Search

Objective: There is no information on disparities of patients with psychogenic nonepileptic seizures (PNES) and their caregivers. The objective of this exploratory study is to compare patients with PNES and caregivers with low socioeconomic status (SES) with those of high SES for disparities in healthcare use, seizures, medication adverse effects, psychosocial impact, and knowledge about epilepsy., Methods: Patients with PNES and caregivers completed surveys about the aforementioned outcomes during their Epilepsy Monitoring Unit (EMU) admission. Associations were evaluated using SES as a binary independent variable and the patient- and caregiver-related outcomes as dependent variables., Results: Forty-three patients and 28 caregivers were recruited. The majority of patients were on average 36 years old, single women, unemployed, with some college education. The majority had PNES for 8 years averaging 20 seizures per month and were maintained on ≥2 antiepileptic drugs (AEDs) prior to their EMU admission. Most caregivers were first-degree relatives with a mean age of 43 years, married employed women of higher educational attainment, typically cohabitating with the patients. Low SES patients showed poorer knowledge about epilepsy (p < 0.0001) and higher anxiety levels (p = 0.03). Conversely, high SES patients demonstrated poorer social functioning (p = 0.04). High SES caregivers showed higher caregiving burden (p = 0.01)., Conclusion: There are noteworthy disparities in patients with PNES of different SES and their caregivers. Identification of those disparities is a critical step in the creation of appropriate interventions to address them., Competing Interests: Declaration of competing interest None of the authors has any pertinent interest to disclose. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to examine preliminary evidence of intensive short-term dynamic psychotherapy (ISTDP) as a treatment option for psychogenic nonepileptic seizures (PNES) in terms of impact on healthcare costs, emotional wellbeing, and somatic symptoms., Method: Drawn from a sample of patients treated in a tertiary psychiatric service over a nine-year period, this naturalistic pilot study compared within-group changes from pretreatment with each year up to three years posttreatment, in physician visits, physician costs, hospital admissions, and overall hospital costs., Results: Twenty-eight patients with PNES received ISTDP with average treatment duration of 3.6 sessions. Healthcare costs significantly reduced in follow-up compared with those in baseline, with patient costs falling below the healthy population means, and reductions in healthcare costs compared with those in baseline by 88% in year one, 90% in year two, and 81% in year three. This was accompanied by significant reductions in symptoms and interpersonal problems., Conclusion: These preliminary findings indicate the potential for short-term and long-term healthcare savings and improvements in emotional wellbeing, for patients with PNES from the application of ISTDP. Further research evaluating the impact of ISTDP on seizure reduction and comparing this approach with control conditions is warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Schizophrenia spectrum disorders result in enormous individual suffering and financial burden on patients and on society. In Germany, there are about 1,000,000 individuals suffering from schizophrenia (SZ) or schizoaffective disorder (SAD), a combination of psychotic and affective symptoms. Given the heterogeneous nature of these syndromes, one may assume that there is a difference in treatment costs among patients with paranoid SZ and SAD. However, the current the national system of cost accounting in psychiatry and psychosomatics in Germany assesses all schizophrenia spectrum disorders within one category., Methods: The study comprised a retrospective audit of data from 118 patients diagnosed with paranoid SZ (F20.0) and 71 patients with SAD (F25). We used the mean total costs as well as partial cost, i.e., mean costs for medication products, mean personal costs and mean infrastructure costs from each patient for the statistical analysis. We tested for differences in the four variables between SZ and SAD patients using ANCOVA and confirmed the results with bootstrapping., Results: SAD patients had a longer duration of stay than patients with SZ (p = .02). Mean total costs were significantly higher for SAD patients (p = .023). Further, we found a significant difference in mean personnel costs (p = .02) between patients with SZ and SAD. However, we found no significant differences in mean pharmaceutical costs (p = .12) but a marginal difference of mean infrastructure costs (p = .05) between SZ and SAD. We found neither a common decrease of costs over time nor a differential decrease in SZ and SAD., Conclusion: We found evidence for a difference of case related costs of inpatient treatments for paranoid SZ and SAD. The differences in mean total costs seem to be primarily related to the mean personnel costs in patients with paranoid SZ and SAD rather than mean pharmaceutical costs, possibly due to higher personnel effort and infrastructure.

