defined amount of days these additional revenues stay constant, which will be relevant for the majority of the cases. It is economically optimal for the hospitals to treat patients as long as possible, if the marginal costs lie or sink below these constant revenues per additional day of treatment. Furthermore the system changes result in a more complex casemix structure and the calculation of the cost weights is partially inconsistent, since the marginal revenues do not monotonically decrease. CONCLUSIONS: The modifications lead to a reduction of degressive elements in the PEPP system, which might also be accompanied by a decrease of economically induced pressure on length of stay. The inconsistent calculation of the cost weights and the more complicated casemix structure can be viewed critically.

[Admission and discharge decisions in psychiatric hospitals : The 7-day cycle: analysis based on the VIPP database]. / Aufnahme- und Entlassentscheidungen in der Psychiatrie : Der 7-Tage-Zyklus: Analyse auf Grundlage der VIPP-Datenbank.

BACKGROUND: The legislation requires all scientific societies in the field of inpatient psychiatric and psychosomatic healthcare to survey and assess the effects and financial incentives of the new flat rate day-based remuneration system in psychiatric and psychosomatic facilities (PEPP system). As day-based remuneration systems may be an incentive to extend treatment, it is necessary to measure and analyze the future development of the number of cases and the duration of treatment. OBJECTIVES: This article surveys admission and discharge decisions of psychiatric and psychosomatic facilities. The distribution of admissions and discharges throughout the days of the week were analyzed to search for evidence of a systematic extension of treatment over the weekend. MATERIAL AND METHODS: The analysis is based on data from the Versorgungsrelevante Indikatoren in der Psychiatrie und Psychosomatik (VIPP, treatment-relevant indicators in psychiatry and psychosomatics) project database, which contains routine data from psychiatric and psychosomatic facilities. On this basis the distributions of admissions and discharges throughout the days of the week were analyzed on aggregate and diagnosis-specific levels. RESULTS: Patients were mostly admitted to hospitals within the first 3 weekdays. The discharge mostly took place on Fridays and not as a financial incentive on Mondays. Regarding the patient length of stay a 7-day cycle can be observed, which may indicate the importance of medical and organizational factors in discharge decisions. CONCLUSION: The results do not show evidence for a systematic extension of treatment over the weekend. Over the next years it will be important to observe the development of the duration of treatment and the number of cases to assess the influence of the economic incentives of the PEPP system on the utilization of psychiatric and psychosomatic healthcare.

[Guideline-oriented inpatient psychiatric psychotherapeutic/psychosomatic treatment of anxiety disorders : How many personnel are need?]. / Leitliniengerechte stationäre psychiatrisch-psychotherapeutische/psychosomatische Behandlung von Angsterkrankungen : Wieviel Personal ist erforderlich?

BACKGROUND/OBJECTIVES: The reimbursement of inpatient psychiatric psychotherapeutic/psychosomatic hospital treatment in Germany is regulated by the German personnel ordinance for psychiatric hospitals (Psych-PV), which has remained unchanged since 1991. The aim of this article was to estimate the personnel requirements for guideline-adherent psychiatric psychotherapeutic hospital treatment. METHODS: A normative concept for the required psychotherapeutic "dose" for anxiety disorders was determined based on a literature review. The required staffing contingent was compared to the resources provided by the Psych-PV based on category A1. RESULTS: According to the German policy guidelines for outpatient psychotherapy, a quota of 25 sessions of 50 min each (as a rule plus 5 probatory sessions) is reimbursed. This approach is supported by studies on dose-response relationships. As patients undergoing inpatient treatment for anxiety disorders are usually more severely ill than outpatients, a contingent of 30 sessions for the average treatment duration of 5 weeks seems appropriate in order to fully exploit the costly inpatient treatment time (300 min per patient and week). In contrast, only 70 min are reimbursed according to the Psych-PV. The total personnel requirement for the normative concept is 624 min per patient and week. The Psych-PV only covers 488 min (78 %). CONCLUSION: Currently, the time contingents for evidence-based psychiatric psychotherapeutic/psychosomatic hospital care are nowhere near sufficient. In the development of future reimbursement systems this needs to be corrected.

