BACKGROUND: Case management by health care assistants in small primary care practices provides unclear benefit for improving depression symptoms. OBJECTIVE: To determine whether case management provided by health care assistants in small primary care practices is more effective than usual care in improving depression symptoms and process of care for patients with major depression. DESIGN: Cluster randomized, controlled trial. A central automated system generated the randomization scheme, which was stratified by urban and rural practices; allocation sequence was concealed until groups were assigned. SETTING: 74 small primary care practices in Germany from April 2005 to September 2007. PATIENTS: 626 patients age 18 to 80 years with major depression. INTERVENTION: Structured telephone interview to monitor depression symptoms and support for adherence to medication, with feedback to the family physician. MEASUREMENTS: Depression symptoms at 12 months, as measured by the Patient Health Questionnaire-9 (PHQ-9); secondary outcomes were patient assessment of chronic illness care, adherence to medication, and quality of life. RESULTS: A total of 310 patients were randomly assigned to case management and 316 to usual care. At 12 months, 249 intervention recipients and 278 control patients were assessed; 555 patients were included in a modified intention-to-treat-analysis (267 intervention recipients vs. 288 control patients). Compared with control patients, intervention recipients had lower mean PHQ-9 values in depression symptoms (-1.41 [95% CI, -2.49 to -0.33]; P = 0.014), more favorable assessments of care (3.41 vs. 3.11; P = 0.011), and increased treatment adherence (2.70 vs. 2.53; P = 0.042). Quality-of-life scores did not differ between groups. LIMITATION: Patients, health care assistants, family physicians, and researchers were not blinded to group assignment, and 12-month follow-up of patients was incomplete. CONCLUSION: Case management provided by primary care practice-based health care assistants may reduce depression symptoms and improve process of care for patients with major depression more than usual care. PRIMARY FUNDING SOURCE: German Ministry of Education and Research.

Case management for depression by health care assistants in small primary care practices: a cluster randomized trial.

Gensichen and colleagues evaluated whether telephone case management facilitated by health care assistants can reduce depression symptoms and improve the process of care for patients with major dep...

http://www.allgemeinmedizin.uni-frankfurt.de/forschung4/forn/Gensiche_etal_2009_AIM_prompt.pdf

Case Management for Depression by Health Care Assistants in Small Primary Care Practices

https://zivziv.si/wp-content/uploads/2013publicattitudestowarddepression.pdf

Public attitudes toward depression and help-seeking in four European countries baseline survey prior to the OSPI-Europe intervention

Although an “epidemic” of depression is frequently claimed, empirical evidence is inconsistent, depending on country, study design and depression assessment. Little is known about changes in depression over time in Germany, although health insurance companies report frequency increases. Here we examined time trends in depression prevalence, severity and health-related correlates in the general population. Data were obtained from the mental health module of the “German Health Interview and Examination Survey for Adults” (2009–2012, n = 3265) and the mental health supplement of the “German National Health Interview and Examination Survey 1998” (1997–1999, n = 4176), excluding respondents older than 65. 12-month major depressive disorder (MDD), severity and symptoms were assessed based on the WHO Composite International Diagnostic Interview. Health-related quality of life (SF-36), self-reported sick days or days with limitations in normal daily life activities were examined, too. Calculations were carried out population-weighted. Additional age-standardized analyses were conducted to account for demographic changes. Overall, MDD 12-month prevalence remained stable at 7.4%. Women showed a shifted age distribution with increased prevalence at younger ages, and increasing MDD severity. Time trends in health-related correlates occurred both in participants with and without MDD. Mental health disability increased over time, particularly among men with MDD, reflected by the mental component score of the SF-36 and days with activity limitation due to mental health problems. Demographic changes had a marginal impact on the time trends. In contrast to the ongoing international debate regarding increased depression rates in western countries, we found no increase in overall MDD prevalence in Germany over a long period. In conclusion, increased depression frequencies in national health insurance data and growing health care costs associated with depression are not attributable to overall prevalence changes at a population level. However, shifted age distribution and increased severity among women may reflect a rising depression risk within this specific subgroup, and changes in health-related correlates indicate a growing mental health care need for depression, particularly among men.

https://link.springer.com/content/pdf/10.1186/s12888-018-1973-7.pdf

Time trends in depression prevalence and health-related correlates: results from population-based surveys in Germany 1997–1999 vs. 2009–2012

Antipsychotic drugs (synonym: neuroleptic drugs) are a heterogeneous group of psychotropic substances that were initially used to treat psychotic disorders such as schizophrenia, states of psychomotor excitation, and sleep disorders.

