Search

BACKGROUND: The choice of imaging modality—the use of whole-body computed tomography (WB-CT) versus a step-wise diagnostic procedure—in injured children is controversial. In this study we availed ourselves of data from the TR-DGU, the trauma registry of the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie), to investigate whether the use of WB-CT improves the outcome. METHODS: The TR-DGU data from the period 2012–2021 were evaluated. A three-stage analysis began with comparison of children with adults aged ≤ 50 years. As a second step, the observed and expected mortality in children with WB-CT was compared with the mortality in children without WB-CT. Finally, predictors of the use of WB-CT were identified so that a propensity score analysis of matched pairs could be performed. RESULTS: A total of 65 092 patients were included, 4573 children (7%) and 60 519 adults (93%), with differences in accident type and injury pattern. Comparison of the ratio of observed to expected mortality revealed no difference between the two groups of children (standardized mortality ratio 0.97 with WB-CT, 0.95 without WB-CT). In adults, however, there was an advantage for the WB-CT group. The propensity score analysis of 1101 matched pairs showed identical mortality in the two groups (3.9% with WB-CT, 4.0% without WB-CT). CONCLUSION: The TR-DGU data show no benefit of WB-CT compared with step-wise diagnosis in the care of severely injured children. In view of the radiation exposure involved, with the danger of inducing malignancy, the benefits and risks of the use of WB-CT in children should be weighed up carefully in team discussions.

This paper studies the problem of siting renewable power generation assets using large amounts of climatological data while accounting for their spatiotemporal complementarity. The problem is cast as a combinatorial optimisation problem selecting a pre-specified number of sites so as to minimise the number of simultaneous low electricity production events that they experience relative to a pre-specified reference production level. It is shown that the resulting model is closely related to submodular optimisation and can be interpreted as generalising the well-known maximum coverage problem. Both deterministic and randomised algorithms are discussed, including greedy, local search and relaxation-based heuristics as well as combinations of these algorithms. The usefulness of the model and methods is illustrated by a realistic case study inspired by the problem of siting onshore wind power plants in Europe, resulting in instances featuring over ten thousand candidate locations and ten years of hourly-sampled meteorological data. The proposed solution methods are benchmarked against a state-of-the-art mixed-integer programming solver and several algorithms are found to consistently produce better solutions at a fraction of the computational cost. The physical nature of solutions provided by the model is also investigated, and all deployment patterns are found to be unable to supply a constant share of the electricity demand at all times. Finally, a cross-validation analysis shows that, except for an edge case, the model can successfully and reliably identify deployment patterns that perform well on previously unseen climatological data from historical data spanning a small number of weather years.

Attention Deficit Hyperactivity Disorder (ADHD) negatively impacts Quality of Life (QoL) in adults. Earlier studies on pharmacological treatment have shown short-term beneficial effects on QoL. No data are available on long-term effects on multimodal psychosocial and/or pharmacological interventions. The Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a prospective, multicenter randomized clinical trial, compared cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) and methylphenidate (MPH) with placebo (Plac) (2 × 2 factorial design over a period of 52 weeks). Change of QoL was measured after three months of intensive treatment, after 26 weeks, and after one year of maintenance treatment, using the Quality of life enjoyment and satisfaction questionnaire (Q-LES-Q, eight subscales). A follow-up was performed 1.5 years after treatment completion. Q-LES-Q scores were analyzed descriptively (means and confidence intervals). A linear regression model was used to test for significant differences between the four treatment arms. The full analysis set comprised 419 patients. Q-LES-Q scores increased between baseline and the end of treatment across all Q-LES-Q subscales (with exception of stable scores in the physical health/activities subscale in the CM + Plac group) and remained stable improved at follow-up. Regression analyses did not show any significant differences between the four treatment conditions. COMPAS is the first study to demonstrate stable and long-term improvements of QoL after multimodal treatment regardless of medication with MPH or Placebo, and regardless of structured GPT or individual CM. Trial registration: ISRCTN54096201.

