Isaac Bermejo

Unipolar Depression: Diagnostic and Therapeutic Recommendations From the Current S3/National Clinical Practice Guideline

BACKGROUND Depressive disorders are among the most common illnesses and reasons for obtaining health care. Their diagnosis and treatment are still in need of improvement. In Germany, a new S3/National Clinical Practice Guideline has been developed for this purpose. METHODS The existing guidelines on unipolar depression from Germany and other countries were synoptically compared and supplemented with systematic literature searches. After 14 consensus conferences, a total of 107 evidence-based recommendations were issued. RESULTS Unipolar depression should be diagnosed in accordance with ICD-10 criteria. Screening questionnaires are useful aids to diagnostic classification. When a treatment is chosen, shared decision-making with the patient is essential. Mild depressive episodes can be treated initially by watchful waiting for 14 days. For moderate depressive episodes, pharmacotherapy and psychotherapy are equally effective treatment options. For severe depression, a combination of pharmacotherapy and psychotherapy is recommended. If 4 to 6 weeks of acute therapy are insufficiently effective, lithium augmentation is recommended, rather than combination antidepressant therapy or a switch to another antidepressant. After remission, maintenance therapy should be continued for 4 to 9 months. In recurrent depression, pharmacotherapy and/or psychotherapy, where appropriate, should be continued for at least two years. Specific recommendations are given for patients who have somatic or mental comorbidities or are acutely suicidal, and recommendations are also given for coordination of care. CONCLUSION This guideline is a comprehensive set of evidence- and consensus-based recommendations for the diagnosis and treatment of unipolar depression. An improvement in the care of patients with unipolar depression will require broad implementation of the guideline, both in the inpatient and outpatient setting.

Vergleichende Analyse psychosomatischer Beschwerden bei Personen mit spanischem, italienischem, türkischem und russischem Migrationshintergrund

BACKGROUND To ensure an adequate health care of migrants, differentiated information on the association of cultural background and migration related factors and psychosomatic complaints are necessary. METHOD Cross-sectional questionnaire based survey regarding psychosomatic complaints of migrants from Turkey (n = 77), Italy (n = 95), and Spain (n = 67) and ethnic German resettled from the states of the former Soviet Union (n = 196). Questionnaires distributed by non-health specific counselling agencies of welfare associations. RESULTS The cultural background was a relevant factor for psychosomatic complaints, showing higher complaints in Turkish and ethnic German resettled migrants, also compared to a sample of age corresponding Germans. In contrast, Spanish and Italian migrants showed a lower risk for psychosomatic complaints. Also gender, feeling unwell in Germany and fatalism showed a significant association with psychosomatic complaints. CONCLUSION Migrants in Germany do not have per se a higher risk for psychosomatic complaints. A distinct differentiation by cultural background is necessary.

Effectiveness of Telephone-Based Health Coaching for Patients with Chronic Conditions: A Randomised Controlled Trial

Background Chronic diseases, like diabetes mellitus, heart disease and cancer are leading causes of death and disability. These conditions are at least partially preventable or modifiable, e.g. by enhancing patients’ self-management. We aimed to examine the effectiveness of telephone-based health coaching (TBHC) in chronically ill patients. Methods and Findings This prospective, pragmatic randomized controlled trial compares an intervention group (IG) of participants in TBHC to a control group (CG) without TBHC. Endpoints were assessed two years after enrolment. Three different groups of insurees with 1) multiple conditions (chronic campaign), 2) heart failure (heart failure campaign), or 3) chronic mental illness conditions (mental health campaign) were targeted. The telephone coaching included evidence-based information and was based on the concepts of motivational interviewing, shared decision-making, and collaborative goal setting. Patients received an average of 12.9 calls. Primary outcome was time from enrolment until hospital readmission within a two-year follow-up period. Secondary outcomes comprised the probability of hospital readmission, number of daily defined medication doses (DDD), frequency and duration of inability to work, and mortality within two years. All outcomes were collected from routine data provided by the statutory health insurance. As informed consent was obtained after randomization, propensity score matching (PSM) was used to minimize selection bias introduced by decliners. For the analysis of hospital readmission and mortality, we calculated Kaplan-Meier curves and estimated hazard ratios (HR). Probability of hospital readmission and probability of death were analysed by calculating odds ratios (OR). Quantity of health service use and inability to work were analysed by linear random effects regression models. PSM resulted in patient samples of 5,309 (IG: 2,713; CG: 2,596) in the chronic campaign, of 660 (IG: 338; CG: 322) in the heart failure campaign, and of 239 (IG: 101; KG: 138) in the mental health campaign. In none of the three campaigns, there were significant differences between IG and CG in time until hospital readmission. In the chronic campaign, the probability of hospital readmission was higher in the IG than in the CG (OR = 1.13; p = 0.045); no significant differences could be found for the other two campaigns. In the heart failure campaign, the IG showed a significantly reduced number of hospital admissions (-0.41; p = 0.012), although the corresponding reduction in the number of hospital days was not significant. In the chronic campaign, the IG showed significantly increased number of DDDs. Most striking, there were significant differences in mortality between IG and CG in the chronic campaign (OR = 0.64; p = 0.005) as well as in the heart failure campaign (OR = 0.44; p = 0.001). Conclusions While TBHC seems to reduce hospitalization only in specific patient groups, it may reduce mortality in patients with chronic somatic conditions. Further research should examine intervention effects in various subgroups of patients, for example for different diagnostic groups within the chronic campaign, or duration of coaching. Trial Registration German Clinical Trials Register DRKS00000584