In many Western industrialized countries, there has been a marked increase in the prescription of antipsychotic drugs, and so-called atypical antipsychotic drugs in particular, in recent years—not just for adults, but for children and adolescents as well (increases of up to 750% from the period 1993–1998 to the period 2005–2009) (1, 2). Part of the increase is due to the prescription of these drugs for disorders for which they are neither indicated nor recommended in the relevant guidelines, e.g., attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders (3, 4).

The prescribing of antipsychotic drugs for children and adolescents is problematic in several respects:


Only a few antipsychotic drugs have been approved for use in children and adolescents, and off-label prescriptions are common (3). Moreover, the drugs that do carry approval in Germany for use in children and adolescents are approved mainly for the treatment of schizophrenia spectrum disorders and bipolar disorders (Table 1).



Table 1

Classification of the atypical and classic antipsychotic drugs that were available during the study period and their approval status for use in children and adolescents in Germany




Data on the efficacy of antipsychotic drugs in children and adolescents are sparse (5); long-term studies of their therapeutic effects and side effects are lacking (6, 7, e1).


There is increasing evidence that atypical antipsychotic drugs, once thought to have a more favorable side-effect profile than classic antipsychotic drugs (which cause extrapyramidal motor manifestations such as early and tardive dyskinesia and akathisia), do in fact have major short- or long-term adverse effects including marked weight gain, hyperlipidemia, and extrapyramidal symptoms (8). These are more common in children and adolescents than in adults (9, 10). Atypical antipsychotic drugs were also once thought more effective than the classic ones; this, too, is questionable (11, e2).



There have been only two publications to date regarding the frequency of antipsychotic prescriptions for children and adolescents in Germany. A cross-sectional study based on data of the Gmunder ErsatzKasse (a statutory health-insurance fund) revealed that, in a population of 356 520 children and adolescents, 0.34% received a prescription for an antipsychotic drug in the year 2000 (12). An analysis of data from AOK Hesse (another statutory health-insurance fund) for the years 2000–2006 revealed, among a population of children and adolescents that rose from 56 169 to 65 866, a rise in the frequency of antipsychotic prescriptions from 0.19% to 0.28% (13). This increase was solely due to the prescription of atypical antipsychotic drugs and was most marked among 10- to 14-year-olds. No more recent data are available.

Therefore, in the present study, we examine the current state and secular trend of antipsychotic prescriptions for children and adolescents in Germany.

Antipsychotic prescription in children and adolescents: an analysis of data from a German statutory health insurance company from 2005 to 2012.

Arbeitslosigkeit und Gesundheit

This study aimed to analyse depression-related factors. The prevalence of depression has been shown in prior surveys to vary between East and West Germany. Do these differences also appear in health insurance data? The outpatient data of a large German statutory health insurance company were analysed for regional differences in (a) the prevalence of depression diagnosis, (b) prescription rates of antidepressants and (c) risk factors of being diagnosed with depression or prescribed antidepressants. Diagnosis rates of depression in outpatient care (ICD-10 diagnosis F32/33) were analysed for the first quarter of 2004, and prescription rates of antidepressants were analysed for the first half of 2004. Odds ratios were calculated for the likelihood of being diagnosed with depression and of being prescribed antidepressants whilst considering socio-demographic and regional variables. The prevalence of depression diagnosis is up to 41% lower in East Germany than the expected mean rate and 30% above the expected mean rate in Berlin. Regional distribution rates of antidepressant prescriptions largely follow the same pattern as rates for depression diagnosis, with the exception of Berlin where prescription rates are 10% below the expected mean rate. Unemployed persons in West Germany have a higher chance of being diagnosed with depression and of being prescribed antidepressants than those unemployed in East Germany. Results correspond greatly to findings of epidemiologic surveys. However, the lower rate of depression diagnosis and prescription rates in East Germany might also be due to fewer mental health professionals practising there and possible differences in reporting style of emotional symptoms. This might contribute to the differences in diagnosis and prescription prevalence but cannot be solely responsible for this phenomenon. Probable causes of the different depression prevalence rates in East and West Germany will be discussed in this analysis. More research into factors impacting on regional differences in the prevalence of depression is needed.