Patients with functional neurological symptoms are commonly seen in neurological practice. They have significant disability that may not improve and their care is costly. This article will use case histories to underline the important aspects of caring for patients with functional neurological disorders, including important features of the history, examination, neurobiology, appropriate investigations, and an approach to treatment.

Objectives: There is a high degree of misallocated medical care for patients with somatoform disorders and patients with concomitant mental diseases. This complex of problems could be reduced remarkably by integrating psychosomatic departments into hospitals with maximum medical care. Admitting a few big psychosomatic specialist clinics into the calculation basis decreased the Day-Mix Index (DMI). The massive reduction of the calculated costs per day leads to a gap in funding resulting in a loss of the necessary personnel requirements - at least in university psychosomatic departments. The objective of this article is therefore to empirically verify the reference numbers of personnel resources calculated on the basis of the new German lump-sum reimbursement system in psychiatry and psychosomatics (PEPP)., Methods: The minute values of the reference numbers of Heuft (1999) are contrasted with the minute values of the PEPP reimbursement system in the years 2013 and 2014, as calculated by the Institute for Payment Systems in Hospitals (InEK)., Results: The minute values derived from the PEPP data show a remarkable convergence with the minute values of Heuft's reference numbers (1999)., Conclusions: A pure pricing system like the PEPP reimbursement system as designed so far threatens empirically verifiable and qualified personnel requirements of psychosomatic departments. In order to ensure the necessary therapy dosage and display it in minute values according to the valid OPS procedure codes, the minimum limit of the reference numbers is mandatory to maintain the substance of psychosomatic care. Based on the present calculation, a base rate of at least 285 e has to be politically demanded. Future developments in personnel costs have to be refinanced at 100 %.

In 2013 Germany implemented a new payment system for the inpatient treatment of mental disorders. Besides perpetuating a per-diem payment, the payment system sets up a classification system that groups cases with comparable costs per diem. The first release of the system reveals the principal diagnosis to be the main grouping variable. Especially in psychosomatic and psychotherapy this approach seems to be at least questionable. Because of the insufficiently precise definition of the assignment of the principal diagnosis in the coding standards - and therefore the expected conflicts between clinics and health insurance funds - this paper discusses the difficulties involved in defining the principal diagnosis. It also formulates recommendations of how the principal diagnosis should be assigned.

Introduction: Quality assurance in psychosomatic medicine in Austria is currently based on a voluntary continuing medical education programme in psychosocial, psychosomatic and psychotherapeutic medicine. It is questionable whether psychosomatic care can be sufficiently provided in this manner. In addition, a broadly based proposal to create a subspecialty in psychosomatic medicine in order to facilitate quality assurance, is investigated., Methods: The necessity to reorganize psychosomatic care was explored through semi-structured qualitative interviews with experts. Data-based analyses probed the labour market of the proposed subspecialty, and the literature was reviewed to look into the cost-benefit ratio of psychosomatic treatment., Results: All experts expressed a need to restructure psychosomatic care in Austria. Examples exist for psychosomatic treatment with an efficient cost-benefit relation in diverse medical settings., Conclusion: Establishing a subspecialty in Psychosomatic Medicine seems feasible and could contribute to increased quality assurance and the nationwide provision of psychosomatic care.

