Effectiveness of case management as a cross-sectoral healthcare provision for women with breast cancer

OBJECTIVE

Case management (CM) programs are intended to improve care coordination for cancer patients. This quasi-experimental, controlled study evaluated whether such a program was effective in improving health-related quality of life and reducing the psychological distress of breast cancer patients.

METHODS

For the study, 126 patients with CM and 118 patients with treatment as usual (TAU) were surveyed at baseline, a 6-month follow-up and a 12-month follow-up. Comparisons of the two groups with regard to quality of life (Short Form-8, European Organization for Research and Treatment of Cancer-11; primary outcome) and psychological distress (Hospital Anxiety and Depression Scale, distress thermometer; secondary outcome) were conducted.

RESULTS

Univariate t-tests regarding the primary and secondary outcomes demonstrated improvements in the relevant outcomes at the 6-month and 12-month follow-ups for the intervention group as well as for the control group. An analysis of covariance revealed that the controls showed a higher level of physical quality of life at the 12-month follow-up than the other time points and no differences at 6 months after the baseline.

CONCLUSIONS

The tested CM model did not improve the quality of life or psychological well-being of the patients beyond treatment as usual. Possible reasons include that the treatment was already of high standards in the control group or that there are possibly different impacts than found in the literature regarding different forms of organization in CM. The need for and the tailoring of this CM model as well as the transfer of CM to other oncological indications remain to be clarified. Copyright © 2016 John Wiley & Sons, Ltd.

Symptom change trajectories during inpatient psychotherapy in routine care and their associations with long-term outcomes

This study examined symptom change trajectories during inpatient psychotherapy and the association of these changes with long-term outcomes. In an observational multicenter study, weekly measurements of symptom severity were performed during inpatient treatment and 6 months after discharge. The symptom severity was measured using the 18-item scale of the Hamburg Modules for the Assessment of Psychosocial Health. The sample included 576 inpatients (mean age: 43.9 years; 77.6% female; main diagnoses: depressive (57.2%), adjustment (15.8%), anxiety (7.4%), and eating disorders (7.2%); mean treatment duration: 42.0 days). With empirically and clinically informed growth mixture models four subgroups of symptom change were revealed: gradual response (71%), early response (9%), delayed response (5%), and nonresponse (11%). Particularly low educational level, non-employment and chronic disorders were associated with unfavorable symptom courses (non- and delayed response). Long-term outcomes differed systematically across subgroups (p<0.001; η(2)=0.165). The patients who responded early presented the highest rates of clinically significant improvement (43.9%) from admission to follow-up. Nearly all of these patients (92.7%) showed reliable improvement. Due to the high association of symptom change trajectories with long-term outcomes, results may contribute to interventions that are tailored to the needs of patients and may foster longer lasting therapeutic effectiveness.

[Collaborative and stepped care for depression: Development of a model project within the Hamburg Network for Mental Health (psychenet.de)]

BACKGROUND

Depression is one of the most widespread mental disorders in Germany and causes a great suffering and involves high costs. Guidelines recommend stepped and interdisciplinary collaborative care models for the treatment of depression.

OBJECTIVES

Stepped and collaborative care models are described regarding their efficacy and cost-effectiveness. A current model project within the Hamburg Network for Mental Health exemplifies how guideline-based stepped diagnostics and treatment incorporating innovative low-intensity interventions are implemented by a large network of health care professionals and clinics.

MATERIALS AND METHODS

An accompanying evaluation using a cluster randomized controlled design assesses depressive symptom reduction and cost-effectiveness for patients treated within "Health Network Depression" ("Gesundheitsnetz Depression", a subproject of psychenet.de) compared with patients treated in routine care.

RESULTS

Over 90 partners from inpatient and outpatient treatment have been successfully involved in recruiting over 600 patients within the stepped care model. Communication in the network was greatly facilitated by the use of an innovative online tool for the supply and reservation of treatment capacities. The participating professionals profit from the improved infrastructure and the implementation of advanced training and quality circle work.

CONCLUSIONS

New treatment models can greatly improve the treatment of depression owing to their explicit reference to guidelines, the establishment of algorithms for diagnostics and treatment, the integration of practices and clinics, in addition to the implementation of low-intensity treatment alternatives. These models could promote the development of a disease management program for depression.

[psychenet - The Hamburg Network for Mental Health: Evaluation of the Health Network Depression from the Perspective of Participating General Practitioners, Psychotherapists and Psychiatrists]

OBJECTIVE

Evaluation of satisfaction and acceptance of a stepped care model in the Health Network Depression from the perspective of general practitioners, psychotherapists and psychiatrists.