Lay theories toward cancer and myocardial infarction: a trans-cultural comparison of Germans and Spaniards.

The objective of this study was a transcultural comparison regarding illness-related causal and control attributes using a survey of healthy Germans in Germany, Spaniards in Spain and Spaniards in Germany. Each group contained 100 persons, matched according to sex, age and education. Germans showed more pronounced internal causal as well as control beliefs while Spaniards in Germany showed fatalistic attribution and Spaniards in Spain placed more emphasis on social aspects. It was possible to correctly assign over 75 percent of persons to a group depending on their characteristics in terms of causal and control attributions. Considerations of cultural and migration-related factors regarding public health appear especially promising.

Sick leave and depression - determining factors and clinical effect in outpatient care.

Sickness leave is a major source of societal costs in depression treatment. However, very little is known about the rationale behind sick leave and their effects on depressive symptoms. Aim of the paper is to evaluate the effect of sick leave on treatment outcome and the association of sick leave with patient, depression and treatment-related factors. For this we compared patients with sick leave and non-sick leave regarding symptom reduction following 6 weeks of treatment. A total of 118 patients of 41 physicians in a controlled clinical trial with a naturalistic prospective design were analysed. After 8 weeks of treatment no significant differences were found between patients who had or did not have sick leave, in terms of improvement of depressive symptoms. The analyses of physician, patient and illness-related variables regarding their predictive value showed no significant effect. No systematic effect of sick leave and no clear criteria were found that were related to receiving a sick leave certificate. It can be assumed that physicians do not only base the decision of whether to sign a depressive patient off sick on illness-specific factors. For a targeted implementation of sick leave as therapeutic measure predictors for effectiveness should be defined.

Evaluation of telephone health coaching of German health insurants with chronic conditions

Objective: This study aimed to investigate how patients with chronic conditions evaluate telephone health coaching provided by their health insurance company. Methods: A retrospective survey was conducted among coaching participants (n=834). Outcomes included the general evaluation of the coaching, the evaluation of process and effects and the impact on patient-physician communication. Results: Participants’ average age was 66.2 years and the majority were women (58.3%). The majority (78.3%) of the insured persons were satisfied with the coaching and 82.3% would recommend it to others. More than half of the participants (53.3%) had learned about new options to influence their health condition. Sub-group differences in the evaluation of the health coaching were found for age, gender and medical condition. Conclusion: Health coaching might be useful in supporting patients with chronic conditions. While the results indicate a general positive appraisal, a possibility for improvement could be a stronger focus on the individual situation and the imparting of specific skills. Target groups might be selected in a specified manner for the coaching, as older participants in need of specific care seem to benefit less from the approach. Longitudinal and controlled studies are needed to investigate clinical effects of health coaching.

Ist Patientenzufriedenheit in der stationären Depressionsbehandlung von der Qualität sprachlicher Deutschkenntnisse abhängig

OBJECTIVE To analyze patient satisfaction in inpatient depression treatment depending on German language proficiency. METHODS Documentation of patients in 24 psychiatric hospitals in Baden-Württemberg (South Germany). The following three groups were matched according to age, gender, and education: native German speakers, non-native speakers with good German proficiency, and non-native speakers with limited German proficiency (67 in each group). RESULTS The number of unsatisfied patients was four times higher in the group of non-native speakers with limited German proficiency (24 %) than in the native German speakers group (6,5 %) and more then twice as high as in the group of non-native speakers with good German proficiency (10.2 %). Patient satisfaction was lower in the group of non-native speakers with limited German proficiency independent of treatment outcome than in both other groups, whereas in both groups with good German proficiency, satisfaction was associated with treatment outcome. CONCLUSIONS Good linguistic understanding is more important for patient satisfaction in inpatient depression treatment than treatment outcome.

