An online program with individualized vs automated support for significant others of depressed individuals - study protocol of a randomized controlled trial.

BACKGROUND: Due to budget restrictions in mental health care, non-professional caregivers are increasingly burdened with the emotional and practical care for their depressed relatives. However, informal family caregiving is mostly a stressful role with negative consequences on the physical and mental health of the caretakers to the extent that they have an elevated risk of experiencing psychiatric disorders themselves. While psychoeducation for relatives of depressed individuals showed positive results both in terms of the caretakers' strain and the depressive symptoms of the affected person, there are major barriers to participate in presence in those programs. Digital programs might be a viable alternative. We found no empirically evaluated digital program available for informal caregivers of depressed patients. METHODS: An online program for relatives of depressed individuals has been developed including four interactive modules on 1) psychoeducation, 2) how to strengthen the relationship with the depressed person, 3) how to deal with the depressive symptoms of the patient, and 4) find the right balance between caring for the depressed person and self-care. We investigate if this self-help program is more effective when used with individualized versus automated e-mail support, and if both supported conditions are more effective than treatment-as-usual (TAU in form of written information material) in terms of the risk of mental diseases in caregivers. The primary outcome is the reduction of the caregiver's nonspecific mental distress as measured by the change of the Kessler Psychological Distress Scale score from baseline to four weeks after randomization. Caregivers (n = 500:500:250) will be randomized to one of the three conditions. DISCUSSION: Psychological support for caregivers of individuals with mental disorders such as depression should be offered as part of integrated services. There is a huge potential to develop and implement interactive online approaches to support informal caregivers of patients with depression to function in their multiple roles and to help them to remain healthy. TRIAL REGISTRATION: DRKS, DRKS00025241 . Registered 5 Mai 2021.

Accuracy of self-reports of mental health care utilization and calculated costs compared to hospital records.

Assessments of service utilization is often based on self-reports. Concerns regarding the accuracy of self-reports are raised especially in mental health care. The purpose of this study was to analyze the accuracy of self-reports and calculated costs of mental health services. In a prospective cohort study in Germany, self-reports regarding psychiatric inpatient and day-care use collected by telephone interviews based on the Client Socio-Demographic and Service Receipt Inventory (CSSRI) as well as calculated costs were compared to computerized hospital records. The sample consisted of patients with mental and behavioral disorders resulting from alcohol (ICD-10 F10, n=84), schizophrenia, schizophrenic and delusional disturbances (F2, n=122) and affective disorders (F3, n=124). Agreement was assessed using the concordance correlation coefficient (CCC), mean difference (95% confidence intervals (CI)) and the 95% limits of agreement. Predictors for disagreement were derived. Overall agreement of mean total costs was excellent (CCC=0.8432). Costs calculated based on self-reports were higher than costs calculated based on hospital records (15 EUR (95% CI -434 to 405)). Overall agreement of total costs for F2 patients was CCC=0.8651, for F3 CCC=0.7850 and for F10 CCC=0.6180. Depending on type of service, measure of service utilization and costs agreement ranged from excellent to poor and varied substantially between individuals. The number of admissions documented in hospital records was significantly associated with disagreement. Telephone interviews can be an accurate data collection method for calculating mean total costs in mental health care. In the future more standardization is needed.

Validity and responsiveness of the EQ-5D in assessing and valuing health status in patients with anxiety disorders.

