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The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.
We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.
We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.
Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.
In this naturalistic observational study carried out in an inpatient treatment setting we as yet surveyed the parameters of the metabolic syndrome. A weekly monitoring procedure was implemented. The analysis included data of 350 patients over a time of 12 weeks. The last observation carried forward method was applied. Additionally we are evaluating the informative value of visceral body fat percentage as measured by a body composition analyzer. The patients showed a weight increase over the first 12 weeks (mean increase: 0.87 kg, p < .001) as well as an increase of the body mass index (mean increase: 0.45 kg/m2, p < .001). Accordingly, waist circumference (mean increase: 1.06 cm, p = .007) and visceral fat index (mean increase: 0.19, p = .007) increased. No worsening of fasting glucose and blood lipid concentrations was detected. Spearmens coefficient indicated correlations between visceral fat index and body mass index (ρ = .77; p < .001), waist circumference (ρ = .70; p < .001), and triglyceride concentrations (ρ = .39; p < .001). Correlations between visceral fat index and fasting glucose (ρ = .18; p = .019), and visceral fat index and total cholesterol (ρ = .16; p = .049) were weak but also significant. In contrast, the HDL cholesterol showed a negative relation with ρ < -.39 at each point in time (p < .001).
We conclude that psychiatric patients are at increased risk for the development of metabolic alterations during inpatient treatment. The possible underlying mechanisms of this interaction are discussed.
In the revision of the International Classification of Mental Disorders (currently 10th revision, hence ICD-10), an international scientific partnership network group was founded by the World Health Organisation (Chair: N. Sartorius, Geneva) in order to review the international scientific evidence of putative significance for the revision of ICD-10 in different language areas. The group of German-speaking countries was founded during the annual congress of the German Society of Psychiatry, Psychotherapy and Nervous Diseases in 2007. The core group consists of representatives from Austria, Germany, Switzerland and representatives of other German-speaking countries.
A major task of the German-speaking group was to design and test an international survey questionnaire addressing the perceived need for changes to the classification criteria in ICD-10 for mental disorders, the scientific rationale for such proposals, and a general assessment of the foodnes of fit with which the current classification criteria represent the respective mental disorders. The survey was started in August 2008 and results will be presented in this symposium.
The results of and experiences with this questionnaire are expected to influence the questionnaires to be distributed in other language areas, allowing for regional or national differences to be reflected, but also allowing a comparison with previous editions used when ICD-10 was developed. Taken together, the questionnaire is expected to yield insights into the perceived need to adjust ICD-11 to comply with new scientific evidence, but also with practical clinical experiences with its predecessors.
We performed an Internet-based questionnaire survey of the opinions of German-speaking psychiatrists regarding the experiences with the 10th revision of the international classification of mental disorders (chapter F of ICD-10). We received 304 completed questionnaires including more than 500 free-text comments. The responding group was characterized by professionally experienced middle-aged psychiatrists. German-speaking psychiatrists were comparatively content with ICD-10. Most diagnostic categories received a “satisfied” or “very satisfied” rating by the majority of respondents. Negative “goodness of fit” ratings – a possible indicator of the need for revision – were not higher than 50% for any category. Based on free-text entries, neurasthenia was the single diagnostic category most often suggested for deletion in ICD-11. Changes were considered necessary mainly for dementias and personality disorders. Adult attention deficit disorder and narcissistic personality disorder were the two diagnostic categories most frequently suggested to be added as new categories. This study provides valuable information related to perceived clinical utility of the classification, though with a narrow sample. Information about clinicians’ experiences should be combined with scientific evidence for the revision process of ICD-11.
To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.
We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).
Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).
There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.
Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.
Psychotic and psychotic-like experiences (PLEs) are frequently found in the general population when assessed with self-report questionnaires. It is not clear how these assessments can help to predict the future development of mental disorders. The degree of certainty in appraisal or the experience-related distress may add prognostic power of clinical PLE assessments. This study was designed to provide baseline data of PLEs in a representative sample, which will be monitored for the future development.
We studied the frequency of PLEs in a representative sample of 4483 participants of the German population recruited through the Mental Health Module of the German Health Interview and Examination Survey for Adults (DEGS1-MH). Participants were asked if they had had psychotic or psychosis-like experiences over their lifetime. We used the psychosis section of the Composite International Diagnostic Interview (CIDI), the Launay-Slade Hallucination Scale (LSHS) and the Peter's Delusion Inventory (PDI).
33.3% of the participants endorsed at least one item of the CIDI psychosis scale, 68.8% of the PDI and 49.0% of the LSHS. In the PDI assessments, conspiracy-related delusional experiences were most often experienced as distressing, while religious beliefs were experienced less distressing, but with high levels of conviction.
Our findings show frequent endorsement of lifetime psychotic or psychotic-like experiences in the general population in self-report questionnaires with varying degrees of distress and conviction. This provides the needed baseline assessment for follow-up studies observing the development of mental disorders with a view to determine the predictive values of these tests.
One of the priorities in the German mental healthcare system pertains to the development and implementation of evidence-based quality assurance initiatives with the goal to measure quality and optimize the structures, processes and outcomes of mental healthcare services.
To optimize the quality of mental healthcare by developing quality assurance tools including clinical practice guidelines and quality indicators.
To describe quality assurance initiatives in German mental healthcare.
Review of quality assurance initiatives and their current status.
In national and regional initiatives, evidence- and consensus-based clinical practice guidelines and quality indicators are being developed. As examples, the cross-sectoral quality indicators of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and the update process of the German clinical practice and disease management guideline on schizophrenia will be described. A discussion of the critical issues in psychiatric quality indicator and guideline development and implementation will be included.
