OBJECTIVES:The demographic trend towards an ageing society is accompanied by an increase in age-related illnesses, with late-life depression (LLD) being one of the most common mental illnesses in the oldest-old (≥ 80 years). As activity participation potentially prevents LLD, this study examines sex-specific differences in the relationship between activity participation and LLD risk. METHOD:Data were derived from the prospective multicenter cohort study AgeCoDe/AgeQualiDe with 9 follow-ups (FU). LLD was assessed using the 15-item Geriatric Depression Scale (GDS-15, cut-off score 6). Activity participation was first assessed at FU1 based on 14 physical, social and cognitive activities (5-point ordinal scale). Statistical analyses included descriptive statistics, Mann-Whitney U-tests and Cox regressions estimating incident LLD from FU2 to FU9. Time at risk began at FU1, where activity participation was first assessed. RESULTS:Analyses included n = 2,305 at FU1; mean age 81.0; 64% women. Men reported significantly more physical activity (U = 569,468, p = 0.010), women more cognitive activity (U = 658,426, p = 0.002). A higher activity participation at FU1 was associated with a lower risk of LLD with HR = 0.97, 95% CI [0.95, 0.98]. Particularly, participation in physical activities reduced LLD risk with HR = 0.96, 95% CI [0.93, 0.98], which could not be shown for social and cognitive activities. Analyses could not confirm a sex-dependent association. CONCLUSION:Activity participation, especially in physical activities, appears preventive for LLD in the oldest-old. Contrary to the hypothesis, these associations did not differ between men and women.

OBJECTIVES:Enhanced recovery after surgery (ERAS) protocols are patient-centred, interprofessional perioperative care models aimed at reducing hospital stays, complications, healthcare costs, and improving patient satisfaction. Evidence for ERAS in cardiac surgery is scarce; therefore, we aimed to assess its efficacy and safety in minimally invasive heart valve surgery (MIHS). METHODS:Interdisciplinary Perioperative Care in Minimally Invasive Heart Valve Surgery (INCREASE) is a randomized-controlled trial that compares ERAS with standard care in MIHS. The intervention group (IG) received ERAS-based treatment; the control group (CG) standard care. Co-primary end-points were in-hospital stay for cardiovascular reasons within 1 year postoperatively (superiority hypothesis) and physical performance (6-minute walk test [6MWT]) at discharge (non-inferiority hypothesis). Superiority hypothesis was tested primarily in surgically treated patients (modified intention to treat population), while non-inferiority hypothesis was tested in per protocol population. RESULTS:In total, 201 patients scheduled for MIHS were randomized (IG: 101; CG: 100). Total weighted in-hospital stay within 1 year was non-significantly shorter in the IG (adjusted mean difference -2.7 days, 95% confidence interval (CI) (-6.3, 0.9), 1-sided P = .07). Sensitivity analyses favoured the IG (adjusted ratio 0.71, 95% CI, 0.6, 0.85). For 6MWT, adjusted mean difference was -14%, 95% CI (-43%, 15%) exceeding the non-inferiority margin of -15% (1-sided P = .48). Without baseline adjustment, 6MWT values revealed a mean difference between groups of -1%, 95% CI (-10%, 8%), reaching non-inferiority of the IG. Safety outcomes were comparable with the exception of an unexpected higher rate of post-operative atrial fibrillation in patients randomized to ERAS. CONCLUSIONS:ERAS is feasible and safe in MIHS. The trial did not demonstrate a reduction in length of hospital stay during the first postoperative year in the population studied. Exploratory analyses suggest that further evaluation of ERAS concepts is justified.