Background: Some patients are repeatedly referred from primary to secondary care with medically unexplained symptoms (MUS). We aimed to estimate the healthcare costs incurred by such referrals and to compare them with those incurred by other referred patients from the same defined primary care sample., Methods: Using a referral database and case note review, all adult patients aged less than 65 years, who had been referred to specialist medical services from one of five UK National Health Service primary care practices in a five-year period, were identified. They were placed in one of three groups: (i) repeatedly referred with MUS (N=276); (ii) infrequently referred (IRS, N=221), (iii) repeatedly referred with medically explained symptoms (N=230). Secondary care activities for each group (inpatient days, outpatient appointments, emergency department attendances and investigations) were identified from primary care records. The associated costs were allocated using summary data and the costs for each group compared., Results: Patients who had been repeatedly referred with MUS had higher mean inpatient, outpatient and emergency department costs than those infrequently referred (£3,539, 95% CI 1458 to 5621, £778 CI 705 to 852 and £99, CI 74 to 123 respectively. The mean overall costs were similar to those of patients who had been repeatedly referred with medically explained symptoms., Conclusions: The repeated referral of patients with MUS to secondary medical care incurs substantial healthcare costs. An alternative form of management that reduces such referrals offers potential cost savings., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Patients with psychogenic nonepileptic seizures (PNES) frequently use acute health care resources including emergency departments (EDs), resulting in redundant efforts. We asked whether establishing the diagnosis of PNES via video/EEG telemetry reduces subsequent ED use. Twenty-three patients with PNES were studied over a 48-month period surrounding the diagnosis using a provincewide database. There was a 39% reduction in total ED visits and a 51% reduction in ED visits for neurological causes during the 24 months following the diagnosis, and decreased ED use persisted throughout the follow-up period. There was no significant change in ED utilization for psychiatric causes. The proportion of patients with PNES who used ED services once or not at all per year increased from 26% in the 2 years prior to the diagnosis to 57% following the diagnosis. These findings suggest that a definitive, telemetry-based diagnosis relieves diagnostic uncertainties for the patient and physician, but also has quantifiable economic benefits., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Psychogenic nonepileptic seizures (PNES; also known as pseudoseizures, nonepileptic attack disorder) are common. They continue to pose diagnostic difficulties, with mean delays from onset to diagnosis of several years, during which time they are often treated as epilepsy. The literature suggests that clinical diagnosis has limited reliability. However, it may be useful to regard the diagnosis of PNES as having two stages-- that of suspecting the diagnosis and that of confirming it. Clinical features of the history and spells allow the diagnosis of PNES to be suspected in the first place, so that the appropriate expertise and tests can be brought to bear. The diagnosis of PNES is usually confirmed by recording spells using video EEG. A minority of patients also have epilepsy. Once the diagnosis is made, initial management consists of communicating the diagnosis to the patient and carers in a clear and nonpejorative way, as well as withdrawing anticonvulsant medication with appropriate monitoring in patients with no evidence of epilepsy. In many patients, spells will cease without psychological intervention. Emergency healthcare utilization may drop sharply after explanation of the diagnosis, and this may occur even in patients whose spells continue. It is not clear to what degree these positive effects are maintained in the long term.

Objective: Although there is a suggestion that the medical psychiatric unit (MPU) may reduce length of hospital stay (LOS), little is known about costs in terms of medical service use and psychiatric interventions in MPU care., Method: A record linkage study was conducted, linking cost data of hospital medical service use, LOS, and hospital psychiatric interventions to patients admitted to the MPU of the Maastricht University Medical Centre (MUMC) between 1998 and 2004. The data set was analyzed to enable comparison between cost changes of the same complex patient population following either MPU index admission or index admissions to reference MUMC medical wards., Results: Comparisons revealed lower costs of medical service use in favor of the MPU (-euro104; 95% CI -euro174 to -euro35; P<.01). However, cost of psychiatric intervention and cost of LOS were higher after MPU admission (respectively, +euro165; 95% CI +euro25 to +euro305; P<.05; and +euro202; 95% CI +euro170 to +euro235; P<.001). Total costs were higher after MPU admission compared to medical ward admission (+euro263; 95% CI +euro68 to +euro458; P<.05). These differences were not moderated by somatic diagnosis or previous pattern of admissions., Conclusion: The findings suggest that patients at the interface of psychiatric and somatic morbidity are diagnosed and treated adequately at the MPU, leading to a decrease in medical service use and an appropriate increase in exposure to psychiatric interventions. These results are specifically generalizable to MPUs with a focus on psychosomatic conditions, for instance, somatoform disorders or affective disorders with comorbid somatic diseases. However, failure to show cost savings in terms of LOS compared to medical wards outweighs cost-benefit derived from lower medical service use, suggesting that MPU activities may gain in cost-effectiveness if shifted more to outpatient psychosomatic care solutions., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objectives: About seven million people in Germany are affected by overindebtedness and insolvency. Being severely in debt is a very stressful situation that can result in social marginalisation, reducted overall activity, and physical and mental illness. The present study investigated the frequency of financial problems and their effects on physical and mental disorders at a university psychosomatic clinic., Methods: The study included a total of 659 patients. Their mental status was assessed with the Symptom Checklist (SCL-90-R), their physical status with the Gießener Beschwerdebogen (GBB)., Results: 37 percent of the subjects reported experiencing financial problems. We found that subjects with financial problems reported more physical and mental disorders than those without financial problems. Furthermore, therapists more often recommended that patients with financial problems receive inpatient therapy than patients without financial problems., Conclusion: The study suggests that financial problems should be included in any anamnesis, therapeutic recommendation, and actual therapy of patients in psychosomatic treatment.

