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Kruse J, Kampling H, Bouami SF, Grobe TG, Hartmann M, Jedamzik J, Marschall U, Szecsenyi J, Werner S, Wild B, Zara S, Heuft G, Friederich HC. Outpatient Psychotherapy in Germany—an Evaluation of the Structural Reform. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:315-322. [PMID: 38544323 PMCID: PMC11413774 DOI: 10.3238/arztebl.m2024.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND A structural reform of the German psychotherapy guideline in 2017 was intended to facilitate access to outpatient guideline psychotherapy. In the present study, we evaluate the effects of this reform in particular for patients with a comorbidity of mental disorders and chronic physical conditions (cMP). METHODS Pre-post analyses of the two primary endpoints "percentage of mentally ill persons who have made an initial contact with a psychotherapist" and "waiting time for guideline psychotherapy" were carried out employing population-based and weighted routine statutory health insurance data from the German BARMER. The secondary endpoints included evaluations from the patients' perspective, based on a representative survey of patients in psychotherapy, and an overview of the health care situation based on data from the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) (study registration number: DRKS00020344). RESULTS From 2015 to 2018, the percentage of mentally ill persons who had made an initial contact with a psychotherapist rose moderately, from 3.7% (95% confidence interval, [3.6; 3.7]) to 3.9% [3.8; 3.9] among persons with cMP and from 7.3% [7.2; 7.4] to 7.6% [7.5; 7.7] among those with mental disorders but without any chronic physical condition (MnoP). The new structural elements were integrated into patient care. The interval of time between the initial contact and the beginning of guideline psychotherapy became longer in both groups, from a mean of 80.6 [79.4; 81.8] to 114.8 [113.4; 116.2] days among persons with complex disease and from 80.2 [79.2; 81.3] to 109.6 [108.4; 111.0] days among persons with non-complex disease; most patients considered the waiting time. Approximately 8% of the patients who sought psychotherapy reported that they had not obtained access to a psychotherapist. CONCLUSION Neither in general nor for patients with cMP did the introduction of the structural reform appreciably lower the access barriers to psychotherapy. Further steps are needed so that outpatient care can meet the needs of all patients and particularly those with cMP.
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Affiliation(s)
- Johannes Kruse
- These two authors are co-first authors
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
- Department for Psychosomatic Medicine and Psychotherapy, Medical Center of the Philipps University Marburg, Marburg, Germany
| | - Hanna Kampling
- These two authors are co-first authors
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
| | - Soufiane Filali Bouami
- aQua – Institute for Applied Quality Improvement and Research in Health Care GmbH, Göttingen, Germany
| | - Thomas G. Grobe
- aQua – Institute for Applied Quality Improvement and Research in Health Care GmbH, Göttingen, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Johanna Jedamzik
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Münster, Münster, Germany
| | - Ursula Marschall
- Department of Medicine and Health Services Research, BARMER Institute for Health System Research, Wuppertal, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Samuel Werner
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Sandra Zara
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
| | - Gereon Heuft
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Münster, Münster, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
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Meinlschmidt G, Frick A, Baenteli I, Karpf C, Studer A, Bachmann M, Dörner A, Tschudin S, Trost S, Wyss K, Fink G, Schwenkglenks M, Caviezel S, Rocco T, Schaefert R. Prevention of psychosocial distress consequences in somatic hospital inpatients via a stepped and collaborative care model: protocol of SomPsyNet, a stepped wedge cluster randomised trial. BMJ Open 2023; 13:e076814. [PMID: 37996236 PMCID: PMC10668178 DOI: 10.1136/bmjopen-2023-076814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/16/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Approximately 30% of somatic hospital inpatients experience psychosocial distress, contributing to increased (re-)hospitalisation rates, treatment resistance, morbidity, and direct and indirect costs. However, such distress often remains unrecognised and unaddressed. We established 'SomPsyNet', a 'stepped and collaborative care model' (SCCM) for