Ingeborg Warnke

Relationship of suicide rates to economic variables in Europe: 2000-2011

BACKGROUND It is unclear whether there is a direct link between economic crises and changes in suicide rates. AIMS The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates. METHOD Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation. RESULTS There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged. CONCLUSIONS Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

Does psychopathology at admission predict the length of inpatient stay in psychiatry? Implications for financing psychiatric services

BackgroundThe debate on appropriate financing systems in inpatient psychiatry is ongoing. In this context, it is important to control resource use in terms of length of stay (LOS), which is the most costly factor in inpatient care and the one that can be influenced most easily. Previous studies have shown that psychiatric diagnoses provide only limited justification for explaining variation in LOS, and it has been suggested that measures such as psychopathology might be more appropriate to predict resource use. Therefore, we investigated the relationship between LOS and psychopathological syndromes or symptoms at admission as well as other characteristics such as sociodemographic and clinical variables.MethodsWe considered routine medical data of patients admitted to the Psychiatric University Hospital Zurich in the years 2008 and 2009. Complete data on psychopathology at hospital admission were available in 3,220 inpatient episodes. A subsample of 2,939 inpatient episodes was considered in final statistical models, including psychopathology as well as complete datasets of further measures (e.g. sociodemographic, clinical, treatment-related and psychosocial variables). We used multivariate linear as well as logistic regression analysis with forward selection procedure to determine the predictors of LOS.ResultsAll but two syndrome scores (mania, hostility) were positively related to the length of stay. Final statistical models showed that syndromes or symptoms explained about 5% of the variation in length of stay. The inclusion of syndromes or symptoms as well as basic treatment variables and other factors led to an explained variation of up to 25%.ConclusionsPsychopathological syndromes and symptoms at admission and further characteristics only explained a small proportion of the length of inpatient stay. Thus, according to our sample, psychopathology might not be suitable as a primary indicator for estimating LOS and contingent costs. This might be considered in the development of future costing systems in psychiatry.

Supported Employment for the Reintegration of Disability Pensioners with Mental Illnesses: A Randomized Controlled Trial

Work is beneficial for the recovery from mental illness. Although the approach of individual placement and support (IPS) has been shown to be effective in Europe, it has not yet been widely implemented in European health care systems. The aim of this randomized controlled trial was to assess the effectiveness of IPS for disability pensioners with mental illnesses new on disability benefits in Switzerland. In the study at hand, 250 participants were randomly assigned to either the control or the intervention group. The participants in the intervention group received job coaching according to IPS during 2 years. The control group received no structured support. Both groups were interviewed at baseline and followed up every 6 months (baseline, 6, 12, 16, 18, 24 months) for 2 years. Primary outcome was to obtain a job in the competitive employment. IPS was more effective for the reintegration into the competitive employment market for disability pensioners than the control condition. Thirty-two percent of the participants of the intervention group and 12% of the control group obtained new jobs in the competitive employment. IPS is also effective for the reintegration into competitive employment of people with mental illness receiving disability pensions.

Model-based testing for space-time interaction using point processes: An application to psychiatric hospital admissions in an urban area

Spatio-temporal interaction is inherent to cases of infectious diseases and occurrences of earthquakes, whereas the spread of other events, such as cancer or crime, is less evident. Statistical significance tests of space-time clustering usually assess the correlation between the spatial and temporal (transformed) distances of the events. Although appealing through simplicity, these classical tests do not adjust for the underlying population nor can they account for a distance decay of interaction. We propose to use the framework of an endemic-epidemic point process model to jointly estimate a background event rate explained by seasonal and areal characteristics, as well as a superposed epidemic component representing the hypothesis of interest. We illustrate this new model-based test for space-time interaction by analysing psychiatric inpatient admissions in Zurich, Switzerland (2007-2012). Several socio-economic factors were found to be associated with the admission rate, but there was no evidence of general clustering of the cases.

[Psychopathological syndromes according to the AMDP-system as the foundation for clinical case grouping in psychiatry].

OBJECTIVE Diagnoses-related clinical case grouping for an estimation of resource consumption for psychiatric inpatients analogue to the somatic medicine till now did not lead to sufficient prediction of costs. However, this is required when regarding increasing health costs from the economic perspective. METHOD We investigated whether classical psychopathological syndromes according to the AMDP-System at admission would predict the variation of length of hospital stay. Using linear regressions with forward elimination, we analyzed the predictive value of the AMDP syndromes, and also of global assessment of functioning, illness severity and certain sociodemographic factors for the length of stay. RESULTS Together with clinical and sociodemographic factors, we found a variance estimation of 20 %. CONCLUSIONS Our pilot study does not imply AMDP syndromes to be suitable for a case grouping to estimate costs. Other analytical approaches using AMDP syndromes may lead to a better prediction, however, its use shall be regarded critically.

Hospital utilization outcome of an assertive outreach model for schizophrenic patients – results of a quasi-experimental study

We assessed whether an Assertive Outreach (AO) program for patients with schizophrenia implemented in German routine care in rural areas reduces psychiatric hospital admissions and/or psychiatric hospital days. We conducted a quasi-experimental controlled study with 5 assessments in 12 months. Data collection included health care utilization (Client Sociodemographic and Service Receipt Inventory), and clinical parameters. The assessments took place in the practices of the psychiatrists. Admission incidence rates were calculated. For bivariate group comparison, we used U-tests, T-tests and Chi(2)-Tests, multivariate analysis was conducted using zero-inflated regression models. For hospital outcomes, data of 295 patients was analysed. No statistically significant differences between AO and TAU patients in terms of hospital admissions or hospital days were found. Overall hospital utilization was low (8%). Advantages of AO over TAU referring to hospital utilization were not found. However, a spill-over effect might have reduced hospital utilization in both groups. Further research should differentiate patient subgroups. These two appear to be key factors to explain effects or absence of effects and to draw conclusions for the mental health care delivery.