Objective:To assess the economic evidence on school-based prevention and mental health promotion interventions, focusing on costs and outcomes across key societal sectors, including healthcare, education, social care, criminal justice, as well as in productivity and individual expenses. Design:A systematic review with narrative synthesis was conducted following the Synthesis Without Meta-analysis approach, including an assessment of monetised outcomes across all sectors and an additional analysis of non-monetised outcomes in the education sector. Study quality was appraised using Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and Consensus Health Economic Criteria (CHEC). Data sources:Medline, Embase, PsycINFO, Econlit, ERIC and Scopus. Eligibility criteria for selecting studies:Economic evaluations of school-based prevention or mental health promotion interventions for children or adolescents in Europe that report outcomes across healthcare and other societal sectors. Results:20 studies were included, comprising different types of economic evaluations as well as trial-based and model-based evaluations. Based on the primary analyses reported in the studies, which consider costs and benefits across multiple societal sectors, most evaluations suggested favourable economic outcomes. Benefits exceeded costs in four out of five (80%) cost-benefit analyses (average cost-benefit ratio of 5.14). Half of the cost-effectiveness analyses found that interventions were more effective but also more costly than the comparator while two interventions were both more effective and less costly. In cost-utility analyses, 9 out of 10 (90%) fell below commonly used thresholds for good value for money. Reported outcomes covered healthcare, education, social care, criminal justice sectors, as well as productivity and individual expenses. Pronounced cost savings from included interventions were observed in productivity and healthcare, with improvements also observed in non-monetised education outcomes. Study quality was mixed. Conclusions:School-based mental health interventions yield cross-sectoral economic benefits and, in many cases, societal returns on investment, in both the short and longer term, by influencing key determinants of health and well-being across multiple sectors.

Background The EQ-5D-5L is a widely used instrument for measuring preference-based health-related quality of life worldwide. In Germany, normative values for the EQ-5D-5L were determined in 2014. The aim of the study was to update these normative values for the year 2024, and to investigate associations between EQ-5D-5L index scores and EQ-VAS scores and various sociodemographic factors. Methods The study is based on a cross-sectional online survey of the adult general population in Germany. Normative values for the EQ-5D-5L index and EQ VAS were calculated for various sociodemographic groups. To examine the associations between the EQ-5D-5L index and EQ-VAS scores and selected sociodemographic factors, generalized linear models (GLM) were used. Results The sample included n = 5,504 participants. The mean EQ-5D-5L index score was 0.84 (SD 0.21). The mean EQ-VAS score was 69.64 (SD 20.64). Female participants had lower mean EQ-5D-5L index scores than male participants. Participants with a high level of education had higher mean EQ-5D-5L index scores compared to other participants. Comparing different age groups, the GLM showed that the EQ-5D-5L index and the EQ-VAS scores were negatively affected in the youngest age groups, particularly in the group of 18-to-24-year-olds. Conclusion This study updates the normative values of EQ-5D-5L for Germany. A key finding was that younger age groups, no longer showed the highest scores as observed in 2014 but were disadvantaged in comparison to other age groups, suggesting they may have been disproportionately affected by various global crises like the COVID-19 pandemic or armed conflicts.

Listing tools were found to ameliorate drug treatment in older people; the FORTA (Fit-fOR-The-Aged) list is a clinically validated positive-negative list of medication appropriateness. Here, we retrospectively analyze longitudinal correlations between the FORTA score and key measures of physical and cognitive function in older people. 504 participants of a multi-center cohort study (AgeCoDe/AgeQualiDe) for whom the FORTA score (sum of over- and under-treatment errors) had been assessed were studied at three follow-up (FU) time points (FU 6–8; mean age range 87.9–89.7 years); comparisons between data at these FUs separated by 10 months were available for 292–328 patients. The univariate analysis of the association between FORTA_Delta_76 (change of FORTA score between FU 6 and 7) and ADL (Activities of Daily Living)_Delta_76 (− 0.155, p < 0.01) and between FORTA_Delta_76 and MMSE (Mini-Mental State Examination)_Delta_76 (− 0.203, p < 0.01) revealed significant correlations. Multivariable analysis (using a forward selection model, p < 0.05) revealed a significant association between FORTA_Delta_76 and MMSE_Delta_76 (p < 0.05). Univariate analyses for other comparisons were only significant for FORTA_Delta_86 and MMSE_Delta_86. This study indicates that longitudinal non-interventional changes of the FORTA score as an integral index of medication appropriateness are associated with changes in ADL and MMSE: the lower this score the better the functional outcome. These findings are in line with earlier interventional data and underscore the potential of FORTA to improve clinical endpoints in older people.