BACKGROUND: The EQ-5D is a generic questionnaire which generates a health profile as well as index scores for health-related quality of life that may be used in cost-utility analysis. AIMS OF THE STUDY: To examine validity and responsiveness of the EQ-5D in patients with anxiety disorders. METHODS: 389 patients with anxiety disorders completed the EQ-5D at baseline and 6-month follow-up. Subjective measures of quality of life (WHOQOL-BREF) and psychopathology (BAI, BDI-II, BSQ, ACQ, MI) were used for comparison. Validity was analyzed by assessing associations between EQ-5D scores and related other scores. Responsiveness was analyzed by calculating effect sizes of differences in scores between baseline and follow-up for 3 groups indicating more, constant or less anxiety. Meaningful difference scores for shifting to less or more anxiety were derived by means of regression analysis. RESULTS: 88.4% of respondents reported problems in at least one of the EQ-5D dimension at baseline; the mean EQ VAS score was 63.8. The EQ-5D dimension most consistently associated with the measures used for comparison was 'anxiety/depression'. EQ VAS and EQ-5D index scores were highly correlated (|r|>0.5) with scores of the WHOQOL-BREF dimensions 'physical', 'mental' and 'overall' as well as BAI and BDI-II. The EQ-5D index tended to be the most responsive score. Standardized meaningful difference scores were not significantly different between EQ VAS, EQ-5D index and measures used for comparison. CONCLUSIONS: The EQ-5D seems to be reasonably valid and moderately responsive in patients with anxiety disorders. The EQ-5D index may be suitable for calculating QALYs in economic evaluation of health care interventions for patients with anxiety disorders. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15716049.

Cost-effectiveness of a primary care model for anxiety disorders.

BACKGROUND: Individuals with anxiety disorders often do not receive an accurate diagnosis or adequate treatment in primary care. AIMS: To analyse the cost-effectiveness of an optimised care model for people with anxiety disorders in primary care. METHOD: In a cluster randomised controlled trial, 46 primary care practices with 389 individuals positively screened with anxiety were randomised to intervention (23 practices, 201 participants) or usual care (23 practices, 188 participants). Physicians in the intervention group received training on diagnosis and treatment of anxiety disorders combined with the offer of a psychiatric consultation-liaison service for 6 months. Anxiety, depression, quality of life, service utilisation and costs were assessed at baseline, 6-month and 9-month follow-up. RESULTS: No significant differences were observed between intervention and control group on the Beck Anxiety Inventory, Beck Depression Inventory and EQ-5D during follow-up. Total costs were higher in the intervention group (euro4911 v. euro3453, P = 0.09). The probability of an incremental cost-effectiveness ratio

Utility assessment in patients with mental disorders: validity and discriminative ability of the time trade-off method.

BACKGROUND: Preference-based health-state values, also referred to as utility scores, are considered an important measure of outcome in the evaluation of healthcare. A common approach to elicit utility scores is the use of the time trade-off (TTO) method; however, the data on TTO utility scores in patients with mental disorders are scarce. OBJECTIVE: To analyse the TTO method in patients with mental disorders in terms of discriminative ability, validity and the refusal to trade life time (zero trade). METHODS: In patients with affective (n = 172), schizophrenia spectrum (n = 166) and alcohol-related (n = 160) mental disorders, TTO utilities were administered through a standardized interview. Measures of quality of life (QOL) EQ-5D, WHOQOL-BREF, subjective (SCL-90R) and objective (CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of TTO utilities. Validity was analysed by assessing the correlation of TTO utilities with all other scores. The association of a patient's QOL, sociodemographic and disease-related variables with zero trade was analysed by logistic regression. RESULTS: Of patients with affective/schizophrenic/alcohol-related mental disorders, 153/143/145 (89/86/91%), respectively, completed the TTO elicitation; 29/43/28% of the respondents were zero traders. The mean TTO utility was 0.66/0.75/0.61 and the median was 0.85/0.95/0.75. TTO utility scores discriminated well among more impaired mental health states, but discrimination was limited among less impaired health states. In patients with affective and alcohol-related mental disorders, TTO utility scores were significantly correlated (mostly moderate: 0.3 < r < 0.5) with all other scores. However, in schizophrenic patients, TTO utility scores were only a little correlated with other subjective measures and not correlated with objective measures. QOL was significantly associated with zero trade; the influence of the other variables on zero trade was negligible. CONCLUSIONS: TTO utility scores in patients with affective or alcohol-related mental disorders were reasonably valid, but discriminative ability was compromised by a ceiling effect due to zero trade. In schizophrenic patients, validity of TTO utility scores was not demonstrated.