[Introduction of performance- and day-based lump-sum remuneration for stationary psychiatric and psychosomatic treatments in Germany--analysis of incentives of the PEPP system]. / Leistungs- und tagesbezogene pauschale Vergütung in der stationären psychiatrischen und psychosomatischen Versorgung - Eine Analyse der Anreizwirkungen des PEPP-Systems.

PURPOSE: This paper surveys the effects of day-based lump-sum remuneration as defined by the PEPP system on the patients' length of stay and compares its incentives to the mechanisms of the German DRG system and the former remunera-tion system for stationary psychiatric and psychosomatic treatments. METHODS: The analysis identifies the economically optimal length of stay defined as the profit maximising duration of treatment by comparing marginal revenues and marginal costs. Since it is economically optimal to extend the treatment until the marginal costs exceed the marginal revenues, psychiatric and psychosomatic facilities are incentivised to minimise the time gap between average duration of treatment as expected duration of treatment and the economically optimal length of stay. RESULTS: Compared to the German DRG system, which provides a strong incentive to reduce length of stay, the incentives set by the PEPP system imply either a reduction or an extension of treatment duration depending on the underlying cost function. If a degressive cost function is assumed, which is typical for treatments of psychiatric and psychosomatic illnesses, the economically optimal duration of treatment will be at the last upper boundary of the interval of the marginal revenue function in which the average marginal revenues exceed the average marginal costs. It is also feasible that it is economically optimal to treat the patient for as long as possible. The hospital is incentivised to extend or reduce the time of treatment to this point in time. CONCLUSIONS: Psychiatric and psychosomatic hospitals are able to increase their profits by reducing or extending time of treatment. Therefore these facilities have to justify the extent of treatment to the health insurance companies. Since the incentives of the PEPP system and the DRG system diverge, the results of research on supply induced demand in the DRG system cannot be transferred to the discussion about the effects of the introduction of the PEPP system. As long as the average duration of treatment as expected duration of treatment deviates from the economically optimal length of stay, policy makers should consider the options of adaptations, i. e., increase of time intervals or calculating cost weights based on variable costs combined with separate remuneration of fixed costs. The TEPP system and PEPPplus are already being discussed as adaptions or additions.

[Electroconvulsive therapy for the treatment of major depression]. / Elektrokonvulsionstherapie zur Behandlung unipolar depressiver Störungen.

BACKGROUND: Depressive disorders are common and lead to both individual suffering and high socioeconomic costs. Despite the fact that several effective therapies are available, remission is often not achieved. Electroconvulsive therapy (ECT) can be a therapeutic option in these cases. OBJECTIVES: This review outlines the current evidence for the efficacy, safety and tolerability of ECT for depressive disorders. MATERIAL AND METHODS: A selective literature search was carried out with particular consideration of meta-analyses, systematic reviews, and recommendations of national and international therapy guidelines. RESULTS: For the majority of patients ECT is an effective, safe and well-tolerated therapy for the treatment of depressive disorders. There are relatively high remission rates even in patients with pharmacoresistant depression. There is evidence for a particularly high responsiveness in specific populations. In contrast to the proven effectiveness in the acute treatment of depressive disorders, there is a relative lack of data concerning maintenance therapy. Side effects including cognitive deficits are mostly transient. Modifications in the ECT technique have an impact on effectiveness and tolerability. CONCLUSION: When administered correctly ECT is a highly effective therapy for the treatment of depressive disorders. In the light of the abundance of depressive disorders and lack of remission despite adequate pharmacological treatment, a broader availability and application of ECT would be desirable. The same is true for a more intensive research into the mechanisms of action and response predictors of ECT.

[Calculating personnel allocation at 100 % implementation of the Psychiatry Personnel Act. Can it be done on the basis of existing routine data?]. / Berechnung der Personalbemessung bei einer Umsetzung von 100 % Psych-PV. Kann diese auf der Grundlage vorliegender Routinedaten erfolgen?