METHODS

Cross-sectional questionnaire study with n = 61 care providers.

RESULTS

All elements of the stepped care model, e. g. screening, diagnostic, and monitoring checklists, guidelines, low-intensity treatment options and IT-tools were utilized by over 75 % of partners and obtained largely positive ratings.

CONCLUSION

This positive evaluation provides a basis for further participative development and transfer into health care.

Cost-effectiveness of collaborative care for the treatment of depressive disorders in primary care: a systematic review

BACKGROUND

For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care.

PURPOSE

To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care.

METHODS

A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration's tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP).

RESULTS

In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562.

CONCLUSION

Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.

Effectiveness of case management-based aftercare coordination by phone for patients with depressive and anxiety disorders: study protocol for a randomized controlled trial

BACKGROUND

Depressive and anxiety disorders are highly prevalent, but only a small percentage (approximately 50%) of patients receive appropriate treatment. Relevant barriers include communication and coordination gaps between different providers that result from the lack of integration between different care-giving systems. Aftercare following inpatient treatment represents one of these gaps because systematic follow-up care does not exist. Case management-based aftercare coordination by phone might be a promising approach to overcoming this gap and improving long-term treatment outcomes. Case management is a patient-centered and situation-based approach comprising systematic tracking and support of patients by a case manager. The aim of this study is to evaluate the effectiveness of aftercare coordination by phone for patients with depressive and anxiety disorders.

METHODS/DESIGN

The effectiveness of aftercare coordination will be investigated in a prospective randomized controlled trial in four psychotherapeutic inpatient routine care units (St. Franziska-Stift Bad Kreuznach, MediClin Seepark Klinik Bad Bodenteich, Segeberger Kliniken Gruppe Bad Segeberg and Luisenklinik Bad Dürrheim). The patients receiving aftercare coordination (intervention group; IG) will be compared with those who receive treatment as usual (TAU control group; CG). Eligible patients will be required to have a diagnosis of an anxiety and/or depressive disorder and a recommendation for follow-up outpatient psychotherapy. The aftercare coordination consists of six phone contacts at intervals of two weeks that are performed by therapists in the inpatient units. The patients will complete questionnaires at discharge (t1), 3 months after discharge (i.e., at the end of the intervention (t2)) and 9 months after discharge (t3). The primary outcome will be change in symptom severity from t1 to t3, the secondary outcomes will be health-related quality of life and the proportion of patients who manage to begin outpatient psychotherapy by t3.

DISCUSSION

This study will determine whether case management-based aftercare coordination by phone is an adequate approach for overcoming treatment barriers in the clinical pathways of patients with depressive and anxiety disorders. If proven effective, an accessible supplementary treatment approach that will help to maintain and even improve long-term treatment outcomes will be made available for patients following inpatient treatment.

TRIAL REGISTRATION

ClinicalTrials.gov: ( NCT02044913 ).

[Health care barriers on the pathways of patients with anxiety and depressive disorders - a qualitative interview study]

OBJECTIVE

Which health care barriers do patients with anxiety and depressive disorders experience on their clinical pathways?

METHODS

Semi-structured interviews were conducted among 30 patients with anxiety and depressive disorders. Interviews were audio-taped, transcribed, coded and content-analysed.

RESULTS

Following barriers perceived by patients were extracted: a lack of early diagnosis, communication and coordination problems between different services and providers, little information about their illness and its adequate treatment, as well as intrapersonal barriers.

CONCLUSIONS

Patients perceive barriers on the individual, provider and system level. Especially barriers on the system and provider level indicate a need for more information, early recognition and support especially during the help-seeking process.

Effectiveness and cost-effectiveness of a guideline-based stepped care model for patients with depression: study protocol of a cluster-randomized controlled trial in routine care

BACKGROUND

Depression is a widespread and serious disease often accompanied by a high degree of suffering and burden of disease. The lack of integration between different care providers impedes guideline-based treatment. This constitutes substantial challenges for the health care system and also causes considerable direct and indirect costs. To face these challenges, the aim of this project is the implementation and evaluation of a guideline-based stepped care model for depressed patients with six treatment options of varying intensity and setting, including low-intensity treatments using innovative technologies.