Responsiveness of EQ-5D utility indices in alcohol-dependent patients.

INTRODUCTION: The EQ-5D provides community-based preference weights (utilities) for calculating quality adjusted life years (QALYs) in cost-utility analysis. This study aimed to analyze the responsiveness of EQ-5D-based utilities in patients with alcohol dependence. METHODS: In an observational longitudinal cohort study of alcohol-dependent patients (N=52), three different EQ-5D-based utilities (EQ-Index United Kingdom, United States, and Germany) were calculated and compared with the scores of the WHOQOL-BREF (mental domain), HoNOS (total score), and GAF at baseline and at 18 months. Patients were categorized with more/same/less problems according to their self reported consumption of alcohol (patient-based anchor) and their problem status due to alcohol consumption using a question of the HoNOS scale (clinician-based anchor). Effect sizes (ES) were used to compare longitudinal changes in scores within each group; regression analysis was used to derive difference scores in health status associated with a shift from "same" to "less" problems according to the two anchors. RESULTS: ES were rather trivial to medium for all EQ-5D indices (ranging from |0.10| to |0.59|) related to a shift from "same" to "less" problems in the two anchors. Differences in scores of the EQ-5D indices revealing a shift from "same" to "less" problems according to the two anchors were not significant. CONCLUSIONS: These results suggest that the EQ-5D indices are less responsive and require larger patient samples to detect meaningful clinical differences compared to the other used instruments. Additional research is needed to compare societal and clinical views on relevant change in health status in this patient group.

The responsiveness of EQ-5D utility scores in patients with depression: A comparison with instruments measuring quality of life, psychopathology and social functioning.

INTRODUCTION: The EQ-5D provides preference weights (utilities) for health-related quality of life to be used for calculating quality-adjusted life years (QALYs) in cost-utility analysis. The aim of this study was to compare differences in EQ-5D utility scores with differences in quality of life, psychopathology, and social functioning scores. METHODS: In an observational longitudinal cohort study, EQ-5D utilities (EQ visual analogue scale (EQ VAS), EQ-5D indices of the United Kingdom (EQ-5D index-UK) and Germany (EQ-5D index-D)) were compared with scores of the WHOQOL-BREF, CGI, and GAF at baseline and at 18 months (N=104). The patients' health status at follow-up was categorized as "worse", "stable", or "better" using the EQ-5D transition question (patient-based anchor) and the Bech-Rafaelsen melancholy scale (clinician-based anchor). Effect sizes (ES) were used to compare differences in scores within each group over time; regression analysis was used to derive meaningful difference scores in health status associated with a shift from "stable" to "better" health status. RESULTS: The most responsive instrument was the CGI (patient-based anchor: ES=|0.98|; clinician-based anchor: ES=|1.35|); responsiveness was large in EQ VAS (patient-based anchor: ES=|0.84|; clinician-based anchor: ES=|1.19|), but rather small to medium for EQ-5D index-UK (patient-based anchor: ES=|0.55|; clinician-based anchor: ES=|0.65|) and EQ-5D index-D (patient-based anchor: ES=|0.41|; clinician-based anchor: ES=|0.45|). Compared with the other instruments, the shift to a "better health status" was smaller if elicited by the EQ-5D indices. DISCUSSION: Both EQ-5D indices were less responsive and need larger patient samples to detect meaningful differences compared with EQ VAS and the other instruments.

[Health habits of patients with schizophrenia: a general pattern?]. / Das Gesundheitsverhalten schizophrener erkrankter Patienten: ein typisches Verhaltensmuster?