Abstract Survivors of critical illness frequently experience persistent impairments in health-related quality of life (HRQoL), with psychological symptoms contributing substantially to this burden. The relative contribution of co-occurring depression, anxiety, and post traumatic stress symptoms remains insufficiently understood. To address this gap, we conducted a cross-sectional analysis of pre-randomization data from the PICTURE randomized controlled trial, a multicenter study of a brief primary care–based psychological intervention for post-traumatic stress disorder symptoms following critical illness, including 319 intensive care unit survivors. Clinical, demographic, and mental health assessments were obtained after ICU discharge. Latent profile analysis, random forest modeling, and quantile regression were applied to identify determinants of HRQoL measured by the EuroQol Five-Dimension Five-Level (EQ-5D-5L) index and visual analog scale (VAS). The mean EQ-5D-5L index was 0.71 (SD 0.27; median 0.81) and the mean EQ VAS score was 60.7 (SD 19.4; median 60.0), indicating considerable overall impairment. Depression, anxiety, and post-traumatic stress symptoms showed substantial overlap and formed four distinct symptom profiles associated with specific functional impairments. Screening positive for depression on the 2-item Patient Health Questionnaire (PHQ-2) with ≥ 3 points was associated with a median reduction of -0.13 (95% CI -0.19 to -0.07) on the EQ-5D-5L index and -12.45 points (95% CI -17.93 to -6.96) on the EQ VAS, exceeding clinical and demographic predictors. These findings indicate that depressive symptoms are a major determinant of impaired health related quality of life among intensive care survivors with psychological distress and support routine brief depression screening in post-intensive care follow up. Trial registration: ClinTrials.gov: NCT03315390 (Registration date: 2017-10-20); German Clinical Trials Register: DRKS-ID: DRKS00012589 (Registration date: 2017-10-17).

BACKGROUND:Survivors of critical illness often experience persistent functional disability alongside psychological distress. We examined baseline determinants and domain-specific patterns of disability, and the longitudinal effects of a brief primary care intervention for post-traumatic stress disorder (PTSD). METHODS:In the PICTURE randomized controlled trial, 319 adults aged 18-85 years with PTSD symptoms at least 3 months after intensive care unit (ICU) discharge were randomized to three general practitioner (GP)-led narrative exposure consultations or to improved usual care based on PTSD guidelines. Disability was measured using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) at baseline, 6, and 12 months. Baseline determinants, disability profiles, and longitudinal changes in disability were evaluated using descriptive analyses and adjusted linear regression models. RESULTS:Depressive and anxiety symptoms were the strongest correlates of baseline disability, exceeding associations with ICU-related factors. Disability showed distinct domain-specific patterns, with emotional difficulties predominating at lower disability levels and progressively broader impairments at higher levels. No meaningful between-group difference was observed at 6 months, whereas disability showed a greater decline in the intervention group by 12 months (adjusted β = -4.31, 95% CI -8.25 to -0.37). Exploratory item-level analyses suggested the greatest improvements in emotional distress, friendships, and work-related activities. CONCLUSIONS:During the later stages of post-ICU recovery in primary care, psychological symptoms appear to become stronger determinants of functional disability than characteristics of the preceding critical illness. Functional benefits following brief trauma-focused care may emerge gradually, suggesting that psychological recovery translates into broader gains over time.

The termination of U.S. federal funding for research on sexual and gender diverse youth mental health raises the question of what this commentary proposes to call epistemic obstruction: the systematic prevention of knowledge about a vulnerable population. Drawing on the case of Clark et al., it examines the consequences for scientific freedom, health economic reasoning, and international research responsibility.