Introduction The Comparison of Methylphenidate and Psychotherapy in adult ADHD Study (COMPAS) was a prospective, randomized multicenter clinical trial, comparing methylphenidate (MPH) with placebo (PLAC) in combination with cognitive behavioral group psychotherapy (GPT) or individual clinical management (CM) over the period of 1 year. Here, we report results on treatment safety. Methods MPH and PLAC were flexibly dosed. Among 433 randomized patients, adverse events (AEs) were documented and analyzed on an “as received” basis during week 0–52. Electrocardiogram data were recorded at baseline and week 24. Results Comparing 205 patients who received ≥1 dose of MPH with 209 patients who received PLAC, AEs occurring significantly more frequently in the MPH group were decreased appetite (22 vs. 3.8%), dry mouth (15 vs. 4.8%), palpitations (13 vs. 3.3%), gastrointestinal infection (11 vs. 4.8%), agitation (11 vs. 3.3%), restlessness (10 vs. 2.9%), hyperhidrosis, tachycardia, weight decrease (all 6.3 vs. 1.9%), depressive symptom, influenza (both 4.9 vs. 1.0%), and acute tonsillitis (4.4 vs. 0.5%). Syncope occurred significantly more often in the PLAC group (2.4 vs. 0%). Clinically relevant ECG changes occurred very rarely in both groups. Serious AEs were rare and without a significant group difference. The comparison of 206 patients treated with GPT versus 209 patients who received CM revealed no major differences. Serious AE classified as psychiatric occurred in 5 cases in the CM group and in 1 case in the GPT group. Conclusion In this so far longest-running clinical trial, methylphenidate treatment was safe and well-tolerated.

There is broad consensus that to improve the treatment of adult Attention-Deficit/Hyperactivity Disorder (ADHD), the various therapy options need to be tailored more precisely to the individual patient's needs and specific symptoms. This post-hoc analysis evaluates the multimodal effects of first-line medication (methylphenidate [MPH] vs placebo [PLB]) and psychotherapeutic (group psychotherapy [GPT] vs clinical management [CM]) treatments on the ADHD core symptoms inattention, hyperactivity and impulsivity. For the two-by-two factorial, observer-blinded, multicenter, randomized controlled Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS; ISRCTN54096201), 419 outpatients with ADHD were considered for analysis. ADHD symptoms were assessed by blind observer-rated and patient-rated Conners Adult ADHD Rating Scales before treatment (T1), 13 weeks (T2) and 26 weeks (T3) after T1, at treatment completion after 52 weeks (T4), and at follow-up (130 weeks, T5). MPH was superior to PLB in improving symptoms of inattention at almost all endpoints (observer-rated T2, T3, T4, T5; patient-rated T2, T3, T4), while a significant decrease in hyperactivity and impulsivity was at first found after 6 months of treatment. CM compared to GPT decreased inattention and impulsivity in the early treatment phase only (observer-rated T2, patient-rated T2, T3). In conclusion, while MPH seems to have a direct and sustained effect on inattention, premature medication discontinuation should particularly be avoided in patients with hyperactive-impulsive symptoms. Also, especially in high inattention and/or impulsivity presentations, initial individual patient management might be beneficial. Consequently, considering individual core symptom profiles may enhance the efficacy of treatments in adult ADHD.

The accurate representation of variable renewable generation (RES, e.g., wind, solar PV) assets in capacity expansion planning (CEP) studies is paramount to capture spatial and temporal correlations that may exist between sites and impact both power system design and operation. However, it typically has a high computational cost. This paper proposes a method to reduce the spatial dimension of CEP problems while preserving an accurate representation of renewable energy sources. A two-stage approach is proposed to this end. In the first stage, relevant sites are identified via a screening routine that discards the locations with little impact on system design. In the second stage, the subset of relevant RES sites previously identified is used in a CEP problem to determine the optimal configuration of the power system. The proposed method is tested on a realistic EU case study and its performance is benchmarked against a CEP set-up in which the entire set of candidate RES sites is available. The method shows great promise, with the screening stage consistently identifying 90% of the optimal RES sites while discarding up to 54% of the total number of candidate locations. This leads to a peak memory reduction of up to 41% and solver runtime gains between 31% and 46%, depending on the weather year considered., Comment: Accepted to PowerTech2021, Madrid, Spain