OBJECTIVE: Schizophrenia patients have in many aspects an unhealthier lifestyle than the general population. The aim of this study is to determine if disadvantageous health habits of schizophrenia patients present a general pattern that repeats itself in other regions and if psychosocial consequences of schizophrenia (singleness, unemployment) influence patients' health habits. METHODS: 95 schizophrenia outpatients from Germany and 97 from Austria were examined regarding eating-, drinking-, smoking- and physical-activity habits. Differences in health habits and the influence of psychosocial parameters were examined with regression analyses. RESULTS: Health habits of schizophrenia patients in Germany and Austria were very similar. Subjects from Austria lived unhealthier only regarding cigarette consumption and grocery choices, while they had a healthier lifestyle regarding physical activity on the weekend. Singleness had no influence on health habits, unemployment was connected with less physical activity on workdays. CONCLUSIONS: Health habits of schizophrenia patients seem to have a general pattern, but psychosocial consequences of schizophrenia explain little about the patients' health habits.

The EQ-5D in alcohol dependent patients: relationships among health-related quality of life, psychopathology and social functioning.

OBJECTIVE: The EQ-5D, a short generic health-related quality of life (HRQOL) questionnaire, can derive preference-based index scores (e.g. EQ VAS, British and German EQ-5D indices) for economic evaluation. This study examined if the EQ-5D could be a valid measure describing and valuing HRQOL in alcohol dependent individuals. METHODS: In a sample of 103 individuals diagnosed with alcohol dependence (ICD-10 F10.2), we compared the EQ-5D against a quality of life measure (WHOQoL-BREF), a utility scale (TTO), measures of psychopathology (SCL-90R, CGI-S) and measures of social functioning (GAF, GARF, SOFAS, HoNOS). RESULTS: The response rate to EQ-5D dimensions was > 98%. Twelve percent of the individuals indicated "extreme problems" in at least one dimension. Different response levels in the dimension "anxiety/depression" were associated with largest effect sizes (absolute value(d)) of differences in mean scores of the WHOQoL-BREF domain "mental" (absolute value(d) = 1.17), the SCL-90R scales "obsessive-compulsive" (absolute value(d) = 1.15), "depression" (absolute value(d) = 1.16), "anxiety" (absolute value(d) = 1.10) and "GSI" (absolute value(d) = 1.09) indicating a similarity between the underlying constructs; concerning the dimensions "self-care", "usual activities", "pain/discomfort" and "mobility" effect sizes were generally lower (0.74 < absolute value(d) < 1.07) or insignificant. The EQ-5D VAS score (mean 58.0), the British EQ-5D index (mean 0.74) and the German EQ-5D index (mean 0.85) showed moderate correlations with other scales (0.28 < r < 0.60). CONCLUSION: Seventeen out of 30 hypothesized relationships between similar constructs of the EQ-5D and measures used for comparison were confirmed, possibly favoring EQ-5D's validity. However, the EQ-5D showed a moderate ceiling effect. Further confirmatory research is needed to support the EQ-5D suitability for economic evaluation in alcohol dependent populations.

Health habits of patients with schizophrenia.

BACKGROUND: The aim of the study was to analyze the physical activity, dietary, drinking, and smoking habits of schizophrenia patients (SP). METHODS: Data from 194 schizophrenia outpatients collected using sections of the German National Health Interview and Examination Survey were compared with data from the German general population (GP). In addition to univariate data analyses, a multivariate regression analysis was performed. RESULTS: Schizophrenia patients have a supper snack more frequently, consume instant meals and calorie-reduced food more frequently, and eat healthy groceries more rarely. Though they drink less alcohol, a greater proportion currently smokes, smoking on average 4 cigarettes more per day. On workdays they spend less time with strenuous activities, and in leisure time a greater proportion is involved in no sports. Regression analysis revealed that schizophrenia by itself or in interaction with demographic variables influences physical activity as well as alcohol, nicotine, and healthy grocery consumption. Health habits were particularly disadvantageously affected by schizophrenia in connection with unemployment. CONCLUSIONS: Schizophrenia patients are an appropriate target group for public health interventions. They need information about a healthy diet and motivation to prepare their own meals, to quit smoking, and to exercise.