Background Depression screening in primary care has been widely discussed, but its economic implications have remained largely unexplored. The GET.FEEDBACK.GP randomised controlled trial evaluated feedback interventions after depression screening in primary care. The study arms were (a) feedback provided to the general practitioner; (b) feedback to both the patient and the treating general practitioner; and (c) a control group without feedback. Analysis of clinical effectiveness revealed that feedback interventions were not associated with decreased depression severity. Their economic implications were the subject of this study. Aims To evaluate the economic impact of general-practitioner- and patient-targeted feedback following depression screening for adults in German primary care. Method A cost-effectiveness analysis from a societal perspective of feedback interventions after depression screening with a time horizon of 12 months was conducted. Direct and indirect costs were estimated. Quality-adjusted life years were calculated on the basis of the EQ-5D-5L, and incremental cost-effectiveness ratios and cost-effectiveness acceptability curves based on the net monetary benefit were constructed. Sensitivity analyses and post hoc explorative subpopulation analyses were performed. Trial registration: ClinicalTrials.gov, NCT03988985. Results In total, 987 participants who screened positive for at least moderate depression were included. Feedback provision was not significantly associated with changes in costs or quality-adjusted life years during follow-up. Cost-effectiveness probabilities of feedback interventions were lower than 50% compared with no feedback. Higher cost-effectiveness probabilities were observed in patients whose suspected depression was confirmed 1 month post-screening and in those with previous depression. Conclusions The analysed feedback interventions cannot be considered to be cost-effective for the investigated population. Patient-targeted feedback was potentially cost-effective for subpopulations, particularly patients with a later confirmed depression diagnosis; this requires further research.

RECOVER is a severity-stratified, evidence-based care model integrating multiple levels of mental illness. This analysis focuses on individuals with severe and persistent mental illness (SMI/SPMI) and complex care needs, who received outreach-based services through Assertive Community Treatment (ACT) and Crisis Resolution Teams (CRT) as core components of the RECOVER intervention. This study assesses cost-effectiveness from a societal perspective, informed by clinical outcomes. Three domains were analyzed: (1) societal costs over a 12-month follow-up were compared between RECOVER and treatment as usual (TAU) using adjusted generalized linear models; (2) cost-effectiveness was assessed by estimating the incremental cost-effectiveness ratio (ICER) and cost-effectiveness probabilities via net monetary benefit regressions; and (3) psychosocial functioning was assessed via linear mixed model for repeated measures. Among 891 randomized trial participants, 506 (56.8 %) met criteria for SMI/SPMI (RECOVER n = 252, TAU n = 254). RECOVER was associated with lower societal costs (-€6681; p < 0.01). Although outpatient costs increased (+€1593; p < 0.001), these were more than offset by inpatient cost savings (-€6382; p < 0.001), resulting in a substantial net cost reduction. The ICER revealed dominance of RECOVER compared to TAU; cost-effectiveness probabilities exceeded 99 % across varying willingness-to-pay thresholds. Effectiveness analyses showed improved psychosocial functioning in the RECOVER group relative to TAU. The RECOVER model, characterized by outreach-based care (ACT/CRT), demonstrated cost-effectiveness and reductions in inpatient service use. Results highlight the economic and structural benefits of shifting from inpatient to community-focused care for individuals with SMI/SPMI. RECOVER offers a scalable framework for sustainable mental health service reform and should inform future standard care models.

Previous experience of violence and other traumata as well as post-migration stressors affect the mental health of refugees and asylum seekers. There is a fundamental gap between mental health needs and care utilization. To address this gap, it is important to understand the perceived access barriers to mental health care among refugees and asylum seekers. This review analyzed the barriers using Penchansky and Thomas’ (1981) concept of access. A systematic review of qualitative studies was conducted in April 2024 by two independent reviewers. The search included three databases: PubMed, Web of Science and PsycINFO. Studies published since 2013, with self-reported barriers or hurdles to access mental health services by legal adult refugees or asylum seekers were included. Information about the study design and setting, participant characteristics, and reported barriers to mental health care utilization were extracted. Risk of bias was assessed by the Mixed Methods Appraisal Tool. Due to the high heterogeneity, a narrative analysis was chosen. 25 studies were identified. Barriers were social and cultural factors as well as a lack of awareness. Here, most prominent was the negative stigmatization of mental health and misinformation about mental health services. Furthermore, language barriers hinder refugees and asylum seekers to seek help. Accommodation was a rarely mentioned barrier. The reported access barriers occurred in a specific combination of country of origin and destinations. In contrast to previous studies, we identified the refugees’ and asylum seekers’ fear of experiencing discrimination and the perceived lack of benefits of therapy as barriers. Refugees and asylum seekers had a preference to solve mental health problems by getting support in their social environment. Epistemic injustice and the relationship between different barriers highlight the complexity of access barriers. The generalizability might be limited. Self-reported access barriers among refugees and asylum seekers are multidimensional. Access barriers occur within the health care system as well as within the refugees’ and asylum seekers’ community. A rise in awareness, acceptability, and availability of mental health services is needed to ensure adequate care. Furthermore, cultural and religious differences between the providers and the refugees and asylum seekers should be considered.

