C. Wolff-Menzler

Increased cortical inhibition deficits in first-episode schizophrenia with comorbid cannabis abuse

Rationale/objectivesThere is a high prevalence of substance use disorder (SUD) in first-episode schizophrenia (SZ), but its contribution to the underlying SZ pathophysiology remains unclear. Several studies using transcranial magnetic stimulation (TMS) have observed abnormalities in human motor cortex (M1) excitability in SZ. Studies on cortical excitability comparing SZ patients with and without comorbid substance abuse are lacking.MethodsA total of 29 first-episode SZ patients participated in this study; 12 had a history of comorbid cannabis abuse (SZ-SUD) and 17 did not (SZ-NSUD). We applied TMS to right and left M1 areas to assess the resting motor threshold (RMT), short-interval cortical inhibition (SICI), intracortical facilitation (ICF), and the contralateral cortical silent period (CSP).ResultsIn SICI and ICF conditions, right M1 stimulation led to significantly higher motor evoked potential ratios in SZ-SUD compared to SZ-NSUD. This suggests lower cortical inhibition and increased ICF in first-episode SZ with previous cannabis abuse. There were no group differences in RMT and CSP duration. Neither were there any significant correlations between psychopathology (as indexed by Positive and Negative Syndrome Scale), disease characteristics, the extent of cannabis abuse, and TMS parameters (SICI, ICF, and CSP).ConclusionsComorbid cannabis abuse may potentiate the reduced intracortical inhibition and enhanced ICF observed in first-episode SZ patients in some previous studies. This finding suggests an increased alteration of GABAA and NMDA receptor activity in cannabis-abusing first-episode patients as compared to schizophrenia patients with no history of substance abuse. This may constitute a distinct vulnerability factor in this special population.

Pauschalierendes Entgeltsystem in der Psychiatrie und Psychosomatik

ZusammenfassungDer erste Entgeltkatalog für das pauschalierende Entgeltsystem in der Psychiatrie und Psychosomatik ist seit Anfang 2013 gültig. Dies bedeutet einen weiteren Schritt auf dem Weg zu einer leistungsbezogenen Finanzierung von stationären und teilstationären Aufenthalten in der Psychiatrie und Psychosomatik. Der damit einhergehende Systemwechsel erfordert eine Begleitforschung, die die Folgen dieser Entwicklung in den Blick nimmt. Der Artikel beleuchtet die gesetzlichen Grundlagen der Begleitforschung, den derzeitigen Umsetzungsstand sowie aktuelle Ansätze, die Auswirkungen des neuen Entgeltsystems einer eigenen kritischen Analyse zu unterziehen.SummaryThe 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.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.

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.ZusammenfassungHintergrundDepressive Störungen sind häufig und führen zu hohem individuellem Leiden sowie sozioökonomischen Kosten. Trotz verschiedener effektiver Therapieoptionen wird die Remission als Ziel der Behandlung oft nicht erreicht. Der Einsatz der Elektrokonvulsionstherapie (EKT) kann hier eine sinnvolle Option sein.Ziel der ArbeitDiese Arbeit stellt die aktuelle Evidenz zu Wirksamkeit, Sicherheit und Verträglichkeit der EKT bei depressiven Störungen dar.Material und MethodenEs wurde eine selektive Literaturrecherche unter besonderer Berücksichtigung von Metaanalysen, systematischen Reviews sowie Empfehlungen nationaler und internationaler Leitlinien durchgeführt.ErgebnisseEKT stellt ein wirksames und für die meisten Patienten sicheres und gut verträgliches Verfahren zur Therapie depressiver Störungen dar. Auch bei Pharmakotherapieresistenz finden sich noch relativ hohe Remissionsraten. Für bestimmte Populationen scheint eine besonders gute Wirksamkeit zu bestehen. Im Gegensatz zur gut belegten Wirksamkeit der Akuttherapie fehlen weitgehend belastbare Daten zur Erhaltungstherapie. Unerwünschte Wirkungen, insbesondere kognitive Störungen, sind in der Regel nur kurzfristig vorhanden. Modifikationen in der Durchführung haben Auswirkungen auf die Wirksamkeit und Verträglichkeit.DiskussionMit der EKT steht ein bei korrekter Anwendung hochwirksames Therapieverfahren zur Behandlung depressiver Störungen zur Verfügung. Angesichts der Häufigkeit depressiver Störungen und einer vielfach nicht erreichten Remission wäre eine weitere Ausweitung der Verfügbarkeit und Anwendung der EKT genauso wünschenswert wie eine intensivierte, ggf. multizentrische Forschung zu den Wirkmechanismen und Responseprädiktoren der EKT.SummaryBackgroundDepressive 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.ObjectivesThis review outlines the current evidence for the efficacy, safety and tolerability of ECT for depressive disorders.Material and methodsA selective literature search was carried out with particular consideration of meta-analyses, systematic reviews, and recommendations of national and international therapy guidelines.ResultsFor 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.ConclusionWhen 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.