Validity of the EQ-5D in assessing and valuing health status in patients with schizophrenic, schizotypal or delusional disorders.

PURPOSE: The EQ-5D is a generic questionnaire generating a health profile and a single index score for health-related quality of life. This study aimed to analyse the discriminative ability and validity of the EQ-5D in patients with schizophrenic, schizotypal or delusional disorders. SUBJECTS AND METHODS: One hundred sixty-six patients with schizophrenic, schizotypal or delusional disorders (ICD-10 F2) completed the EQ-5D. Measures of quality of life (WHOQOL-BREF), utility (TTO), subjective (SCL-90R) and objective (PANSS, CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of EQ-5D scores. Validity of the EQ-5D self-classifier was analysed by assessing differences in related other scores grouped by response levels of EQ-5D items. Validity of the visual analogue scale (EQ VAS) and the EQ-5D index (UK social tariff) was analysed by assessing their correlation with all other scores. RESULTS: Seventy-nine percent of respondents reported problems in at least one of the EQ-5D dimensions (anxiety/depression 57%, usual activities 45%, pain/discomfort 44%, self-care 29%, mobility 22%). The mean EQ VAS score/EQ-5D index was 65.7/0.71. The four most frequently reported EQ-5D health states covered 45% of all respondents. For almost all EQ-5D dimensions, different response levels were associated with significantly different scores of measures used for comparison. Correlation of EQ VAS score and EQ-5D index were largest with scores of subjective measures (SCL-90R: -0.50 and -0.73; WHOQOL mental subscore 0.62 and 0.58; always P<0.001). DISCUSSION AND CONCLUSION: The EQ-5D showed a moderate ceiling effect and seems to be reasonably valid in this patient group.

Heavy use of psychiatric inpatient care from the perspective of the patients affected.

BACKGROUND: Patients who spend an above-average amount of time in inpatient care are termed heavy users. Up to this point, very little has been known about what drives these patients to their heavy use of inpatient treatment. AIM: For this reason, the present study investigates the causes for frequent inpatient admissions of heavy users from the perspective of the patients affected. METHODS: Twenty heavy users who were identified in a quantitative preliminary study were interviewed using a qualitative analysis of the contents. RESULTS: Heavy users housed in sheltered accommodation either experienced frequent inpatient stays because of their symptomatic burden, or because of poor integration in their residences. Among the heavy users living in private residences was a subgroup that compensated for the lack of support from the private sphere with frequent hospital visits. A second subgroup turned to hospital care only during acute relapse episodes. In a third subgroup, secondary substance abuse accounted for the high demand for inpatient treatment. CONCLUSION: Findings suggest that, using community-based psychiatric support offers tailored to the needs of the heavy user subgroups, inpatient treatment could be avoided.

[Hyperkinetic disorders in children and adolescents in Germany: administrative prevalence and regional differences regarding the frequency of diagnosis assignment]. / Hyperkinetische Störungen bei Kindern und Jugendlichen in Deutschland: Administrative Prävalenz und regionale Unterschiede in der Diagnosehäufigkeit.

OBJECTIVE: To analyse the administrative prevalence and regional differences in hyperkinetic disorder (HK) diagnoses in Germany. METHODS: The administrative prevalence of HK (ICD-10 F90) was analysed for 3,6 million children, up to 18 years old and in the whole year 2009 insured by the AOK, using health insurance data. Additionally, administrative prevalence changes between 2006 and 2008 were investigated. The prevalence analyses were differenciated according to postal code areas and regions of the associations of statutory health insurance physicians (SHIP-regions). RESULTS: The analyses revealed a continous increase of the administrative HK-prevalence between 2006 (2,8 %) and 2009 (3,8 %). The administrative prevalence was notably lower in the city states Bremen, Hamburg and Berlin, but rather high in four of five SHIP-regions in the New Laender. 14 % of children with HK were diagnosed with HK and ICD-10 F98.8. In 47 % these different diagnoses had been coded by different physicians. CONCLUSIONS: Regional differences in administrative prevalence rates and discrepancies in diagnosis coding by different physicians may indicate uncertainties regarding HK-diagnosis in routine health care. Future studies should analyse these associations more detailed.