Prevalence of depression diagnosis and prescription of antidepressants in East and West Germany: an analysis of health insurance data

Background Depressive disease is becoming increasingly relevant in industrialised countries. For public health policy and planning it is important to know about the epidemiology of this disease as well as the extent to which this epidemiology impacts on health service provision. Method Analysis of data from a major German statutory health insurance company: Longitudinal micro-level claims data containing information about diagnoses obtained from inpatient and outpatient sources as well as information collected from prescriptions issued for antidepressants. Data was analysed with regard to the differences in drug utilisation and the risk of being diagnosed with depression according to age, sex, marital status and area of residence. Results Results correspond significantly with the findings of population surveys on depression epidemiology. They also confirm the finding of a lower prevalence of depression in East Germany compared to West Germany. However, the claims data revealed an unexpectedly high prevalence of depression diagnosis in older age groups. Conclusion Statutory health insurance data seems to be a reliable source of epidemiological information that is both easily accessible and longitudinally available, and thus provides important information that is needed for health policy and service planning.With regard to service provision it should be considered that depression in old age is a greater problem than is suggested by most epidemiological surveys.

Who is diagnosed as suffering from depression in the German statutory health care system? An analysis of health insurance data

Studies on the treatment of depression using epidemiological survey methods suggest a high level of under-treatment. Little is known about the characteristics of those people receiving treatment and indeed what kind of treatment they are likely to receive. Analysis of the data of a statutory health insurance company in Germany. In middle-aged groups, about 50% of those diagnosed as being depressed in outpatient care are prescribed antidepressants and/or psychotherapy in the course of a year. There is more pharmacologic treatment provided in rural areas and more psychotherapy in cities, suggesting that treatment is dependent upon service availability rather than evidence-based treatment decisions. Treatment rates are considerably lower in the very young and the very old and show gender bias. Young females receive less pharmacologic treatment than young males, and elderly men are, in general, treated less than women, suggesting under-treatment at least for these groups. The low treatment rates following the diagnosis of depression in the young and the old require attention, in particular with respect to gender aspect.

Who is treated, and how, for depression? An analysis of statutory health insurance data in Germany.

Ziel der Studie Pravalenzschatzungen fur Depression zeigen in Primar- vs. Sekundardaten divergente Ergebnisse. Ursachen liegen u. a. in der Betrachtung verschiedener Indikatoren zu abweichenden Zeitpunkten. In der vorliegenden Arbeit werden Depressionshaufigkeiten in Survey- und Routinedaten fur einen vergleichbaren Erhebungszeitraum und Altersbereich ermittelt. Unterschiede zwischen den Datenquellen und den Depressionsmasen werden untersucht. Methodik Drei Indikatoren werden fur das Jahr 2010 gegenubergestellt: im Bevolkerungssurvey erhobene a) selbstberichtete arztliche Diagnosen, b) Diagnosen in standardisiertem klinischen Interview sowie c) in Routinedaten einer gesetzlichen Krankenkasse administrativ erfasste Diagnosen. In Sensitivitatsanalysen werden privat versicherte Surveyteilnehmende sowie Versicherte mit Pflegebedarf aus den Routinedaten ausgeschlossen. Die Definition der administrativen Depressionsdiagnose wird variiert je nach Kodierhaufigkeit und Diagnosespezifitat. Ergebnisse Die hochste Pravalenzrate zeigt sich mit 9,8% fur administrativ erfasste Depressionen, die niedrigste mit 5,9% fur die selbstberichtete Depressionsdiagnose im Survey. Die Pravalenz der im klinischen Interview erhobenen Depression betragt 8,4%. Es zeigen sich jeweils spezifische alters- und geschlechtsabhangige Verteilungen. Bleiben unspezifische Depressionsdiagnosen (F3x.8, F3x.9) unberucksichtigt, sinkt die administrative Pravalenzrate deutlich ab. Schlussfolgerung Je nach Definition der administrativen Depressionsdiagnose reduzieren sich Pravalenzunterschiede im Vergleich zur selbstberichteten Diagnose. Differenzen zu Pravalenzen basierend auf klinischem Interview bleiben hingegen bestehen und weisen auf die Erfassung unterschiedlicher Personengruppen hin.

Thomas G. Grobe

Papers

Arbeitslosigkeit und Gesundheit

Prevalence of depression diagnosis and prescription of antidepressants in East and West Germany: an analysis of health insurance data

Who is diagnosed as suffering from depression in the German statutory health care system? An analysis of health insurance data

Who is treated, and how, for depression? An analysis of statutory health insurance data in Germany.

Prävalenzen von Depressionen bei Erwachsenen – eine vergleichende Analyse bundesweiter Survey- und Routinedaten