Auf dem Weg zu kultursensitiven Patienteninformationsmaterialien: Ergebnisse einer Fokusgruppenuntersuchung

AIM This study was part of a double-blind randomised controlled trial aimed to evaluate the effects of culture-sensitive patient information materials (PIM) compared with standard translated material. The study aimed to obtain the data for the development of culture sensitive PIM about unipolar depression for the 4 largest migrant groups in Germany (Turkish, Polish, Russian and Italian migration background). METHOD A qualitative study using 4 manual-based focus groups (FG), one for each migrant group, with 29 participants (9 with a Turkish (TüG), 8 with a Polish (PoG), 5 with a Russian (RuG) and 7 with an Italian (ItG) migration background) was conducted. The discussions were recorded, transcribed and analyzed using qualitative content analysis. RESULTS 7 categories were identified. For the (1.) development of a good culture-sensitive PIM an easy language, a clear structure, an assessable extent of information and the avoidance of stereotypes were highlighted cross-culturally in all four FG. RuG and PoG had the largest (2.) lack of information about the German health care system. Concerning the (3.) illness perception RuG named problems with recognizing and understanding depression. PoG, RuG and TüG thematized (4.) feared consequences of the illness and of professional helpseeking. ItG, PoG, RuG had fears concerning (5.) psychotropic drugs as a result from insufficient knowledge about medication. For (6.) doctor-patient relationship cultural specifics were identified in RuG and TüG and for (7.) migration or culture specific reasons for depression in RuG, ItG and TüG. CONCLUSION Although the identified categories were relevant for all or for the majority of migrant groups, for most categories specific cultural aspects were discovered. These findings show the importance of a culture sensitive adaptation of PIM.

Depression and anxiety in elderly immigrants in Germany

Background: The association between migration and mental health remains unclear. To ensure an adequate health care of migrants, differentiated information on the association between migration and mental disorders is necessary. Method: Cross-sectional study on depression and anxiety symptoms of people migrated to Germany from Turkey, Italy, and Spain as well as ethnic Germans repatriated from the states of the former Soviet Union (n=435). Depression and anxiety symptoms were measured with the Patient Health Questionnaire scales offered both in German and native language. Questionnaires were distributed by non-health-specific counselling agencies from welfare associations and migrants’ self-organisations. Results: High rates of anxiety (23.0%) as well as depression (15.8%) were found. The Turkish migrants reported the highest level of symptoms, while the Spanish migrants the lowest. Logistic regression analyses showed that retired migrants with lower school qualifications and who report lower subjective wellbeing in Germany have a higher probability of suffering from anxiety or depression. Severity of depressive symptoms varied across cultures, showing the highest likelihood of symptoms for the Turkish migrants. Conclusion: Our results suggest that migrants in Germany have a high risk of suffering from anxiety and depression. Cultural background is an independent predictor for depression but not for anxiety. Correspondence to: Isaac Bermejo, Medical Center University of Freiburg, Head of Supervision and Coaching Service for Employees Hartmannstraße 1 • 79106 Freiburg, Germany, Tel: +49 761 270-60181; Fax: +49 761 270-60182, Tel: +310 341-3143; Fax: 626-815-6000; E-mail: Isaac.bermejo@uniklinik-freiburg.de

1411 – Integrated care of depression in germany - the freiburger modell

Background Although in Germany a very well developed healthcare system for mental disorders exists, there is empirical evidence of under diagnosis and under treatment. There is also evidence that a carefully planned integrated care model of inand outpatient treatment is a promising way to achieve improvements in care. Method Within the framework of the Freiburger Model of integrated care for depressive disorders a network of psychiatrists, primary care physicians and a university medical center a coordinated treatment for patients was initiated. Complementary to an evidence-based outpatient treatment the department of Psychiatry offers a complex treatment where patients can use different inpatient measures during outpatient treatment. Patients with a chronic depression could use a specific treatment program. To analyze the effects a continuous project evaluation was conducted. Results 40 physiciansincluded 227 patients. Unipolar depressions constitute the most frequent disorders. Most depression. Most having a recurrent depressive disorder (61.0%) show a moderate depression (57.7%) and 36.3% a severe. Over two thirds (74.9%) are treated exclusively by general practitioners. According to physicians’ ratings, 57.6% of patients were remitted or showed subsyndromal symptoms in the eighth treatment week. After 16 weeks, it raised to 70.3%. According to the PHQ, 58.6% of patients were remitted or showed minimal symptoms. Conclusion As a concrete implementation of an intersectorial and interdisciplinary framework concept for an integrated care of depressive disorders the Freiburger Model offers a evidence based model to assure in- and outpatient treatment by improving collaboration care through defined interfaces and clinical pathways.