A comparison of methods to handle skew distributed cost variables in the analysis of the resource consumption in schizophrenia treatment.

BACKGROUND: Transformation of the dependent cost variable is often used to solve the problems of heteroscedasticity and skewness in linear ordinary least square regression of health service cost data. However, transformation may cause difficulties in the interpretation of regression coefficients and the retransformation of predicted values. AIMS OF THE STUDY: The study compares the advantages and disadvantages of different methods to estimate regression based cost functions using data on the annual costs of schizophrenia treatment. METHODS: Annual costs of psychiatric service use and clinical and socio-demographic characteristics of the patients were assessed for a sample of 254 patients with a diagnosis of schizophrenia (ICD-10 F 20.0) living in Leipzig. The clinical characteristics of the participants were assessed by means of the BPRS 4.0, the GAF, and the CAN for service needs. Quality of life was measured by WHOQOL-BREF. A linear OLS regression model with non-parametric standard errors, a log-transformed OLS model and a generalized linear model with a log-link and a gamma distribution were used to estimate service costs. For the estimation of robust non-parametric standard errors, the variance estimator by White and a bootstrap estimator based on 2000 replications were employed. Models were evaluated by the comparison of the R2 and the root mean squared error (RMSE). RMSE of the log-transformed OLS model was computed with three different methods of bias-correction. The 95% confidence intervals for the differences between the RMSE were computed by means of bootstrapping. A split-sample-cross-validation procedure was used to forecast the costs for the one half of the sample on the basis of a regression equation computed for the other half of the sample. RESULTS: All three methods showed significant positive influences of psychiatric symptoms and met psychiatric service needs on service costs. Only the log- transformed OLS model showed a significant negative impact of age, and only the GLM shows a significant negative influences of employment status and partnership on costs. All three models provided a R2 of about.31. The Residuals of the linear OLS model revealed significant deviances from normality and homoscedasticity. The residuals of the log-transformed model are normally distributed but still heteroscedastic. The linear OLS model provided the lowest prediction error and the best forecast of the dependent cost variable. The log-transformed model provided the lowest RMSE if the heteroscedastic bias correction was used. The RMSE of the GLM with a log link and a gamma distribution was higher than those of the linear OLS model and the log-transformed OLS model. The difference between the RMSE of the linear OLS model and that of the log-transformed OLS model without bias correction was significant at the 95% level. As result of the cross-validation procedure, the linear OLS model provided the lowest RMSE followed by the log-transformed OLS model with a heteroscedastic bias correction. The GLM showed the weakest model fit again. None of the differences between the RMSE resulting form the cross- validation procedure were found to be significant. DISCUSSION: The comparison of the fit indices of the different regression models revealed that the linear OLS model provided a better fit than the log-transformed model and the GLM, but the differences between the models RMSE were not significant. Due to the small number of cases in the study the lack of significance does not sufficiently proof that the differences between the RSME for the different models are zero and the superiority of the linear OLS model can not be generalized. The lack of significant differences among the alternative estimators may reflect a lack of sample size adequate to detect important differences among the estimators employed. Further studies with larger case number are necessary to confirm the results. IMPLICATIONS: Specification of an adequate regression models requires a careful examination of the characteristics of the data. Estimation of standard errors and confidence intervals by nonparametric methods which are robust against deviations from the normal distribution and the homoscedasticity of residuals are suitable alternatives to the transformation of the skew distributed dependent variable. Further studies with more adequate case numbers are needed to confirm the results.

[How does the Regional Psychiatry Budget (RPB) work in an area with initially low capacity of psychiatric hospital beds?]. / Wie wirkt das Regionale Psychiatriebudget (RPB) in einer Region mit initial niedriger Bettenmessziffer?