Background: Since the economic recession in Sweden in the 1990s alarming reports about deteriorating mental and psychosomatic health among young people have repeatedly been published but reliable survey data are rare. The purpose of the study is to describe the trends in psychosomatic health problems among adolescents, focusing on gender differences., Methods: The analysis is based on repeated cross-sectional data collected 1988-2005 among about 15,000 adolescents (15- to 16-years old) within a county in Sweden. The data were collected in schools using a questionnaire that was completed anonymously. A composite measure of psychosomatic health problems based on eight items was used., Results: Psychosomatic health complaints among boys increased mainly during the in-recession time period, while the health problems among girls increased only slightly during the crisis, but increased dramatically in the post-recession time period. Only among boys did the variance in psychosomatic health increase successively across years of investigation, implying that the psychosomatic health among boys on average did not change over time., Conclusions: In showing different trend patterns across genders, the present study nuances and qualifies previous reports on deteriorating mental and psychosomatic health among adolescents. Whether the gender-related trend patterns are due to differences in the relative influence of economic and social stress factors or if they reflect other factors such as changes in the educational systems should be addressed in future studies.

Background: In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use., Method: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties., Conclusion: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

The decision of the German legislator to limit rehabilitation programme participation under the health-insurance scheme to a duration of three weeks had been oriented less by rehabilitation-scientific findings rather than by economic considerations. This is the background for discussing the question to what extent medical experience and empirical data are providing new information as to the durations of rehabilitation necessary and feasible in the field of psychosomatic rehabilitation and as to measures capable of supporting its effectiveness without extending the duration of therapy.

Purpose: Compared to patients with explained illness, patients with medically unexplained illness (MUI) may be at elevated risk of applying for disability. Accordingly, patients with MUI may account for a disproportionate number of disability claims and for a disproportionate percentage of salary reimbursement costs. The study was conducted to determine: (a) The prevalence of MUI among disability insurance claimants; (b) the cost of salary reimbursement; and (c) the impact of psychiatric comorbidity on length and cost of disability., Method: An insurance database of 26,451 short-term disability (STD) recipients with long-term disability (LTD) coverage was analyzed to determine the prevalence and salary reimbursement costs of MUI. Applicants with medically explained and psychiatric illness were included for comparison., Results: The prevalence of MUI among STD recipients was lower than clinical and community rates. Rates of application and receipt of LTD benefits for MUI were similar to explained illness. When LTD payments were projected to retirement age, costs associated with unexplained back pain and fibromyalgia were comparable to those of explained illness. The length of disability and salary reimbursement costs were greater when comorbid psychiatric illness was present., Conclusions: Patients with MUI did not account for a disproportionate number of disability claims or amount of the money spent on salary reimbursement. Comorbid psychiatric illness increased the length and cost of disability.

In 1965, the effectiveness of psychoanalytic therapy was demonstrated, which was then included in the reimbursement schemes of the statutory health insurance. In 1987, epidemiologic evidence was provided for the high prevalence of psychosomatic diseases, often associated with a high risk load. Later a phase model described the effects of psychotherapy by the successive levels of remoralisation, symptom and functional improvement. On the basis of health insurance data Felliti (2002) provided plausible evidence for the psychosocial aetiology of most chronic somatic diseases. These data correspond to a dramatically reduced life expectancy. Thus, a causal bio-psycho-social chain exists between adverse childhood events (ACE), unspecific bodily tensions, dysfunctional health-related coping behavioural strategies (risk load), serious chronic diseases and premature death. In summary, psychosomatic medicine and psychotherapy is a field of health care with a variety of target dimensions which can be brought together in an appropriate model.