somatic hospital inpatients, aiming at alleviating this issue through early identification of distress and provision of appropriate care, providing problem-focused pathways and strengthening collaborative care. We report the protocol of the 'SomPsyNet' study, aiming to evaluate implementation and impact of the SCCM on distressed patients' health-related quality of life. Secondary objectives include assessing efficacy of the screening procedures, influence of SCCM on other health outcomes and associated costs. METHODS AND ANALYSIS Our stepped wedge cluster randomised trial conducted at three tertiary hospitals comprises three conditions: treatment as usual (TAU) without screening for distress (phase 0), TAU with screening but without consequences (phase I, main comparator) and TAU with screening and psychosomatic-psychiatric consultations for those distressed (phase II). The time-of-transition between phases I and II was randomised. Sample size target is N=2200-2500 participants, with 6 month follow-up for distressed (anticipated n=640-700) and a subsample of non-distressed (anticipated n=200) patients. Primary outcome is mental health-related quality of life (SF-36 'Mental Health Component Summary score'); secondary outcomes include psychosocial distress, anxiety, depressive and somatic symptoms, symptom burden and distress, resilience, social support and qualitative of life, assessed by internationally accepted instruments, with good psychometric properties. Further, health claims data will be used to assess SCCM's impact on direct and indirect costs. ETHICS AND DISSEMINATION SomPsyNet adheres to the Helsinki Declaration and is approved by the 'Ethikkommission Nordwest- und Zentralschweiz' (2019-01724). Findings will be published in peer-reviewed journals and communicated to participants, healthcare professionals and the public. TRIAL REGISTRATION NUMBER Swiss National Clinical Trials Portal; ClinicalTrials.gov (NCT04269005, updated 19.09.2023).
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Affiliation(s)
- Gunther Meinlschmidt
- Department of Digital and Blended Psychosomatics and Psychotherapy, Psychosomatic Medicine, University of Basel, Basel, Switzerland
- Clinical Psychology and Psychotherapy (focus CBT), International Psychoanalytic University Berlin gGmbH, Berlin, Germany
- Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Psychosomatic Medicine, University of Basel, Basel, Switzerland
| | - Alexander Frick
- Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Iris Baenteli
- Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Psychosomatic Medicine, University of Basel, Basel, Switzerland
| | - Christina Karpf
- Division of Prevention, Department of Health Canton Basel-Stadt, Basel, Switzerland
| | - Anja Studer
- Division of Prevention, Department of Health Canton Basel-Stadt, Basel, Switzerland
| | - Marco Bachmann
- Department of Psychosomatic Medicine and Psychotherapy, Klinik Barmelweid AG, Barmelweid, Switzerland
| | | | - Sibil Tschudin
- Department of Obstetrics and Gynecology, University Hospital Basel, Basel, Switzerland
- Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland
| | - Sarah Trost
- Department of Geriatric Medicine, Universitäre Altersmedizin FELIX PLATTER, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Matthias Schwenkglenks
- Health Economics Facility, Department of Public Health, University of Basel, Basel, Switzerland
| | - Seraina Caviezel
- Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Psychosomatic Medicine, University of Basel, Basel, Switzerland
| | - Tabea Rocco
- Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Psychosomatic Medicine, University of Basel, Basel, Switzerland
| | - Rainer Schaefert
- Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Psychosomatic Medicine, University of Basel, Basel, Switzerland
- Department of Psychosomatics and Psychiatry, Bethesda Hospital Basel, Basel, Switzerland
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Kampling H, Kruse J, Friederich HC, Heuft G, Christoffer A, Grobe TG, Marschall U, Szecsenyi J, Wild B, Hartmann M. Evaluating effects of the structural reform of outpatient psychotherapy for patients with mental disorders in Germany: comparing patients with and without comorbid chronic physical condition - rationale and study protocol of the ES-RiP project. BMJ Open 2022; 12:e057298. [PMID: 36691158 PMCID: PMC9442475 DOI: 10.1136/bmjopen-2021-057298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 08/12/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION In 2017, in Germany, a structural reform of the outpatient psychotherapy guideline took place, aiming to reduce waiting times, to facilitate flexible low-threshold access (eg, general reachability by phone) and to lower access barriers