OBJECTIVE: To analyze the impact of a capitated multi-sector-financing model for psychiatric care (RPB) in the model region Rendsburg-Eckernförde on costs and effectiveness of care. METHODS: In a prospective controlled cohort study 244 patients with a diagnosis according to ICD-10: F10, F2 or F3 were interviewed in the model region (MR) and compared to 244 patients from a control region (CR) financed according to the fee-for-service principle. At baseline, 1.5 years and 3.5 years follow-up patients were interviewed using measures of psychopathology (CGI-S, HONOS, SCL-90 R/GSI, PANSS, BRMAS/BRMES), functioning (GAF, SOFAS), quality of life (EQ-5 D) and service use/costs (CSSRI). RESULTS: Subjective symptom severity (GSI) and functioning (GAF) developed more favourably in the MR than in the CR, the HONOS score developed slightly worse in the MR. The latter effect occurred mainly in ICD-10: F10 patients, while patients with F2/3 rather did benefit under RPB conditions. The development of total costs of care was not different between MR and CR. The potential to reduce costs of in-patient care was low due to the initially low capacity of inpatient beds. CONCLUSIONS: The RPB did not reduce the total costs of mental health care, but certain diagnosis groups may benefit from improved trans-sectoral treatment flexibility.

[Factors influencing the decision of future psychiatrists to practice establishment. Results from a survey of young physicians in Germany]. / Prädiktoren für die Niederlassungsabsicht angehender Psychiater. Ergebnisse einer postalischen Befragung junger Ärzte in Deutschland.

OBJECTIVE: Office based psychiatrists are playing a decisive role regarding the provision and coordination of community based, continuous mental health care. Although the estimated need for office based psychiatrists and neurologists is covered to 125 % in Germany, a physician shortage is emerging in some regions. Therefore, the present study aimed to investigate factors influencing the decision of future psychiatrists to a practice establishment. METHODS: 14,939 young physicians aged under 40 without completed specialist medical training were contacted by mail using databases of five state chambers of physicians (Lower Saxony, Westfalen-Lippe, Saxony, Saxony-Anhalt, Mecklenburg-Western Pomerania). The physicians were asked to answer questions regarding socio-demographic characteristics, the aspired medical speciality, their purpose to establish a practice, and an 18-items questionniare regarding important aspects for the latter decision. As revealed in a former study, the 18 items are related to six factors for practice establishment. The answers of 5,053 respondents were eligible for data analysis. RESULTS: 4.3 % of the examined physicians aspired a medical specialist training in psychiatry, 44 % of them plan to establish a practice. Future psychiatrists as well as other physicians valued the surrounding conditions for family as most important factor regarding a practice establishment, followed by professional duties (e. g. on-call duty) and financial conditions. The quality of life in the surrounding area had least importance. CONCLUSIONS: The results point on measures which could be suited making a practice establishment for young physicians attractive.

Development of a set of schizophrenia quality indicators for integrated care.

AIM: We aimed at developing a prioritized set of quality indicators for schizophrenia care to be used for continuous quality monitoring. They should be evidence-based and rely on routine data. METHODS: A systematic literature search was performed to identify papers on validated quality indicators published between 1990 to April 2008 in MEDLINE, the Cochrane databases, EMBASE and PsycINFO. Databases of relevant national and international organizations were searched. Indicators were described with respect to meaningfulness, feasibility and actionability. A workshop with relevant stakeholders evaluated the measures through a structured consensus process. RESULTS: We identified 78 indicators through literature search and selected 22 quality indicators. Furthermore, 12 structural and case-mix indicators were choosen. Only five quality indicators were rated "essential indicators" (priority 1), 14 were rated "additional first choice" (priority 2), and three were rated as "additional second choice" (priority 3). Only four indicators assessed outcome quality. In the majority of indicators the evidence base supporting the indicator recommendation was weak. None of the selected indicators was validated in experimental studies. CONCLUSIONS: Evidence and validation base played only a subordinate role for indicator prioritisation by stakeholders indicating that there are discrepancies between clinical questions and requirements in schizophrenia care and scientific research.