Evidence- and consensus-based approaches are crucial to the development of relevant and valid instruments for quality assurance. One of the main challenges is the implementation of clinical practice guidelines and their evaluation by means of quality indicators as well as the establishment of a common framework of standardized quality indicators that address relevant quality aspects in mental healthcare.
According toepidemiologic studies, depression is one of the most frequentmental disorders in Germany. Based on the secondary data of three statutoryhealth insurers and the German Pension Fund, the utilization of mental healthcare services of people with depression was analyzed.
The analysesdescribe the utilization of in- and outpatient mental health care services ofpeople with depression by different disciplines and utilization patterns overtime (pathways of care).
The main aim was to analyze mental healthcareutilization of people with depression in Germany in 2005–2007 in order toidentify areas of potential optimization of mental health care.
Secondary data of three statutory health insurancecompanies and of the German Pension Funds of the years 2005-2007 were used forthese analyses. The analyses are based on 1,435,133 persons with at least onediagnosis of a depression (F32/F33) in 2005-2007.
The majority (73 %) of depression diagnoses wereclassified as ‘‘unspecified’’. For both inpatients and outpatients, aconsiderable proportion of care for mental illnesses was provided by primarycare physicians/other specialists in somatic medicine. Analyses of the pathwaysof care of people with severe depression revealed low levels of collaborationbetween primary and specialized care as well as outpatient and inpatienttreatment.
Setting aside boundaries between different disciplines and sectors, theuse of secondary data can, despite its limitations, contributes to thedetection of under- and overdiagnosis, mistaken allocation, and intersectoralinterface problems.
Psychiatric comorbidity is an important aspect of neurological disorders. It affects about 30-50% of neurologic patients but is frequently underrecognized.
Our objective was to determine the prevalence and severity of the symptoms of mental disorders in neurologic in-patients.
Between May and September 2014, all neurologic in-patients of a university neurologic center were asked to complete two self report questionnaires for assessing symptoms of mental disorders, namely the Beck Depression Inventory (BDI) and the Brief Symptom Inventory (BSI), which allow to assess a range of nine different psychiatric domains. We performed a multivariate covariance analysis in order to relate the type and frequency of symptoms of mental disorders with the neurological discharge diagnosis, while age, gender, and duration of in-patient treatment served as putative covariates.
Of all responders (n = 157), 51% stated to have suffered from psychological distress within the past seven days, and 43% indicated depressive symptoms (21% mild, 17% moderate, 5% severe). The mean global severity index GSI (M = 0.64, SD = 0.52) exceeded the 1 SD range of healthy persons but was lower than that of psychiatric in-patients known from the literature. Furthermore, our subanalysis revealed different patterns of symptoms of mental disorders between neurologic patients with degenerative, vascular, demyelinating or epileptic disoders.
Psychometric measurement is useful to characterize the burden of the symptoms of mental disorders and will be used to further develop the psychiatric liaison services.
The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.
Anxiety disorders are among the most common mental disorders in Germany. Different sectors and disciplines participate in mental healthcare of these patients, but there is a lack of empirical evidence of the treatment outcomes in different settings.
The study focuses on analyzing the care pathways of patients with anxiety disorders and the effects of such pathways on critical events like sick leave, early retirement and mortality.
The analysis aims at developing recommendations for optimizing treatment with a view to minimize the rate of occurrence of critical events during the care pathway.
Secondary data of three statutory health insurance companies and of the German Pension Funds of the years 2005–2007. The analyses are based on 744,742 persons with at least one diagnosis of an anxiety disorder.
The analyses reveal a low rate of changes between primary and specialized care. There was a high number of care pathways (n = 2.608).The most common type was care by primary care physicians/somatic specialists only (60.5% of patients), followed by a treatment by a psychiatrist only (9.5%). Patients, who were only treated by general practitioners/somatic specialists, had significantly lower rates of sick leave and early retirement. This may indicate that cases with more favourable prognoses are found with this care pathway.
Analyses of care pathways using secondary data can contribute to identify potential for optimizing mental health care services and provide information about intersectoral interface problems, which should be considered in the quality management of mental healthcare.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The aim of this EPA guidance was to develop recommendations on eMental health interventions in the treatment of posttraumatic stress disorder (PTSD). A systematic literature search was performed and 40 articles were retrieved and assessed with regard to study characteristics, applied technologies, therapeutic approaches, diagnostic ascertainment, efficacy, sustainability of clinical effects, practicability and acceptance, attrition rates, safety, clinician-supported vs. non-supported interventions and active vs. waiting-list controls. The reviewed studies showed a great heterogeneity concerning study type, study samples, interventions and outcome measures. Based on these findings, five graded recommendations dealing with symptom reduction, acceptability, type of administration, clinician support, self-efficacy and coping were developed.
To advance mental health care use by developing recommendations to increase trust from the general public and patients, those who have been in contact with services, those who have never been in contact and those who care for their families in the mental health care system.
We performed a systematic literature search and the retrieved documents were evaluated by two independent reviewers. Evidence tables were generated and recommendations were developed in an expert and stakeholder consensus process.
We developed five recommendations which may increase trust in mental health care services and advance mental health care service utilization.
Trust is a mutual, complex, multidimensional and dynamic interrelationship of a multitude of factors. Its components may vary between individuals and over time. They may include, among others, age, place of residence, ethnicity, culture, experiences as a service user, and type of disorder. For mental health care services, issues of knowledge about mental health services, confidentiality, continuity of treatment, dignity, safety and avoidance of stigma and coercion are central elements to increase trust.
Evidence-based recommendations to increase mutual trust of service users and psychiatrists have been developed and may help to increase mental health care service utilization.
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