for specific patient groups. The reform included new service elements, such as the implementation of additional psychotherapeutic consultations, acute short-term psychotherapeutic interventions and relapse prophylaxis as well as the promotion of group therapies, the facilitation of psychotherapists' availability, and the installation of appointment service centres. The ES-RiP project aims to thoroughly evaluate the effects of the reform with a special focus on patients with a comorbidity of mental disorders and chronic physical conditions (cMPs) compared with patients with a mental disorder but no long-term physical condition (MnoP). The project aims to evaluate (a) the extent to which the reform goals were achieved in the large group of patients with cMPs compared with MnoP, (b) the barriers that might hinder the implementation of the new guideline and (c) the procedures required for further developing and improving outpatient psychotherapy. METHODS AND ANALYSIS A mixed-methods design (quantitative, qualitative) along with a multilevel approach (patients, service providers, payers) triangulating several data sources (primary and secondary data) will be applied to evaluate the reform from different perspectives. ETHICS AND DISSEMINATION Ethical approval was obtained from the coordinating committee as well as one local ethics committee, Justus Liebig University Giessen and Marburg - Faculty of Medicine (approval number: AZ 107/20) and Heidelberg (approval number: S-466/2020). The results of this study will be disseminated through expert panels, conference presentations and publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER DRKS00020344.
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Affiliation(s)
- Hanna Kampling
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
| | - Johannes Kruse
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Gereon Heuft
- Section of Psychosomatic Medicine and Psychotherapy, Clinic for Mental Health, University Hospital Munster, Munster, Germany
| | - Andrea Christoffer
- Section of Psychosomatic Medicine and Psychotherapy, Clinic for Mental Health, University Hospital Munster, Munster, Germany
| | - Thomas G Grobe
- aQua - Institute for Applied Quality Improvement and Research in Health Care GmbH, Gottingen, Germany
| | - Ursula Marschall
- Department of Medicine and Health Services Research, BARMER Institute for Health System Research, Wuppertal, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
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Nikendei C, Greinacher A, Berkunova A, Junghanss T, Stojkovic M. Psychological burden and resilience factors in patients with Alveolar Echinococcosis - A cross-sectional study. PLoS Negl Trop Dis 2019; 13:e0007082. [PMID: 30615695 PMCID: PMC6336346 DOI: 10.1371/journal.pntd.0007082] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/17/2019] [Accepted: 12/15/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Alveolar echinococcosis (AE) is a parasitic zoonosis resembling malignancy due to its clinically silent infiltrative growth, predominately in the liver. The comorbid psychological burden and fear of disease progression in AE patients have hardly been examined to date. The aim of this study was to evaluate depression, anxiety, quality of life, and fear of disease progression in AE patients. METHODOLOGY/PRINCIPAL FINDINGS In a cross-sectional study, n = 57 AE patients were invited to report on depression (PHQ-9), anxiety (GAD-7), somatic symptom load (SSS 8), trauma symptoms (PTSS-10), quality of life (SF-12) and on fear of disease progression (FoP-Q-SF) using validated psychometric instruments. Furthermore, attachment style was assessed (RQ-2). N = 47 patients completed the questionnaires (response rate 82.5%). Depression, anxiety, and somatic symptom load were above norm sample means, while physical quality of life was below norm sample means. Existing traumatic symptoms were comparable to those in cancer patients, while fear of disease progression even exceeded cancer patient scores. Patients with a secure attachment style showed less pronounced psychological burden than patients with other attachment styles. Adequate, guideline-based depression and anxiety treatment was very rarely installed. CONCLUSION/SIGNIFICANCE The present study revealed remarkable levels of psychological burden in AE patients. In our study sample, we discovered high depression and anxiety levels, a significant reduction of physical quality of life, and fear of disease progression. These results show how important it is for AE patients to be thoroughly assessed with regard to psychological symptoms and mental disorders so that those in need can receive sufficient psychosocial support and treatment according to official guidelines.