[The regional psychiatry budget (RPB): a model for a new payment system of hospital based mental health care services]. / Das Regionale Psychiatriebudget (RPB): Ein Modell für das neue pauschalierende Entgeltsystem psychiatrischer Krankenhausleistungen?

OBJECTIVE: To analyze the impact of a capitated multi-sector-financing model for psychiatric care (RPB) on costs and effectiveness of care. METHODS: Patients with a diagnosis according to ICD-10 F10, F2 or F3 were interviewed in the model region (MR, n = 258) and a control region (CR, n = 244) financed according to the fee-for-service principle. At baseline, 1.5 years and 3.5 years follow-up patients were interviewed using measures of psychopathology (CGI-S, HoNOS, SCL-90R, PANSS, BRMAS / BRMES), functioning (GAF, SOFAS) and quality of life (WHOQOL-BREF, EQ-5D). Use of care was determined semi-annually. RESULTS: There were no significant differences in the development of psychopathology and quality of life between MR and CR. In the MR, functioning of patients with schizophrenia and affective disorders improved significantly more strongly. The development of total mental health care costs was not different between MR and CR. However, the costs of office based mental health care increased slightly more strongly in the MR, indicating a small cost-shift from the RPB to extrabudgetary financed services. CONCLUSIONS: The RPB showed slight advantages regarding the effectiveness of care and did not significantly change the total mental health care costs.

[The regional psychiatry budget: costs and effects of a new multisector financing model for psychiatric care]. / Das Regionale Psychiatriebudget: Kosten und Effekte eines neuen sektorübergreifenden Finanzierungsmodells für die psychiatrische Versorgung.

OBJECTIVE: To evaluate a new multi-sector financing model for psychiatric care based on the capitation principle (Regional Psychiatry Budget, RPB). METHODS: Patients with a diagnosis according to ICD-10 F10, F2, and F3 were interviewed in the model region (MR, N=258) and a control region (CR, N=244) financed according to the fee-for-service principle. Effectiveness of care was assessed before RPB-introduction and after 1.5 years. Use of care was determined semi-annually. RESULTS: Costs of inpatient psychiatric treatment decreased more strongly in the MR, while hospital based outpatient care and day clinic treatment were intensified in comparison to the CR. Quality of life, severity of illness and illness-specific symptoms in patients improved similarly in MR and CR. The functional level improved more in the MR than in the CR, which was especially evident in schizophrenia patients. CONCLUSIONS: Inpatient psychiatric care costs can be reduced with the RPB without compromising the quality of care.

[Is quality of life in dementia patients validly estimable?]. / Kann Lebensqualität bei Demenzkranken valide bestimmt werden?

OBJECTIVE: The measurement of quality of life (QoL) in dementia is a methodological challenge because of the patients' cognitive impairment and anosognosia. This review gives an overview of the possibilities and methodological problems of QoL measurement in dementia patients. METHODS: With literature searches conducted in PubMed and Web of Science 12 dementia-specific QoL-measures were identified. RESULTS: Most authors agreed that patients with mild to moderate dementia themselves can validly and reliably estimate their QoL. But with increasing severity of the disease, patient ratings must mostly be replaced by proxy ratings. The latter are especially essential in longitudinal studies, but are not a satisfying substitute for the patients' perspective. Thus, the influence of depression and care-related burden on the proxies' QoL-ratings should be controlled. CONCLUSIONS: QoL-instruments, applicable to all stages of dementia should be preferred, because longitudinal QoL-measures are more meaningful than cross sectional analyses. The patients' perspective should be taken into consideration as long as possible, since proxies assess the QoL of dementia patients differently from the persons affected.