Background Surveillance testing within healthcare facilities provides an opportunity to prevent severe outbreaks of coronavirus disease 2019 (COVID-19). However, the quantitative impact of different available surveillance strategies and their potential to decrease the frequency of outbreaks are not well-understood. Methods We establish an individual-based model representative of a mental health hospital yielding generalizable results. Attributes and features of this facility were derived from a prototypical hospital, which provides psychiatric, psychosomatic and psychotherapeutic treatment. We estimate the relative reduction of outbreak probability for three test strategies (entry test, once-weekly test and twice-weekly test) relative to a symptom-based baseline strategy. Based on our findings, we propose determinants of successful surveillance measures. Results Entry Testing reduced the outbreak probability by 26%, additionally testing once or twice weekly reduced the outbreak probability by 49% or 67% respectively. We found that fast diagnostic test results and adequate compliance of the clinic population are mandatory for conducting effective surveillance. The robustness of these results towards uncertainties is demonstrated via comprehensive sensitivity analyses. Conclusions We conclude that active testing in mental health hospitals and similar facilities considerably reduces the number of COVID-19 outbreaks compared to symptom-based surveillance only.

Background Few data are available on the characteristics of inpatient treatment and subsequent outpatient treatment for depression in Germany. In this study, we aimed to characterize the inpatient and outpatient treatment phases, to determine the rates of readmission and mortality, and to identify risk factors. Methods We carried out a descriptive statistical analysis of routine administrative data from a large health-insurance carrier (BARMER). All insurees aged 18 to 65 who were treated in 2015 as inpatients on a psychiatry and psychotherapy service or on a psychosomatic medicine and psychotherapy service with a main diagnosis of depression were included in the analysis. Risk factors for readmission and death were determined with the aid of mixed logistic regression. Results Of the 22 893 patients whose data were analyzed, 78% had been hospitalized on a psychiatry and psychotherapy service and 22% on a psychosomatic medicine and psychotherapy service. The median length of hospital stay was 42 days. Follow-up care in the outpatient setting failed to conform with the recommendations of the pertinent guidelines in 92% of the patients with a main diagnosis of severe depression during hospitalization, and in 50% of those with moderate depression. 21% of the patients were readmitted within a year. The mortality at one year was 961 per 100 000 individuals (adjusted for the age and sex structure of the German population), or 3.4 times the mortality of the population at large. In the regression model, more treatment units during hospitalization and subsequent treatment with psychotherapy were associated with a lower probability of readmission, while longer hospitalization with subsequent pharmacotherapy or psychotherapy was associated with lower mortality. Conclusion The recommendations of the national (German) S3 guidelines for the further care of patients who have been hospitalized for depression are inadequately implemented at present in the sectored structures of in- and outpatient care in the German health care system. This patient group has marked excess mortality.

This paper provides a detailed account of the impact of different offshore wind siting strategies on the design of the European power system. To this end, a two-stage method is proposed. In the first stage, a highly-granular siting problem identifies a suitable set of sites where offshore wind plants could be deployed according to a pre-specified criterion. Two siting schemes are analysed and compared within a realistic case study. These schemes essentially select a pre-specified number of sites so as to maximise their aggregate power output and their spatiotemporal complementarity, respectively. In addition, two variants of these siting schemes are provided, wherein the number of sites to be selected is specified on a country-by-country basis rather than Europe-wide. In the second stage, the subset of previously identified sites is passed to a capacity expansion planning (CEP) framework that sizes the power generation, transmission and storage assets that should be deployed and operated in order to satisfy pre-specified electricity demand levels at minimum cost. Results show that the complementarity-based siting criterion leads to system designs which are up to 5% cheaper than the ones relying the power output-based criterion when offshore wind plants are deployed with no consideration for country-based deployment targets. On the contrary, the power output-based scheme leads to system designs which are consistently 2% cheaper than the ones leveraging the complementarity-based siting strategy when such constraints are enforced. The robustness of the results is supported by a sensitivity analysis on offshore wind capital expenditure and inter-annual weather variability, respectively., Comment: Submitted to Applied Energy