METHODS/DESIGN

The study is a randomized controlled intervention trial of a consecutive sample of depressive patients from primary care assessed with a prospective survey at four time-standardized measurement points within one year. A cluster randomization at the level of participating primary care units divides the general practitioners into two groups. In the intervention group patients (n = 660) are treated within the stepped care approach in a multiprofessional network consisting of general practitioners, psychotherapists, psychiatrists and inpatient care facilities, whereas patients in the control condition (n = 200) receive routine care. The main research question concerns the effectiveness of the stepped-care model from baseline to t3 (12 months). Primary outcome is the change in depressive symptoms measured by the PHQ-9; secondary outcomes include response, remission and relapse, functional quality of life (SF-12 and EQ-5D-3 L), other clinical and psychosocial variables, direct and indirect costs, and the incremental cost-effectiveness ratio. Furthermore feasibility and acceptance of the overall model as well as of the separate treatment components are assessed.

DISCUSSION

This stepped care model integrates all primary and secondary health care providers involved in the treatment of depression; it elaborates innovative and evidence-based treatment elements, follows a stratified approach and is implemented in routine care as opposed to standardized conditions. In case of positive results, its sustainable implementation as a collaborative care model may significantly improve the health care situation of depressive patients as well as the interaction and care delivery of different care providers on various levels.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov, number NCT01731717 (date of registration: 24 June 2013).

[Data analysis based on the Classification of Therapeutic Procedures (CTL) of inpatient rehabilitation of depressive disorders]

OBJECTIVE

As an initiative of the German Pension Insurance Association (DRV), evidence-based therapeutic modules (ETM) for the rehabilitation of patients with depression were developed. The objective of the subsequent analysis was to analyse the therapeutic procedures in inpatient rehabilitation on the basis of the ETM to evaluate the principal needs for therapeutic standards.

METHODS

Data based on the German Classification of Therapeutic Procedures (KTL) for 21 529 patients treated in rehabilitation clinics for people with mental illnesses was analysed with respect to differences between diagnostic groups/clinics regarding type, quantity and duration of measures coded.

RESULTS

The mean quantity and duration of the interventions for patients with depressive disorders encoded varied greatly between the ETM. No or only minor differences were found between patients with depression and those with other diagnoses regarding the type, quantity and duration of measures coded. However, there were great variances between clinics.

CONCLUSIONS

Therapeutic standards for rehabilitative practice appear necessary in order to reduce treatment heterogeneity between rehabilitation facilities, which could improve the quality of healthcare.

Rationale and content of psychenet: the Hamburg Network for Mental Health

With the public-funded research and development project psychenet: the Hamburg Network for Mental Health (2011-2014), the Federal Ministry of Education and Research contributes to strengthening healthcare regions in Germany by establishing new trans-sectoral cooperations and implement and evaluate selected innovations. More than 60 partners from research, health care, health industry and government in the Free and Hanseatic City of Hamburg are promoting innovative measures to improve the treatment for mental disorders. The main objective is to implement integrated healthcare networks based on evidence for effective treatment methods, deriving from high-quality research throughout five indications such as psychosis, depression, somatoform and functional syndromes, anorexia and bulimia and addiction illnesses in adolescence. Those networks are accompanied by additional measures, for example, for improving information and education, addressing occupational health or strengthening the participation of patients and their families suffering from mental illness.

Non-pharmacological treatment of depressive disorders: a review of evidence-based treatment options

BACKGROUND

The primary goals of this paper are to describe the collection and evaluation of various nonpharmacological treatment options for depressive disorders and to establish a basis for the development of a standard for the treatment of patients with depressive disorders.

METHOD

To identify evidence-based treatment elements, a comprehensive investigation of national and international guidelines was conducted. The extracted guidelines were then assessed with regard to aspects of methodological quality and evidence-based treatment elements. In a further step, specific and systematic literature searches for residual treatment elements were conducted. For the corresponding literature search, a hierarchical approach was chosen in which current guidelines were reviewed first and systematic reviews and meta-analyses second. Psychopharmacological treatments were excluded from the analysis because this is covered by specific guidelines.

RESULTS

The treatment elements with an adequate level of evidence were identified as follows: psychotherapeutic interventions, marital/couples/family therapy and counseling, inclusion of family members, psycho-education, exercise, problem solving therapy, guided self-help and behavioral activation treatments. Further evidence-based methods include diagnostic treatment elements, participative decision-making, development of the therapeutic alliance, Cognitive Behavioral Analysis System for Psychotherapy, computerized cognitive behavior therapy, psychopharmacological therapy, combined psychopharmacological and psychotherapeutic therapy, electroconvulsive therapy, phototherapy, sleep deprivation, repetitive trans-cranial magnetic stimulation (rTMS) and acupuncture.

CONCLUSION

In summary, using a hierarchical approach, it was possible to assign different levels of evidence to the various treatment options for depression.

Self-efficacy and fear of cancer progression during the year following diagnosis of breast cancer

OBJECTIVE

The aim of this study was to investigate fear of disease progression (FoP) during the year following diagnosis of breast cancer and its association with general self-efficacy (SE).