Objectives: Over the last years the use of diagnosis-related groups (G-DRG) was introduced into most areas of the German health care system, which led to changed compensation for departments outside the G-DRG system as well. We evaluated the development of revenues in 17 different psychosomatic departments over the last three years., Methods: Our analyses were based on official daily rates for each of the clinics included. If daily rates changed within one year, we used the average daily rate for that year., Results: Together all departments provided 547 in-patient beds for the treatment of acute psychosomatic patients. With 85% occupancy all departments would achieve a revenue of 62.5 million euro in 2005, two million euro less than three years previously. Due to the introduction of the German DRG system their average income was reduced by approx. 3%. The loss was greater for psychosomatic departments at larger hospitals, which have a higher percentage of departments included in the G-DRG system., Conclusions: The introduction of the G-DRG system leads to reduced revenues for departments outside the G-DRG system, while performance was expected to remain at the same level and costs have increased. Thus, to ensure the spectrum of psychosomatic medicine as it is today, it has become increasingly important to demonstrate the real costs of treatment to political decision makers.

Beside the stabilization of the health status the reintegration into employment are the main ambitions of the medical rehabilitation. Thereby occupational rehabilitation plays an important role in the rehabilitation system. To recommend occupational rehabilitation physicians have to know the requirements patients have to comply with. In addition formal conditions of the medical report upon discharge have to be accomplish that benefits for participation at working life will be provided by the pension insurance. In our study the differences of the amount of recommendation for occupational rehabilitation and the appraisal of the ability to work in the medical reports upon discharge of psychosomatic and orthopaedic patients are examined. The results show that psychosomatic patients achieved significantly less recommendations for occupational rehabilitation than orthopaedic patients. At the same time more psychosomatic patients who achieved the recommendation didn't claim benefits for participation at working life. In addition orthopaedic patients get a rehabilitation approval certification more often than psychosomatic patients. At the same time it appears that maybe the recommending clinics were insecure about the connection between the occupational capacity assessment and the recommendations for benefits for participation at work life. The outcomes presume that work place problems in medical rehabilitation are not taken into consideration adequately.

Objective: To review the value provided when health care systems independently manage medical and psychiatric care., Method: The authors draw on data from the world literature, their own experiences and reflections (one author as an international consultant in the coordination of physical and behavioural health care), and input from colleagues throughout the world who face similar challenges to improve outcomes for complex, high cost patients in their own health care systems., Results: Most health care systems in the world approach the administration and delivery of mental health care separately from that of general medical care. This practice is no longer supported as effective, efficient or inexpensive. Rather accumulating data indicates that concurrent and coordinated medical and psychiatric care, which can only be accomplished by integrating physical and behavioural health through infrastructure change, should replace the present system of independently provided sequential care; that is, one which provides first medical and then psychiatric treatment, or vice versa, with little communication between clinicians in the two sectors., Conclusions: By making mental health treatment an integral part of general medical care through reorganization of the funding system, a higher percentage of those now untreated for their psychiatric disorders, both within and outside of the medical setting, can have their mental health needs addressed in coordination with their physical disorders. At the same time, the number of patients that can be treated within the same budget will be expanded.

Measures of post-traumatic stress disorder (PTSD) and depression were used to predict Veterans Affairs outpatient treatment costs among Persian Gulf War veterans with medically unexplained physical symptoms. Patients (N = 206) enrolled in a Veterans Affairs primary care clinic for Persian Gulf War veterans completed study assessments at the initial appointment or at a proximal follow-up visit. Costs of care for mental health, medical, and pharmacy services for these veterans were computed for the subsequent 6-month period. Depression and PTSD symptoms explained a significant share of variance in costs of mental health care and pharmacy services, after adjustment for covariates. None of the mental status measures was significantly related to costs of medical care. Models using global measures of mental health status were as robust as models using disorder-specific measures of PTSD and depression in predicting mental health care and pharmacy costs. The implications of these findings for anticipating costs of care for Persian Gulf War veterans are discussed.