Obwohl eine grose Zahl von Studien die generelle Wirksamkeit psychotherapeutischer Behandlungen depressiver Storungen zeigt, variiert die Wirksamkeit in Abhangigkeit von therapeuten- und patientenseitigen Einflussfaktoren sowie der Art des depressiven Storungsbildes. Ziel ist die zusammenfassende Darstellung des aktuellen Wissens zu psychotherapeutischen Behandlungen bei Patienten mit chronischen bzw. therapieresistenten depressiven Storungen und bei Patienten mit psychischen oder somatischen Komorbiditaten. Im Rahmen der 2015 durchgefuhrten Revision der aktuell gultigen S3- bzw. Nationalen VersorgungsLeitlinie (NVL) Unipolare Depression erfolgte eine systematische Evidenzrecherche zu Psychotherapie bei spezifischen Patientengruppen. Diese Ergebnisse in Verbindung mit einem systematischen Rechercheupdate werden dargestellt. Fur die spezifischen Patientengruppen der chronisch depressiven bzw. therapieresistenten Patienten sowie mit komorbiden psychischen oder somatischen Erkrankungen liegen Hinweise fur die Wirksamkeit von Psychotherapie im Hinblick auf die Reduktion depressiver Symptome vor. Insbesondere fur depressive Patienten mit psychischen Komorbiditaten ist die Evidenzlage allerdings noch nicht ausreichend. Basierend auf der aktuellen Evidenz und/oder auf klinischem Expertenkonsens empfiehlt die NVL eine alleinige Psychotherapie oder eine Kombination mit Antidepressiva bei den meisten der genannten Patientengruppen. Es bestehen Kenntnislucken, die deutlich machen, dass weitere wissenschaftliche Bemuhungen notwendig sind, um die Behandlung spezifischer depressiver Patientengruppen weiter zu verbessern.

Depressive Storungen beeintrachtigen wie kaum eine andere Erkrankung in zentraler Weise das Wohlbefinden und das Selbstwertgefuhl von Patienten. Neben der Pharmakotherapie gehort die Psychotherapie zu den primaren Behandlungsstrategien bei depressiven Storungen. Ziel ist die Darstellung des aktuellen Wissens zu psychotherapeutischen Behandlungen bei depressiven Storungen. Im Rahmen der 2015 durchgefuhrten Revision der aktuell gultigen S3- bzw. Nationalen VersorgungsLeitlinie (NVL) Unipolare Depression erfolgte eine systematische Evidenzrecherche. Die Ergebnisse zu verschiedenen psychotherapeutischen Verfahren in Verbindung mit einem systematischen Rechercheupdate werden in komprimierter Form dargestellt. Die kognitive Verhaltenstherapie (KVT) ist das am haufigsten untersuchte Psychotherapieverfahren, ihre Wirksamkeit ist durch zahlreiche Studien belegt. Wirksamkeitsnachweise zur Behandlung depressiver Storungen liegen auch fur die tiefenpsychologisch fundierte Psychotherapie und die interpersonelle Therapie (IPT) vor, gefolgt von der systemischen Therapie und der Gesprachspsychotherapie (GPT); die Evidenz ist aber weniger robust. Die Wirksamkeit psychotherapeutischer Behandlungen alleine oder in Kombination mit pharmakologischen Behandlungen kann als sehr gut gesichert betrachtet werden. Psychotherapie stellt einen zentralen Bestandteil der Behandlung depressiver Storungen dar.