Berechnung der Personalbemessung bei einer Umsetzung von 100 % Psych-PV: Kann diese auf der Grundlage vorliegender Routinedaten erfolgen?

ZusammenfassungNach Abschluss der Konvergenzphase wird am 01.01.2019 die Psychiatriepersonalverordnung (Psych-PV) nicht mehr Grundlage der Verhandlungen der psychiatrischen Fachkliniken und Abteilungen mit den Krankenkassen sein. Stattdessen wird das pauschalierende Entgeltsystem für psychiatrische und psychosomatische Einrichtungen den neuen Rahmen darstellen. Der Gemeinsame Bundesausschuss (G-BA) hat die Aufgabe erhalten, auf der Grundlage der Psych-PV eine Richtlinie zu erstellen, um die notwendige Personalbemessung zu definieren. Dies setzt voraus, dass belastbare Daten zur Einstufung von Patienten nach Psych-PV in den psychiatrischen Kliniken und Abteilungen vorhanden sind und darauf basierend eine exakte Berechnung des den Kliniken zustehenden Personals möglich sein wird.Dieser Artikel zeigt, dass dies mit Daten des sog. §-21-Datensatzes aus der Datenbank des Projektes „Versorgungsrelevante Indikatoren in der Psychiatrie und Psychosomatik“ (VIPP) möglich ist. Diese VIPP-Daten wurden als Ausgangspunkt der Berechnung des Personalbedarfs genutzt. In den exemplarischen Auswertungen wird deutlich, dass die vorliegenden Informationen zur Psych-PV sich annäherungsweise in Minuten/Tag, Minuten/Monat und Vollkraftstellen umrechnen lassen. Damit stünden diese Informationen grundsätzlich auch dem Institut für das Entgeltsystem im Krankenhaus (InEK) zur Verfügung.SummaryFrom 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).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).