Purpose: Depression care management for primary care patients results in sustained improvement in clinical outcomes with diminishing costs over time. Clinical benefits, however, are concentrated primarily in patients who report to their primary care clinicians psychological rather than exclusively physical symptoms. This study proposes to determine whether the intervention affects outpatient costs differentially when comparing patients who have psychological with patients who have physical complaints., Methods: We undertook a group-randomized controlled trial (RCT) of depression comparing intervention with usual care in 12 primary care practices. Intervention practices encouraged depressed patients to engage in active treatment, using nurses to provide regularly scheduled care management for 24 months. The study sample included 200 adults beginning a new depression treatment episode where patient presentation style could be identified. Outpatient costs were defined as intervention plus outpatient treatment costs for the 2 years. Cost-offset analysis used general linear mixed models, 2-part models, and bootstrapping to test hypotheses regarding a differential intervention effect by patients' style, and to obtain 95% confidence intervals for costs., Results: Intervention effects on outpatient costs over time differed by patient style (P <.05), resulting in a $980 cost decrease for depressed patients who complain of psychological symptoms and a 1,378 dollars cost increase for depressed patients who complain of physical symptoms only., Conclusions: Depression intervention for a 2-year period produced observable clinical benefit with decreased outpatient costs for depressed patients who complain of psychological symptoms. It produced limited clinical benefit with increased costs, however, for depressed patients who complain exclusively of physical symptoms, suggesting the need for developing new intervention approaches for this group.

We sought to determine whether an intervention labeled "biofeedback" could be implemented with patients who were diagnosed with "functional" disorders (Irritable Bowel Syndrome, Fibromyagia/Chronic Fatigue Syndrome, Myofascial Pain, Anxiety with somatic features, or Noncardiac Chest Pain), in a primary care setting, and whether cost savings through lowered utilization of medical services would be realized. Seventy patients were initially randomized into a treatment group or comparison group based on willingness to participate. Ultimately, 19 patients completed treatment and 30 were followed through usual treatment as a comparison. Treatment patients completed symptom diaries while working with a biofeedback therapist in the primary care facility. Both group's medical expenses were tracked for 6 months prior to and 6 months after the treatment time interval. Patients in the treatment group lowered symptom frequency and severity significantly. Medical costs were differentially reduced in this group such that all costs were $72 less in the treatment group and $9 in the comparison for the 6 months following the treatment time period. (p < .001). Unfortunately, a large group of assigned treatment patients did not start or complete treatment. These patients had high initial costs and went up even higher post. No comparable group could be found among the controls, limiting any inference regarding cost/benefit. Biofeedback based interventions for "functional" disorders can be easily integrated into primary care settings, can reduce symptoms, and may be able to reduce overall medical costs in this group of patients known as heavy utilizers.

The increase in psychological, psychosomatic and chronic diseases is a challenge to claims managers and health experts in the field of rehabilitation. This change highlights the limitations of a diseases-orientated disability concept and forces insurers to rethink claims management procedures.

The medical diagnoses and their economic level of severity as well as the treatment costs and the proceeds of an integrated internal - psychosomatic ward C were compared with two conventional internal wards A and B of a general medical department within a hospital of tertiary care level. With a similar economic level of severity of the diagnoses, lethality and costs for nursing care given the medical treatment costs of C were significant lower and the proceeds (minus medical treatment costs and nurses' salaries) calculated according to G-DRG version 1.0 higher than those of A and B. Integrated internal medicine is more cost effective compared to conventional internal medicine.

Background: The objective of the present study was to determine if persons who use more adaptive defenses have lower physician health care costs compared to those who use less adaptive defenses., Methods: We randomly selected 667 persons from the 1995 population-based Nova Scotia Health Survey who completed a videotaped structured interview. Each interview was rated for typical defense use by the Defense-Q. We obtained physician health care costs for 3 months before and after the interview, as well as medical diagnoses and measures of psychological functioning., Results: A more adaptive defense profile significantly predicted lower future physician health care costs. These results were found when controlling for other psychosocial variables, before and after controlling for previous physician health care costs, and when testing only within a physically healthy subsample. Results of secondary analyses showed that a more adaptive defense profile was positively related to a number of psychosocial variables, such as nurse's rating of competence, lack of depressive symptoms, and days at work., Conclusions: The adaptiveness of a person's defense use in managing affect is important in predicting physician health care costs as well as psychosocial functioning., (Copyright 2003 S. Karger AG, Basel)