Zusammenfassung Ziele Untersuchung der Bereitschaft zur Inanspruchnahme internetbasierter Maßnahmen nach stationärer Behandlung. Methodik Querschnittbefragung an ehemals stationären Patienten (N = 247). Ergebnisse 44,9 % sind bereit, ein Angebot über Videokonferenz zu nutzen, 34,7 % über Chat, 50,0 % über Mail und 38,0 % als Onlinetherapie. In älteren Altersgruppen ist die Bereitschaft geringer. Vorteile werden in der Flexibilität und Nachteile im unpersönlichen Charakter gesehen. Schlussfolgerungen Ein relevanter Anteil vor allem jüngerer Patienten ist bereit, internetbasierte Maßnahmen in Anspruch zu nehmen.

Hintergrund Die storungsspezifische psychotherapeutische Weiterbehandlung nach stationarer Entlassung ist aufgrund langer Wartezeiten und Versorgungsdisparitaten insbesondere in landlichen Regionen erschwert. Da eine fast flachendeckende Internetabdeckung in Deutschland gegeben ist, konnten psychotherapeutische Konzepte nach stationarer Entlassung uber Videokonferenzen fortgefuhrt werden, um die Behandlungskontinuitat zu ermoglichen. Das Kompetenzzentrum Psychotherapie an den Medizinischen Fakultaten Baden-Wurttemberg verfugt uber die Infrastruktur, videokonferenzbasierte Masnahmen nach aktuellen Datenschutzbestimmungen umzusetzen.

Key Points Question What are the long-term results of multimodal treatment for adult attention-deficit/hyperactivity disorder (ADHD) when comparing cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) in combination with either methylphenidate or placebo? Findings In this follow-up assessment of the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a multicenter randomized clinical trial, 256 adults participated in follow-up 1.5 years after the intervention ended. The severity of ADHD symptoms improved in all 4 prior treatment groups, with no significant difference found between GPT and CM, but methylphenidate was associated with a larger improvement in symptoms compared with placebo. Meaning Results from the COMPAS trial demonstrate an improvement of ADHD symptoms over 1.5 years in adults with ADHD after 1 year of treatment with methylphenidate plus either GPT or CM., This follow-up assessment of the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a multicenter randomized clinical trial, evaluates the long-term efficacy of multimodal treatment for attention-deficit/hyperactivity disorder (ADHD)., Importance Knowledge about the long-term effects of multimodal treatment in adult attention-deficit/hyperactivity disorder (ADHD) is much needed. Objective To evaluate the long-term efficacy of multimodal treatment for adult ADHD. Design, Setting, and Participants This observer-masked, 1.5-year follow-up of the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a prospective, multicenter randomized clinical trial, compared cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) and methylphenidate (MPH) with placebo (2 × 2 factorial design). Recruitment started January 2007 and ended August 2010, and treatments were finalized in August 2011 with follow-up through March 2013. Overall, 433 adults with ADHD participated in the trial, and 256 (59.1%) participated in the follow-up assessment. Analysis began in November 2013 and was completed in February 2018. Interventions After 1-year treatment with GPT or CM and MPH or placebo, no further treatment restrictions were imposed. Main Outcomes and Measures The primary outcome was change in the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score from baseline to follow-up. Secondary outcomes included further ADHD rating scale scores, observer-masked ratings of the Clinical Global Impression scale, and self-ratings of depression on the Beck Depression Inventory. Results At follow-up, 256 of 433 randomized patients (baseline measured in 419 individuals) participated. Of the 256 patients participating in follow-up, the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score was assessed for 251; the mean (SD) baseline age was 36.3 (10.1) years; 125 patients (49.8%) were men; and the sample was well-balanced with respect to prior randomization (GPT and MPH: 64 of 107; GPT and placebo: 67 of 109; CM and MPH: 70 of 110; and CM and placebo: 55 of 107). At baseline, the all-group mean ADHD Index of Conners Adult ADHD Rating Scale score was 20.6, which improved to adjusted means of 14.2 for the GPT arm and 14.7 for the CM arm at follow-up with no significant difference between groups (difference, −0.5; 95% CI, −1.9 to 0.9; P = .48). The adjusted mean decreased to 13.8 for the MPH arm and 15.2 for the placebo arm (difference, −1.4; 95% CI, −2.8 to −0.1; P = .04). As in the core study, MPH was associated with a larger reduction in symptoms than placebo at follow-up. These results remained unchanged when accounting for MPH intake at follow-up. Compared with participants in the CM arm, patients who participated in group psychotherapy were associated with less severe symptoms as measured by the self-reported ADHD Symptoms Total Score according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) of Conners Adult ADHD Rating Scale (AMD, −2.1; 95% CI, −4.2 to −0.1; P = .04) and in the subscale of reducing pure hyperactive symptoms, measured via the Diagnostic Checklist for the diagnosis of ADHD in adults (AMD, −1.3; 95% CI, −2.8 to 0.1; P = .08). Regarding the Clinical Global Impression scale assessment of effectiveness, the difference between GPT and CM remained significant at follow-up (odds ratio, 1.63; 95% CI, 1.03-2.59; P = .04). No differences were found for any comparison concerning depression as measured with the Beck Depression Inventory. Conclusions and Relevance Results from COMPAS demonstrate a maintained improvement in ADHD symptoms for adults 1.5 years after the end of a 52-week controlled multimodal treatment period. The results indicate that MPH treatment combined with GPT or CM provides a benefit lasting 1.5 years. Confirming the results of the core study, GPT was not associated with better results regarding the primary outcome compared with CM. Trial Registration isrctn.org Identifier: ISRCTN54096201