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Affiliation(s)
- Christoph Nikendei
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Germany
| | - Anja Greinacher
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Germany
| | - Anastasiya Berkunova
- Section Clinical Tropical Medicine, Department of Infectious Diseases, University Hospital Heidelberg, Germany
| | - Thomas Junghanss
- Section Clinical Tropical Medicine, Department of Infectious Diseases, University Hospital Heidelberg, Germany
| | - Marija Stojkovic
- Section Clinical Tropical Medicine, Department of Infectious Diseases, University Hospital Heidelberg, Germany
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Tegethoff M, Stalujanis E, Belardi A, Meinlschmidt G. Chronology of Onset of Mental Disorders and Physical Diseases in Mental-Physical Comorbidity - A National Representative Survey of Adolescents. PLoS One 2016; 11:e0165196. [PMID: 27768751 PMCID: PMC5074457 DOI: 10.1371/journal.pone.0165196] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 10/08/2016] [Indexed: 01/10/2023] Open
Abstract
Background The objective was to estimate temporal associations between mental disorders and physical diseases in adolescents with mental-physical comorbidities. Methods This article bases upon weighted data (N = 6483) from the National Comorbidity Survey Adolescent Supplement (participant age: 13–18 years), a nationally representative United States cohort. Onset of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition lifetime mental disorders was assessed with the fully structured World Health Organization Composite International Diagnostic Interview, complemented by parent report. Onset of lifetime medical conditions and doctor-diagnosed diseases was assessed by self-report. Results The most substantial temporal associations with onset of mental disorders preceding onset of physical diseases included those between affective disorders and arthritis (hazard ratio (HR) = 3.36, 95%-confidence interval (CI) = 1.95 to 5.77) and diseases of the digestive system (HR = 3.39, CI = 2.30 to 5.00), between anxiety disorders and skin diseases (HR = 1.53, CI = 1.21 to 1.94), and between substance use disorders and seasonal allergies (HR = 0.33, CI = 0.17 to 0.63). The most substantial temporal associations with physical diseases preceding mental disorders included those between heart diseases and anxiety disorders (HR = 1.89, CI = 1.41 to 2.52), epilepsy and eating disorders (HR = 6.27, CI = 1.58 to 24.96), and heart diseases and any mental disorder (HR = 1.39, CI = 1.11 to 1.74). Conclusions Findings suggest that mental disorders are antecedent risk factors of certain physical diseases in early life, but also vice versa. Our results expand the relevance of mental disorders beyond mental to physical health care, and vice versa, supporting the concept of a more integrated mental-physical health care approach, and open new starting points for early disease prevention and better treatments, with relevance for various medical disciplines.