The aim of this study was to find out whether the diagnostic profile for patients seen in the psychosomatic Consultation-Liaison (CL) services in three Berlin hospitals in 1994 and 2001changed. All referrals to the psychosomatic CL service within 3 months in 1994 (N = 229) and within 3 months in 2001 (N = 196) were recorded and documented. It could be shown that the referred patients of the three Berlin hospitals more frequently had only mentally caused symptoms (without organ diseases) in the first data recording (1994) and more frequently organic diseases with concomitant mental comorbidity in the second data recording (2001). If this finding reflects a general tendency, it requires an adjustment in the competence of psychosomatic CL services and health policies that ensure the inclusion of mental aspects in hospital care.

Background: Functional somatic disorders are often seen in medical practice. This study describes their financial consequences for the national insurance scheme., Material and Methods: National Insurance Administration data for the year 2000 were collected on sickness leave and disability pensions for fibromyalgia, whiplash injuries, chronic fatigue syndrome, dissociative and somatoform disorders, functional gastrointestinal disorders, chronic pelvic pain, and non-cardiac chest pain., Results: Functional somatic disorders caused 2.9% of all sick leave among employees. Most of these were caused by fatigue/exhaustion or fibromyalgia. 6.3% of all new disability pensioners had a functional disorder, two thirds of them fibromyalgia. Functional disorders were more frequent in women, and in the 25-59 age group., Interpretation: Functional disorders, fibromyalgia especially, are a great concern for the national insurance system. More focus on individual functioning rather than the disorder might contribute to better follow-up for these patients.

The medical ideology being based on structure instead of function (specifically on the cgs-logic--centimetre, gram, second) instead of a patient-orientation, the patient's resources are rarely ever even touched. This is the basis for operating difficulties in self- and patient-management. Changes of this uneconomic approach should centre on training, focusing especially on how to increase the professional's sensitivity for the relationship with his patient. Unfortunately, Austria's situation is characterized by deficitary psychosomatic competence in medical professionals. In addition, the absence of universitary or other structures centering on psychosomatic training and co-ordination is to be criticized. An interuniversitary-psychosomatic structure in Austria is proposed as a starting-point to overcome these serious short-comings.

Research has shown that health among young people, particularly women, deteriorates during a recession compared to a boom. It seems that the trade cycle mainly affects the health of those who are not long-term unemployed. The aim of this study was to analyse the relation between the health of non-unemployed people and the levels of unemployment in society. Two groups of young people aged 21 were surveyed, one in 1986 (the boom group, n = 1083) and one in 1994 (the recession group, n = 898). The non-response rate was 2% in the first and 10% in the second group. Both groups were investigated with a self-administered questionnaire, which included questions about somatic and psychological health, as well as experiences of employment, unemployment, education and labour market programmes. Young men and women generally reported more somatic and psychological symptoms during recession than boom. The only exception was psychological symptoms among men, which was of the same magnitude during both periods. Poorer health during recession was found among women in work and in labour market programmes, as well as among both male and female students. Multiple regression analysis was performed in order to analyse if the occupational-related health effects of the trade cycle remained after controlling for possible moderating factors. The effects of unemployment in society on young people's health may be mediated through pessimism about the future, high demands and financial problems. Lack of control over the work situation may also be an important contributing factor to ill health among women during recession. The trade cycle was correlated with ill health among women only. Possible explanations for poorer health among women during a recession were discussed.

The social conflict model called mobbing has hitherto almost remained undetected by private personal insurance systems. The mental and functional somatic disturbances caused by mobbing, however, have been well known for a long time and do not differ from those caused by other conflicts. Problems for the personal insurance develop from the fact that more often than not a (feigned) conflict solution will be sought by medical certifications of unfitness to work, referrals to hospitals and striving for acknowledgement of occupational disablement, none of which have a medical justification. A considerable portion of the national economic burden of mobbing will therefore--mostly unknowingly--be shouldered by private insurance companies. There are numerous medical diagnoses which may hide a mobbing conflict and are difficult to comprehend. This article represents instructions for better understanding and handling.