Electroconvulsive therapy for the treatment of major depression

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.ZusammenfassungHintergrundDepressive Störungen sind häufig und führen zu hohem individuellem Leiden sowie sozioökonomischen Kosten. Trotz verschiedener effektiver Therapieoptionen wird die Remission als Ziel der Behandlung oft nicht erreicht. Der Einsatz der Elektrokonvulsionstherapie (EKT) kann hier eine sinnvolle Option sein.Ziel der ArbeitDiese Arbeit stellt die aktuelle Evidenz zu Wirksamkeit, Sicherheit und Verträglichkeit der EKT bei depressiven Störungen dar.Material und MethodenEs wurde eine selektive Literaturrecherche unter besonderer Berücksichtigung von Metaanalysen, systematischen Reviews sowie Empfehlungen nationaler und internationaler Leitlinien durchgeführt.ErgebnisseEKT stellt ein wirksames und für die meisten Patienten sicheres und gut verträgliches Verfahren zur Therapie depressiver Störungen dar. Auch bei Pharmakotherapieresistenz finden sich noch relativ hohe Remissionsraten. Für bestimmte Populationen scheint eine besonders gute Wirksamkeit zu bestehen. Im Gegensatz zur gut belegten Wirksamkeit der Akuttherapie fehlen weitgehend belastbare Daten zur Erhaltungstherapie. Unerwünschte Wirkungen, insbesondere kognitive Störungen, sind in der Regel nur kurzfristig vorhanden. Modifikationen in der Durchführung haben Auswirkungen auf die Wirksamkeit und Verträglichkeit.DiskussionMit der EKT steht ein bei korrekter Anwendung hochwirksames Therapieverfahren zur Behandlung depressiver Störungen zur Verfügung. Angesichts der Häufigkeit depressiver Störungen und einer vielfach nicht erreichten Remission wäre eine weitere Ausweitung der Verfügbarkeit und Anwendung der EKT genauso wünschenswert wie eine intensivierte, ggf. multizentrische Forschung zu den Wirkmechanismen und Responseprädiktoren der EKT.SummaryBackgroundDepressive 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.ObjectivesThis review outlines the current evidence for the efficacy, safety and tolerability of ECT for depressive disorders.Material and methodsA selective literature search was carried out with particular consideration of meta-analyses, systematic reviews, and recommendations of national and international therapy guidelines.ResultsFor 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.ConclusionWhen 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.

Berechnung der Personalbemessung bei einer Umsetzung von 100 % Psych-PV

ZusammenfassungNach Abschluss der Konvergenzphase wird am 01.01.2019 die Psychiatriepersonalverordnung (Psych-PV) nicht mehr Grundlage der Verhandlungen der psychiatrischen Fachkliniken und Abteilungen mit den Krankenkassen sein. Stattdessen wird das pauschalierende Entgeltsystem für psychiatrische und psychosomatische Einrichtungen den neuen Rahmen darstellen. Der Gemeinsame Bundesausschuss (G-BA) hat die Aufgabe erhalten, auf der Grundlage der Psych-PV eine Richtlinie zu erstellen, um die notwendige Personalbemessung zu definieren. Dies setzt voraus, dass belastbare Daten zur Einstufung von Patienten nach Psych-PV in den psychiatrischen Kliniken und Abteilungen vorhanden sind und darauf basierend eine exakte Berechnung des den Kliniken zustehenden Personals möglich sein wird.Dieser Artikel zeigt, dass dies mit Daten des sog. §-21-Datensatzes aus der Datenbank des Projektes „Versorgungsrelevante Indikatoren in der Psychiatrie und Psychosomatik“ (VIPP) möglich ist. Diese VIPP-Daten wurden als Ausgangspunkt der Berechnung des Personalbedarfs genutzt. In den exemplarischen Auswertungen wird deutlich, dass die vorliegenden Informationen zur Psych-PV sich annäherungsweise in Minuten/Tag, Minuten/Monat und Vollkraftstellen umrechnen lassen. Damit stünden diese Informationen grundsätzlich auch dem Institut für das Entgeltsystem im Krankenhaus (InEK) zur Verfügung.SummaryFrom 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).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).

Aufnahme- und Entlassentscheidungen in der Psychiatrie

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.

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.

Erratum zu: Leitliniengerechte stationäre psychiatrisch-psychotherapeutische/psychosomatische Behandlung von Angsterkrankungen. Wieviel Personal ist erforderlich?

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Routine Data Indicators of Treatment for Dementia and Old-Age Depression

Complications in the course of dementia are one of the leading reasons for treatment in German psychiatric hospitals. One way to assess treatment quality with a moderate effort is to analyze existing routine data. A large routine dataset exists for psychiatric hospitals in Germany. This work reports on the indicators of inpatient treatment of patients with dementia and compares them to those found with old-age depression. Among other results it was shown that no specific dementia diagnosis was defined in more than 15% of all cases, and that the readmission rate within 30 days was more than 25%. Depressed people, on the other hand, showed lower readmission rates: They got more specific diagnoses and more therapeutic contacts. In conclusion, several aspects of diagnosis and treatment demand improvement among patients with dementia.