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Affiliation(s)
- Marion Tegethoff
- Division of Clinical Psychology and Psychiatry, Department of Psychology, University of Basel, Basel, Switzerland
- * E-mail:
| | - Esther Stalujanis
- Division of Clinical Psychology and Psychiatry, Department of Psychology, University of Basel, Basel, Switzerland
| | - Angelo Belardi
- Division of Clinical Psychology and Psychiatry, Department of Psychology, University of Basel, Basel, Switzerland
| | - Gunther Meinlschmidt
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
- Faculty of Medicine, Ruhr-University Bochum, Bochum, Germany
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Association between mental disorders and physical diseases in adolescents from a nationally representative cohort. Psychosom Med 2015; 77:319-32. [PMID: 25851547 DOI: 10.1097/psy.0000000000000151] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Pediatric health care and research focus mostly on single morbidities, although the single-disease framework has been challenged. The main objective was to estimate associations between childhood mental disorders and physical diseases. METHODS This study is based on weighted data (n = 6482) from the National Comorbidity Survey Replication Adolescent Supplement (age, 13-18 years). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition lifetime mental disorders were assessed using the fully structured World Health Organization Composite International Diagnostic Interview, complemented by parent report. Lifetime medical conditions and doctor-diagnosed diseases were assessed by adolescent self-report. RESULTS Of 6469 participants, 2137 (35.33%) reported at least one mental disorder and one physical disease. The most substantial associations included those between affective disorders and diseases of the digestive system (odds ratio [OR] = 3.46, 95% confidence interval [CI] = 2.28-5.24), anxiety disorders and arthritis (OR = 2.27, CI = 1.34-3.85), anxiety disorders and heart diseases (OR = 2.41, CI = 1.56-3.73), anxiety disorders and diseases of the digestive system (OR = 2.18, CI = 1.35-3.53), and eating disorders and epilepsy/seizures (OR = 5.45, CI = 1.57-18.87). Sociodemographic factors did not account for the association between mental disorders and physical diseases. CONCLUSIONS Findings suggest that mental disorders and physical diseases often co-occur in childhood. This association is a major public health challenge, and the child health system needs additional strategies in patient-centered care, research, medical education, health policy, and economics to develop well-coordinated interdisciplinary approaches linking mental and physical care in children.
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Park AL, McDaid D, Weiser P, Von Gottberg C, Becker T, Kilian R. Examining the cost effectiveness of interventions to promote the physical health of people with mental health problems: a systematic review. BMC Public Health 2013; 13:787. [PMID: 23988266 PMCID: PMC3765875 DOI: 10.1186/1471-2458-13-787] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 08/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently attention has begun to focus not only on assessing the effectiveness of interventions to tackle mental health problems, but also on measures to prevent physical co-morbidity. Individuals with mental health problems are at significantly increased risk of chronic physical health problems, such as cardiovascular disease or diabetes, as well as reduced life expectancy. The excess costs of co-morbid physical and mental health problems are substantial. Potentially, measures to reduce the risk of co-morbid physical health problems may represent excellent value for money. METHODS To conduct a systematic review to determine what is known about economic evaluations of actions to promote better physical health in individuals identified as having a clinically diagnosed mental disorder, but no physical co-morbidity. Systematic searches of databases were supplemented by hand searches of relevant journals and websites. RESULTS Of 1970 studies originally assessed, 11 met our inclusion criteria. In addition, five protocols for other studies were also identified. Studies looked at exercise programmes, nutritional advice, smoking, alcohol and drug cessation, and reducing the risk of blood borne infectious diseases such as HIV/AIDS and hepatitis. All of the lifestyle and smoking cessation studies focused on people with depression and anxiety disorders. Substance abuse and infectious disease prevention studies focused on people with psychoses and bipolar disorder. CONCLUSIONS There is a very small, albeit growing, literature on the cost effectiveness of interventions to promote the physical health of people with mental health problems. Most studies suggest that value for money actions in specific contexts and settings are available. Given that the success or failure of health promoting interventions can be very context specific, more studies are needed in more settings, focused on different population groups with different mental health problems and reporting intermediate and long term outcomes. There is a need to better distinguish between resource use and costs in a transparent manner, including impacts outside of the health care system. Issues such as programme fidelity, uptake and adherence should also be accounted for in economic analysis. The role of behavioural psychological techniques to influence health behaviours might also be considered.
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Affiliation(s)
- A-La Park
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK.
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Mayor morbilidad y uso de servicios médicos en atención primaria en pacientes con trastorno depresivo mayor y sus familiares: un estudio de cohorte retrospectivo. Aten Primaria 2012; 44:471-7. [DOI: 10.1016/j.aprim.2011.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 10/20/2011] [Accepted: 11/01/2011] [Indexed: 11/22/2022] Open
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