From 1 January 2019, after completion of the convergence phase, the Psychiatry Personnel Act (Psych-PV) will no longer be the basis of budget negotiations of psychiatric hospitals and departments with the health insurance funds in Germany. Instead, the new compounding remuneration system for psychiatric and psychosomatic inpatient institutions (PEPP) will provide a new framework. The Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) has been given the task of elaborating a directive on the basis of the expiring Psych-PV in order to redefine standards for personnel allocation within this new framework. This task presupposes the existence of reliable data in the psychiatric hospitals and departments for categorizing patients following the Psych-PV. It presupposes further that these data allow an exact calculation of the personnel to which the clinics are entitled. This article shows that the so-called §-21 dataset from the database of the VIPP project (indicators of patient care in psychiatric and psychosomatic facilities) allows this calculation. The VIPP dataset was used as a basis to calculate the personnel requirements. Exemplary analyses illustrate that the information available regarding the Psych-PV can be transformed in minutes per day, minutes per month and full time positions. Therefore, this information would also be available to the Institute for the Hospital Remuneration System (InEK).

[Management documentation of therapeutic units on inpatient treatment for people with dementia--does it allow conclusion to be drawn them about inpatient services? An exploratory analysis]. / Leistungsdokumentation durch Therapieeinheiten bei stationär behandelten Menschen mit dementieller Erkrankung--erlauben sie Rückschlüsse auf das Leistungsgeschehen? Eine explorative Analyse.

BACKGROUND: Against the background of the continuously growing incidence rates of gerontopsychiatric disorders, their economic dimen-sions, and the effects on persons affected as well as their social environments, the present study focuses on an analysis of the services provided in acute psychiatric care settings for patients with dementia. RESULTS are based on secondary data. AIM OF THE STUDY: We aim to compare therapeutic service units of different clusters of occupational groups (physicians/psychologists, nurses/special therapists) for the ICD-10 diagnostic groups F00-F03 and G30 in the years 2010 (starting with July) and 2011. Main research question is how many patients are mappable with 'therapeutic units' (Therapieeinheiten, TE) of the operation and procedures catalogue (OPS). METHODS: The present study is based on an analysis of the §21 KHEntgG data record of 35 acute psychiatric facilities. Data collection took place within the project "Versorgungsindikatoren für die Psychiatrie und Psychosomatik (VIPP)", "Supply indicators for psychiatric and psychosomatic settings". The data record implies statewide data of specialised hospitals, university hospitals and departments of psychiatry of the Federal Republic of Germany. RESULTS: In total, 5 111 cases were included in the analysis. Nurses and special therapists carried out significantly more therapeutic units in the main diagnoses groups (F01, F03 and G30) and the care groups (regular vs. intensive) than physicians and psychologists (p<0.05). It was not possible to map all patients with the use of therapeutic units (G30 78.8%, F01 83.4%, F03 81.2%). Mapping of patients was significantly higher in the intensive care compared to regular care in both occupational clusters (p<0.05). CONCLUSIONS: We demonstrated that the "therapeutic units" of the OPS codes are now used in the routine data (§21 KHEntgG), and that they are able to portray relevant aspects of non-medication therapeutic service. The present study provides a preliminary/exploratory overview on the services provided, mapped by therapeutic units. Future research should focus on the overlap between the category "therapeutic" units and the services actually provided.

[The new payment system in psychiatry - do elderly people belong to the losers? An analysis on the basis of the VIPP1 data base]. / Das neue Entgeltsystem in der Psychiatrie - gehören ältere Patienten zu den Verlierern? Eine Analyse auf der Grundlage der VIPP-Datenbank.

The development of the lump-sum reimbursement System in psychiatry and psychosomatics (PEPP) (Klimke et al., 2014) is being negatively considered - also in gerontopsychiatry.Thus it is reasonable to make a timely analysis of the effects of PEPP on health-care structures. For this two analyses have been carried out. On the one hand the day mix index of elderly patients (> 64 years) was compared with that of younger ones (> 17 years, < 65 years). On the other hand younger and older were included in the analysis with regard to the available treatment minutes in exact daily classifications according to the PsychPV. It is seen that evaluation of the individual day was markedly higher for gerontopsychiatric patients not only in inpatient (difference > 0.1) but also in outpatient (difference > 0.07) setting. The exact daily classifications according to PsychPV, however, were markedly poorer for the elderly patients. Thus, on the basis of routine data of VIPP projects, a clear change can be seen in favour of the elderly patient under PEPP conditions as compared to financing according to PsychPV. However, concern remains that the ageing population and modernisation of therapy are not being sufficiently taken into account. The new reimbursement system merely regulates the distribution of available resources; if these resources are too low nothing will change by the PEPP-System.