Background: Evidence on the long-term efficacy of psychotherapeutic approaches for chronic depression is scarce. Objective: To evaluate the effects of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) compared to Supportive Psychotherapy (SP) 1 year and 2 years after treatment termination. Methods: In this study, we present 1- and 2-year follow-up assessments of a prospective, multicenter, evaluator-blinded, randomized clinical trial of outpatients with early-onset chronic major depression (n = 268). The initial treatment included 32 sessions of CBASP or SP over 48 weeks. The primary outcome was the rate of “well weeks” (Longitudinal Interval Follow-Up Evaluation; no/minimal symptoms) after 1 year and 2 years. The secondary outcomes were, among others, clinician- and self-rated depressive symptoms, response/remission rates, and quality of life. Results: Of the 268 randomized patients, 207 (77%) participated in the follow-up. In the intention-to-treat analysis, there was no statistically significant difference between CBASP and SP patients in experiencing well weeks (CBASP: mean [SD] of 48.6 [36.9] weeks; SP: 39.0 [34.8]; rate ratio 1.26, 95% CI 0.99–1.59, p = 0.057, d = 0.18) and in remission rates (CBASP: 1 year 40%, 2 years 40.2%; SP: 1 year 28.9%, 2 years 33%) in the 2 years after treatment. Statistically significant effects were found in favor of CBASP 1 year after treatment termination regarding the rate of well weeks, self-rated depressive symptoms, and depression-related quality of life. Conclusions: CBASP lost its superiority over SP at some point between the first and the second year. This suggests the necessity of maintenance treatment for early-onset chronically depressed patients remitted with CBASP during the acute therapy phase, as well as the sequential integration of other treatment strategies, including medication for those who did not reach remission.