This paper reflects the thinking, experience as well as diagnostic and therapeutic strategies of the Gelderland specialized clinic for psychotherapy and psychosomatic medicine with regard to extrinsically motivated patients, i.e., patients "sent" for treatment. The objective is to develop a therapeutic concept and to establish guidelines concerning the sociomedical aspects to be taken into account in this patient group. The problem analysis should start out at the situation at hand initially: Not only do these patients as a rule refuse to take an active part in therapy; they all to often attempt to sabotage any rehabilitation offers perceived as running counter to their own desires and goals (e.g. pension, retraining, collection of benefits during illness-related unemployment, etc.). Attempts to elucidate the psychosomatic problem complex of these patients are in addition hampered by their predominantly body-centred concept of disease. The particular motivational and therapy-related features of these patients are illustrated by case studies. A standardized procedure for sociomedical performance appraisals is presented which takes the specific features of this patient group into account and has stood the test in the clinical setting. Special mention should be made of: pre-admission diagnostics, inpatient psychodiagnostics, multidisciplinary systematic behavioural observation of the patient in the framework of group therapy, and a sensitive approach to conveying diagnostic results to the patient. The double role of psychotherapist and appointed expert is one demanding the highest degree of professional expertise. Besides, the expectations of the social security and financially responsible agencies which "sent" the client have to be taken into account as well. The sociomedical evaluation serves as the starting point for all therapeutic efforts and identification of the extent of a patient's extrinsic motivation. Along with a thorough review of the patient's medical records, pre-admission diagnostic efforts are in place in this respect for assessing a patient's motivation for therapy.

Because of the new hospital finance law a DRG (Diagnosis Related Groups) controlled discount liquidation under consideration of the medical impairment becomes necessary. In this paper the importance of a correct and complete description of the psychic comorbidity for the development of German-Refined-DRGs (GR-DRGs) in the orthopedic field is described. Therefore we analysed data of orthopedic in-patients, who are diagnosed by consultation of the clinic for psychosomatics and psychotherapy. A psychic comorbidity (ICD-10 Chapter F (V)) was diagnosed by 95% of the consulted patient. 30% of the patients showed difficulties in coping with their disease. 40% suffered from chronical psychoneurotic patterns and conflicts, which can be explained (a) as consequence of a difficult psychosocial adaptation by chronic disease or after an amputation (b) as basic mental disorders (c) as cause of the orthopaedic complications. Therefore the number of indications for a psychotherapeutic or psychiatric treatment is very high. The knowledge about a psychic comorbidity can--beside financial aspects--help the team on the orthopaedic station in the treatment of difficult patient.

Ambulatory rehabilitation concepts for women with psychosomatic disorders and with pre-school children are rare and moreover not yet assessed. An economic concept for the evaluation of indirect costs and (patient) time costs is being developed in this article and applied to an ongoing ambulatory rehabilitation programme for mothers at the Hanover Medical School. In health economic evaluations time cost is expressed by loss and reduction of working time, time for housework, and leisure time. These are indirect cost items (working time) and direct non-medical costs (housework and leisure time). To estimate the loss of working time (and hence production loss) the human capital approach and the frictional cost approach can be applied. Loss of time due to housework can be estimated either by the production of goods and services or by the opportunity costs of the equivalent working time. Loss of leisure time can be partial or total whereas a total loss and a loss of working time are considered to be analogous. The health economic evaluation of the ambulatory rehabilitation programme for mothers is designed as a randomised controlled study with repeated data collection. The parameters of indirect and direct non-medical costs are measured at the beginning of the rehabilitation programme and until twelve months later by means of questionnaires, face-to-face and telephone interviews. So far, results of the evaluation show that the actual time cost of the rehabilitation programme is DM 6,162 for each mother and the time cost because of the utilisation of the health care system is DM 996 per four weeks. Therefore, the patient costs are obviously higher than the direct medical costs for the programme which makes it clear that taking into account the costs of the patient (especially the time costs) can make a decisive difference in the evaluation of alternative treatment programmes and may possibly reverse the advantages of an alternative.