[Indicators of patient care in Psychiatric and Psychosomatic Facilities (VIPP project)--a database project]. / Versorgungsindikatoren in der Psychiatrie und Psychosomatik (VIPP)--Ein Datenbank-Projekt.

INTRODUCTION: In Germany a new and unique remuneration system for psychiatric and psychosomatic stationary treatments (PEPP system) was introduced in 2013 on an optional basis. From 2015 it will be mandatory for psychiatric and psychosomatic facilities. The introduction of the PEPP system brings up different questions regarding the possible incentives of the new remuneration system and its effects on the supply of psychiatric and psychosomatic treatments. To conduct these necessary analyses a reliable database is needed. MATERIAL AND METHODS: The goal of the project "Indicators of patient care in Psychiatric and Psychosomatic Facilities" (VIPP project) is to gather a representative database which reflects the situation of day-to-day patient care performed by German psychiatric and psychosomatic facilities. The §â€Š21 data set represents the basis of this database which will be complemented by other data sources (i. e., financial statements and other economic data). A number of more than 100 ,000 cases per year has already been exceeded. These case data were provided by a wide range of psychiatric hospitals, departments and universities that participate in this project. The dataset is anonymised and by pooling the data it is not possible to identify the cases of a specific clinic. Participants receive a web-based access and have the possibility to analyse the data independently. RESULTS: Using the examples of coding accuracy and rehospitalisation rates the variety as well as the enormous potential of this database can be demonstrated. DISCUSSION: On the base of the VIPP database valid patient care indicators can be identified and cross-sectional analyses can be conducted. From such results key data on health economic strategies can be derived and the incentives, strengths and limitations of this constantly changing system can be identified.

[Lump sum payment system in psychiatry and psychosomatics: concomitant research - quo vadis?]. / Pauschalierendes Entgeltsystem in der Psychiatrie und Psychosomatik : Begleitforschung - quo vadis?

The new lump sum payment scheme for psychiatric and psychosomatic services is coming into force in 2013. This constitutes another step on the way to performance-based financial compensation of inpatient and day hospital treatment in psychiatric and psychosomatic hospitals in Germany. This fundamental change needs to be accompanied by scientific evaluation with regards to its effects. This article reflects on the legal foundations of such evaluations and the current progress of preparation. Furthermore, own approaches for analysing the effects of the new finance scheme are presented.

Combination therapy in the treatment of schizophrenia.

BACKGROUND: Although the international guidelines for the treatment of schizophrenia recommend antipsychotic monotherapy as the treatment of choice, many schizophrenia patients receive two or more antipsychotics in clinical practice, while co-treatment with antidepressants, mood stabilizers and benzodiazepines is also common. AIM: The aim of the present review is to summarize the results of the randomized controlled trials of combination therapy versus monotherapy in schizophrenia and to discuss possible implications of these results. DISCUSSION: Altogether, recommendations are based upon theoretical assumptions rather than upon evidence-based knowledge regarding the combination of different antipsychotics or antipsychotics with other psychotropic agents in schizophrenia treatment, since the available studies reveal conflicting results. The augmentation with antidepressants for the treatment of persisting negative symptoms and with mood stabilizers in patients with additional affective symptoms seems to be a successful strategy. CONCLUSIONS: Further randomized controlled trials are warranted to provide substantial evidence and to suggest combination strategies for treatment-resistant schizophrenia.

[Not Available]. / Wie lange muss mindestens behandelt werden?

Anxiety disorders show a tendency to become chronic. Behavioral treatment and pharmacotherapeutic measures must frequently be applied over a lengthy period of time. The most suitable drugs for long-term treatment are the selective serotonin reuptake inhibitors (SSRI) and the serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine. With regard to side effects, the specific characteristics of the anti-anxiety drugs used for long-term therapy must be taken into account.

[Anxiety disorders: long-term treatment and replapse prevention]. / Wie lange muss mindestens behandelt werden?

Anxiety disorders show a tendency to become chronic. Behavioral treatment and pharmacotherapeutic measures must frequently be applied over a lengthy period of time. The most suitable drugs for long-term treatment are the selective serotonin reuptake inhibitors (SSRI) and the serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine. With regard to side effects, the specific characteristics of the anti-anxiety drugs used for long-term therapy must be taken into account.