Background Gray matter reduction mainly in the anterior cingulate cortex, the basal ganglia, and the cerebellum has been reported in attention-deficit/hyperactivity disorder (ADHD). Yet, respective data remain contradictory and inconclusive. To clarify if structural alteration in these brain areas can be verified in a large cohort of adult patients and if a history of stimulant medication has an effect on brain structure, magnetic resonance imaging was performed in the context of a clinical trial on the efficacy of group psychotherapy, clinical management, methylphenidate, and placebo (Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study Trial). Methods Between January 2007 and August 2010, 1480 patients from seven study centers across Germany, aged 18 to 58, were prescreened; 518 were assessed for eligibility; 433 were randomized; and 187 were eligible for neuroimaging. The control group included 121 healthy volunteers. Structural magnetic resonance imaging data sets were acquired. Following strict quality control, 131 patient and 95 control data sets could be analyzed. All patients were unmedicated for at least 6 months. The established method of voxel-based morphometry (VBM8 segmentation and diffeomorphic anatomical registration through exponentiated lie normalization) was used to assess global and regional brain volumes. Results Patients displayed subtle global cerebral volume reductions. There was no evidence of regional gray matter volume abnormalities. The inattentive ADHD subtype was linked to smaller volumes in the left dorsolateral prefrontal cortex. A history of previous medication did not modulate brain volumes. Conclusions ADHD in adulthood is associated with global rather than regional volumetric abnormalities. Previous use of stimulant medication does not seem to modify subsequent brain volumes in a significant way.

Borderline-Personlichkeitsstorungen (BPS) gehoren zu den schwerwiegenden psychischen Erkrankungen mit hohem Druck auf das psychiatrische Versorgungssystem. Mittlerweile liegen evaluierte storungsspezifische Behandlungskonzepte auch fur den stationaren Bereich in Deutschland vor. Diese zeigen sehr gute und lang anhaltende Verbesserungen der Psychopathologie sowie der poststationaren sozialen Teilhabe. Die Umsetzung dieser evidenzbasierten stationaren Psychotherapieprogramme setzt jedoch gut trainierte Behandlerteams sowie eine entsprechende Finanzierung des Ressourcenaufwandes voraus. Ermittlung einer normativen Bedarfsdefinition der Behandlungsdauer und -intensitat fur eine leitliniengerechte und empirisch nachweisbar wirksame stationare Behandlung der Borderline-Personlichkeitsstorung sowie den daraus abgeleiteten Personalbedarf, im Vergleich zu den aktuell im Rahmen der Psych-PV verfugbaren Ressourcen. Der Ressourcenbedarf wurde auf Basis evaluierter Modellstationen, der Empfehlungen der S2-Leitlinien sowie der Kriterien von Fachgesellschaften ermittelt und mit der Personalbemessung nach Psych-PV verglichen. Es zeigt sich fur ein normativ festgelegtes Behandlungsprogramm, selbst bei Anwendung eines 100 %igen Psych-PV-Satzes, eine deutliche Unterdeckung der Finanzierung des ermittelten Ressourcenbedarfs. Storungsspezifische stationare Behandlungsprogramme fur Borderline-Personlichkeitsstorungen sind wissenschaftlich nachweisbar hoch wirksam. Die Ressourcenanalyse zeigt jedoch, dass zur wirksamen Umsetzung dieser Programme ein Personalaufwand notwendig ist, der deutlich uber der Finanzierung durch die Psych-PV liegt. Die derzeitige Unterfinanzierung fuhrt zu unzureichenden Behandlungsergebnissen mit hohen Wiederaufnahmequoten und daraus resultierenden hohen direkten und indirekten Krankheitskosten.

Eine leitliniengerechte stationare psychiatrisch-psychotherapeutische Behandlung ist ein wesentlicher Bestandteil der Versorgung von Patienten mit einer Zwangsstorung. Moglicherweise wird der Aufwand fur diese Psychotherapie im gegenwartigen Personalbudget nach Psychiatrie-Personalverordnung (Psych-PV) jedoch nicht ausreichend abgebildet. Das Ziel dieses Beitrages ist, die fur eine leitliniengerechte stationare psychiatrisch-psychotherapeutische Behandlung notwendigen Personalressourcen zu bestimmen und mit dem Personalbudget in der Psych-PV zu vergleichen. Auf Grundlage der S3-Leitlinienempfehlung zur Behandlung von Zwangsstorungen und einer Metaanalyse zur Behandlungsintensitat wurde ein normativer Wochenbehandlungsplan erstellt. Ausgehend davon wurden die fur diesen Behandlungsplan notwendigen Personalressourcen berechnet. Diese wurden mit dem in der Psych-PV in der Kategorie A1 (Regelbehandlung) vorgesehenen Personalbudget verglichen. Die Therapiezeit fur eine leitliniengerechte stationare psychiatrisch-psychotherapeutische Behandlung der Zwangsstorung betragt 23,5 h in der Woche. Das entspricht einem Personalbedarf von 20,9 h in der Woche. Dieser Personalbedarf ist in der Psych-PV nur zu 82,8 % (17,3 h) berucksichtigt. Die Deckung des Personalbedarfs im Bereich arztliche und psychologische Psychotherapie betragt sogar nur 38,3 % (183 min im Behandlungsplan vs. 70 min in der Psych-PV). Der vorliegende Beitrag macht deutlich, dass eine leitliniengerechte stationare, psychotherapeutische Behandlung einer Zwangsstorung im Psych-PV-Budget nicht ausreichend abgebildet ist. Die tatsachliche Lucke wird hier moglicherweise sogar unterschatzt.