METHODS

In a prospective study, 118 breast cancer patients were recruited shortly after diagnosis disclosure (response rate: 54%) and at 1-year follow-up (follow-up rate: 90%). Participants completed self-report measures of general self-efficacy (General Self-Efficacy Scale) and fear of progression (short form of the Fear of Progression Questionnaire).

RESULTS

Cross-sectional regression analysis revealed that high FoP is significantly associated with low SE, even when controlling for demographic and medical characteristics (total R² = 0.17). Having children and a relatively short time since diagnosis also significantly predicted higher FoP. Longitudinal analyses showed that FoP decreased significantly over time (p = 0.001; d = 0.25), but a significant decrease was only observed for patients with high initial FoP (p < 0.001; d = 0.74) and not for those with low initial FoP (p = 0.688; d = 0.08). SE was not a significant predictor of FoP at follow-up when controlling for initial FoP and other patient characteristics (incremental R² = 0.001; p = 0.674; total R² = 0.47). Overall, only initial FoP significantly predicted FoP at follow-up (p < 0.001; β = 0.671).

CONCLUSION

Findings that low SE is associated with high FoP can help to improve the treatment of dysfunctional fears in breast cancer patients. As FoP changes only slightly over time, treatment to enhance SE and reduce FoP should be initiated soon after disease disclosure.

Effectiveness of systematic treatment selection for psychodynamic and cognitive-behavioural therapy: randomised controlled trial in routine mental healthcare

BACKGROUND

Although cognitive-behavioural therapy (CBT) and psychodynamic therapy (PDT) are both effective treatments for mental disorders, they show clear dissimilarities concerning their therapeutic models and treatment rationales.

AIMS

To determine the effectiveness of systematic treatment selection (STS) to CBT or PDT in a mental healthcare setting compared with a control procedure of random treatment selection (RTS).

METHOD

A randomised controlled trial in a consecutive sample of 291 in-patients with at least one ICD-10 mental disorder was performed. The primary outcome was symptom severity (General Severity Index of the Symptom Checklist-14) at 6-month follow-up. Health-related quality of life was the secondary outcome, determined using the Short Form-8.

RESULTS

Analyses revealed no general effect for systematic treatment selection. However, there was a differential effect: systematic selection resulted in a better longer-term outcome for PDT, but not for CBT; STS-PDT patients showed a significantly larger reduction in symptom severity than RTS-PDT patients. This difference was not observed in CBT.

CONCLUSIONS

Since systematic treatment selection seems to be able to optimise treatment outcome, at least for PDT, pursuing systematic treatment assignment strategies in mental healthcare settings is a worthwhile endeavour.

Diabetes in primary care: prospective associations between depression, nonadherence and glycemic control

BACKGROUND

Findings are inconsistent regarding the degree to which depression may exert a negative impact on glycemic control in patients with type 2 diabetes. We therefore aimed to examine the longitudinal relationship between depression, behavioral factors, and glycemic control.

METHODS

In a prospective component of a nationally representative sample, 866 patients with type 2 diabetes aged >or=18 years completed a standardized assessment including a laboratory screening, questionnaires, and diagnostic measures. Subsequent to baseline (t(0)), patients were tracked over a period of 12 months (t(1)). Depression was assessed according to DSM-IV and ICD-10 criteria. Glycemic control was determined by levels of glycosylated hemoglobin (HbA(1c)); a level of >or=7% was judged as unsatisfactory. Regression analyses were performed to analyze the prospective relationship between depression, medication adherence, diabetes-related health behavior, and HbA(1c).

RESULTS

Patients with depression at t(0) revealed increased rates of medication nonadherence (adjusted OR: 2.67; CI: 1.38-5.15) at t(1). Depression (adjusted regression coefficient: beta = 0.96; p = 0.001) and subthreshold depression (beta = 1.01; p < 0.001) at t(0) also predicted increased problems with diabetes-related health behavior at t(1). Adjusted ORs for poor glycemic control (HbA(1c) >or=7%) at t(1) were also increased for patients with baseline depression (2.01; CI: 1.10-3.69). However, problems with medication adherence as well as problems with diabetes-related health behavior at t(0) did not predict poor glycemic control at t(1).

CONCLUSIONS

In a prospective representative study of patients with type 2 diabetes, baseline depression predicted problems with medication adherence, problems with health-related behaviors, and unsatisfactory glycemic control at follow-up.