Antidepressants: relationship to the time to psychiatric readmission and probability of being in hospital in depressive patients.

Introduction: Although antidepressants play a major role in the treatment of patients with depression, it is unclear which specific antidepressants are more efficacious than others. This study aims to analyze the relationship between several antidepressant substances and the time to readmission as well as the probability of being in hospital in a given week by using prescription data. Methods: The database was health-insurance claim data from the new Federal States in Germany. The analysis consisted of all patients with unipolar depression at their index admission in 2007 (N = 1803). Patients were followed up for 2 years after discharge from index hospitalization. Statistical analyses were conducted by discrete-time hazards models and general estimation equation models, accounting for various predictors. Results: Of all prescribed antidepressant substances, sertraline was related to an increased time to readmission by 37% and to a reduction in the probability of being in hospital in a given week by 40%. However, it was prescribed to only about 5% of the patients. Conclusion: In this study, only sertraline appeared to have clinical and economic advantages. It is remarkable that just a minority of patients received sertraline in our study, thus differing from the prescription pattern in the US.

Age- and gender-specific mortality risk profiles for depressive outpatients with major chronic medical diseases

BACKGROUND As leading causes of death, chronic medical diseases, particularly common cardiovascular diseases, are associated with depression. The combination of depression and chronic medical disease in turn is linked with poorer health and premature death. Despite numerous studies on mortality in people with depression and chronic medical disease, the effects of age and gender were not consistently considered. To appropriately estimate mortality in the clinical setting, we aimed to analyse age- and gender-specific mortality profiles in outpatients with depression and chronic medical disease by considering depression severity. METHODS We examined data from N=327,018 outpatients with depression aged 18 years and older (mean=60 years), which we obtained from German electronic health-insurance claims data covering the years 2007-2010. We considered major chronic medical disease groups: cardiovascular diseases, diabetes, diseases of the respiratory system and cancer. To analyse both adjusted mortality risk and rates over one year in a comprehensive manner, we calculated General Estimation Equation (GEE) Poisson models for binary data. RESULTS The mortality risk increased with age and was higher for males. Especially patients below 60 years of age with cancer or diabetes had an increased mortality risk, but not patients with cardiovascular disease. Mortality was comparably increased in patients with severe depression, diabetes or respiratory disease. LIMITATIONS We did not have data from a control group without depression. CONCLUSIONS Notably, not cardiovascular diseases but cancer and, to a lesser extent, diabetes, both in younger patients, respiratory diseases and severity of depression require particular attention in outpatient care to reduce mortality.

PW01-94 - Psychopathological syndromes according to the AMDP-system as a foundation for clinical case grouping in psychiatry?

Objective In the face of increasing health care costs, appropriate financing systems are not only required for somatic medicine but also for psychiatry. However, diagnosis-related groups (DRGs) did not lead to sufficient prediction of resource use for psychiatric inpatient care. Clinical case groupings besides groupings by diagnosis were rarely assessed so far. Method We investigated whether the classical psychopathological syndromes according to the AMDP-System (Arbeitsgemeinschaft fur Methodik und Dokumentation in der Psychiatrie) at admission would explain the variation of length of stay in psychiatric hospital. Using linear regressions with forward elimination, we analyzed the predictive value of the AMDP syndromes (n=998), and also of global assessment of function, illness severity and certain sociodemographic factors for the dependent variable length of stay (n=613). Results Considering solely the AMDP-Syndromes within the linear regression resulted in a variance estimation of 6% with an influence of the paranoid-hallucinatoric and the psychoorganic syndrome on length of stay. Together with clinical and sociodemographic factors, we found a variance estimation of 20%, then with an influence of age, global assessment of function, severity of illness, voluntariness of admission and habiting situation, but no more the syndromes. Conclusions Our pilot study does not imply AMDP syndromes to be suitable for a case grouping to estimate length of stay. Other analytical approaches using AMDP might nevertheless lead to a better prediction, however, its use, however, shall be regarded critically.

Duration of Absence from Work Is Related to Psychopathology, Personality, and Sociodemographic Variables in a Longitudinal Cohort.

Objective To examine, in a non-clinical sample, the association of psychopathology, personality, sociodemographic information, and psychosocial indicators of non-occupational functioning with the duration of absence from work in the past 12 months. Method A longitudinal community cohort of 591 adults from Switzerland was analyzed using multilevel ordered logistic regression, with several alternative models as robustness checks. Psychopathology was assessed using the total score (Global Severity Index) of the Symptom Check List-90 Revised. Results The highest psychopathology levels were associated with absences of 3 or more week duration, largely independently of age. Extraversion and being divorced, widowed or separated also corresponded with longer absences from work in some analyses. No effect of sex was found. Most effects tested were not statistically significant and estimates showed large uncertainty. Conclusion Although tentative, our results suggest a possible influence of psychopathology on work participation. It may thus be desirable in insurance-medical appraisals of work ability to include instruments for measuring psychopathology.