Patients with Major Depressive Disorder (MDD) and no improvement after two weeks of antidepressant pharmacotherapy have a high risk of treatment failure. The aim of the study was to determine whether an early medication change (EMC) strategy is superior to a guideline-based treatment in MDD patients without improvement after two weeks of antidepressant pharmacotherapy. Eight-hundred-and-eighty-nine patients with MDD were enrolled, 879 patients received the SSRI escitalopram. Of those, 192 patients had no improvement, defined as a reduction of < 20% on the Hamilton Depression Rating Scale (HAMD-17) after 14 days of treatment, and were randomly assigned to open treatment with the EMC strategy (n = 97; venlafaxine XR for study days 15-56; in case of sustained non-improvement on day 28, lithium augmentation for days 29-56) or TAU (n = 95; escitalopram continuation; non-responders on day 28 were switched to venlafaxine XR for four weeks, i.e. days 29-56). The primary outcome was remission (HAMD-17 ≤ 7) after 8 weeks of treatment as assessed by blinded raters. Remission rates were 24% for EMC and 16% for TAU, which was not significantly different (p = 0.2056). Sensitivity analyses for the primary and secondary effectiveness endpoints consistently showed favorable results for patients randomized to EMC. The results confirm data from post-hoc analyses of clinical trials showing that early non-improvement identifies patients who likely need alternate interventions. However, the herein used two-step switch/augmentation strategy for this risk group was not more effective than the control intervention. Alternate strategies and other design aspects are discussed in order to support researchers addressing the same research question.

Die chronische Depression ist eine haufige und subjektiv wie gesamtwirtschaftlich sehr belastende psychische Erkrankung. Die effektive storungsspezifische Therapie dieser Storung setzt eine entsprechende Finanzierung des Ressourcenaufwandes voraus. Ermittlung einer normativen Bedarfsdefinition der Behandlungsdauer und -intensitat fur eine leitliniengerechte und empirisch nachweisbar wirksame stationare Behandlung der chronischen Depression und des daraus abgeleiteten Personalbedarfs im Vergleich mit den aktuell im Rahmen der Psychiatrie-Personalverordnung (Psych-PV) verfugbaren Ressourcen. Der entsprechend der nationalen Versorgungsgleitlinie und empirischer Befunde ableitbare Ressourcenbedarf wurde mit der Personalbemessung nach Psych-PV verglichen. Es zeigt sich fur ein normativ festgelegtes Behandlungsprogramm, selbst bei Anwendung eines 100%igen Psych-PV-Satzes, eine deutliche Unterdeckung der Finanzierung des ermittelten Ressourcenbedarfs. Die Ergebnisse zeigen deutlich, dass selbst bei Annahme einer vollstandigen Umsetzung der Psych-PV eine spezifische und wirksame stationare Therapie der chronischen Depression deutlich unterfinanziert ist. Zusatzlich besteht die Schwierigkeit der fehlenden Abbildung der chronischen Depression in der ICD-10, die eine zukunftige Differenzierung des Ressourcenbedarfs im Rahmen des PEPP-Systems verhindert.