[Evidence-based treatments in the rehabilitation of patients with depression--a literature review]

BACKGROUND

In recent years, the importance of guidelines has increased continuously. This development also occurs in the field of rehabilitative health care, where process guidelines are being designed for various indicational groups to ensure quality standards and improvements.

AIM

The primary goal of this paper is to collect and evaluate the evidence for various treatment options for depressive disorders in order to establish a basis for the current development of a process guideline for the rehabilitation of patients with depressive disorders.

METHOD

In order to identify evidence based treatment elements, first a comprehensive investigation of national and international guidelines was conducted. Thirteen selected guidelines were then assessed with regard to aspects of methodological quality and evidence-based treatment elements. In a further step, literature searches were conducted for residual treatment elements, which were identified on the basis of the Classification of Therapeutic Services (KTL) 2007. For the literature search, a hierarchical approach was chosen: At first, meta-analyses and systematic reviews were viewed. In case when there was still a lack of evidence for specific, potentially relevant treatment elements, the search was expanded to the level of primary studies. All selected reviews and primary studies then underwent a standardized assessment especially regarding methodological quality and evidence grades were allocated to treatments.

RESULTS

Thereby, the following treatment elements with an adequate level of evidence were identified: Psychotherapeutic interventions, marital/couples/family therapy and counselling, inclusion of family members, psycho education and exercise, problem solving therapy, guided self-help, and behavioural activation treatments. On the basis of this complementary literature search, various other evident interventions could be identified within the following areas: relaxation techniques, improvement of social competence, occupational therapy, art therapies (music, movement/dance therapies), body-oriented therapies and massage therapy.

CONCLUSION

In summary, using this hierarchical approach, it was possible to assign different levels of evidence to the various treatment elements for depression. Based on the results of this literature search, a next step in the development of a process guideline for the rehabilitative treatment of patients with depression will be the integration of experts in the field of rehabilitation.

Comparison of therapeutic action, style and content in cognitive-behavioural and psychodynamic group therapy under clinically representative conditions

It is still an open question whether psychotherapists adhere to their therapeutic conceptions in routine practice (clinician's treatment adherence) and thus to what extent the two most common approaches, cognitive-behavioural (CBT) and psychodynamic therapy (PDT), differ from each other as theoretically expected (treatment differentiation). This holds true especially in case of group therapy.The study compares essential process components of CBT and PDT group treatments under clinically representative conditions using non-participating observer ratings. Results demonstrate that CBT group therapists use more cognitive, behavioural and psychoeducational strategies, foster self-efficacy to a larger extent and are more supporting and empathetic. PDT group therapists use more interpretative and confrontative interventions and focus on interactional and dynamic aspects. The results strongly support that not only in individual psychotherapy-as shown in prior research-but also in the group setting do CBT and PDT reveal very distinct profiles and that therapists primarily abide by their theoretical training also in clinical practice. They allow one to identify differential process components of the group setting and to trace back parameters of outcome to the process of CBT and PDT for clinical routines.

[Which integrative and disorder specific treatment approaches are considered in research papers? An analysis on psychotherapeutic treatments in German journals]

In the current discussion on optimizing psychotherapeutic approaches, two important developments have to be considered: a tendency towards integrative and a tendency towards disorder specific approaches. For the years 2005 and 2006, an analysis of three German journals (covering the fields of psychosomatics, psychiatry and clinical psychology) was conducted on the question whether these two developments can be identified in current empirical and conceptual publications. Contrary to the expectations, there are only very few papers dealing with integrative approaches. As expected, there is a major emphasis on psychodynamic and cognitive behavioural approaches; other approaches are only marginally considered. A disorder specific approach can be identified not only for cognitive behavioural, but also for psychodynamic papers.

[On the theoretical and empirical differences of therapeutic interventions, contents, and styles between cognitive behavioural and psychodynamic psychotherapies]

Since cognitive behavioural (CBT) and psychodynamic (PDT) approaches treat patients with comparable disorder spectrums, yet at the same time show very different fundamental concepts, training modalities and treatment rationale, a comparison of the process and outcome of these methods becomes particularly significant. The present article offers an overview of the significance of comparative process research as well as of the theoretical and, in particular, the empirical knowledge concerning the difference between CBT and PDT at the process level (therapeutic interventions, contents and styles). Results show that CBT and PDT display pronounced differences in a broader spectrum of process variables not only on the basis of their theoretical conceptions but also referring to empirical data. While at least within the framework of experimental designs the general result of different profiles can be considered robust, statements concerning the actual treatment practice and clinical routines can only be made on a very isolated basis due to a lack of naturalistic studies. The need for research which can be derived from this, as well as further necessary developments in the field of comparative process research are discussed.