BACKGROUND:Intensive care unit (ICU) survivors frequently experience symptoms of post-traumatic stress disorder (PTSD) and reduced health-related quality of life (HRQoL), yet evidence for effective post-ICU interventions in primary care remains limited. This secondary analysis of the PICTURE randomised controlled trial provides an in-depth evaluation of HRQoL trajectories and potential treatment mechanisms. METHODS:The analysis included 319 adult ICU survivors with at least moderate PTSD symptoms, randomised to a brief general practitioner (GP)-delivered narrative exposure intervention or enhanced usual care. Longitudinal mixed-effects models estimated treatment-by-time effects on HRQoL, based on EuroQol Five-Dimension Five-Level (EQ-5D-5L) index and visual analog scale (VAS), with mediation via PTSD symptom change assessed using structural equation modelling. RESULTS:The mean baseline EQ index was 0.71 ± 0.27 and EQ VAS was 60.7 ± 19.4. Mixed-effects models showed a transient improvement in EQ VAS at 6 months in the intervention group (ß = 5.85; 95% CI 0.84-10.87), followed by a delayed improvement in the EQ index at 12 months (ß = 0.075; 95% CI 0.014-0.136). About one quarter of the 12-month EQ index effect was mediated by PTSD symptom reduction at 6 months. Domain-level analyses indicated greater improvement in anxiety/depression and mobility. CONCLUSIONS:In ICU survivors with PTSD symptoms, a brief GP-delivered psychological intervention was associated with clinically meaningful improvements in health-related quality of life over 12 months, with effects emerging over time and only partly explained by PTSD symptom reduction. TRIAL REGISTRATION:ClinTrials.gov: NCT03315390 (Registration date: 2017-10-20); German Clinical Trials Register (DRKS): DRKS00012589 (Registration date: 2017-10-17).

The early detection of pancreatic cancer is an important step in reducing mortality by offering patients curative treatment. The aim of this study was to synthesize available evidence on the costs and cost-effectiveness of strategies for early pancreatic cancer detection. The electronic databases PubMed, Web of Science, and EconLit were searched for peer-reviewed and published papers in English until April 2024 with no date or contextual restrictions. Economic evaluations of early pancreatic cancer detection strategies compared to alternative or no detection strategies were criteria for inclusion. Thirty-one articles were included, 22 were full and nine were partial economic evaluations. Fifteen studies screened target populations with pancreatic cancer-associated risk factors and 16 conducted surveillance of patients with precancerous lesions. Six studies found early detection strategies to be cost-effective, one did not, and thirteen reported partially cost-effective results. In all studies, populations of interest had an elevated pancreatic cancer risk compared to the general population. Endoscopic ultrasound, magnetic resonance imaging, and computed tomography were the most frequently evaluated imaging modalities. Patient engagement, valuation of outcomes and choice of discount rates were among incomplete reporting categories, and narrow evaluation perspectives may have biased the results. Early detection strategies for pancreatic cancer may be cost-effective for certain high-risk patient groups. However, evaluations so far have applied heterogeneous methods, used different modalities, had various target groups and screened at different frequencies. Further evaluations will be required to systematically synthesize economic evidence regarding specific early detection strategies. PROSPERO registration CRD42023475348.

Background The aim of the study was to analyze the impact of adherence to the intervention components on the effectiveness of AgeWell.de, a multi-domain lifestyle intervention against cognitive decline, on function in everyday activities, quality of life, depressiveness and social isolation. Objective Studying the effect of adherence on health-related outcomes. Methods Participants were aged 60–77 years at baseline and at risk (Cardiovascular Risk Factors, Ageing and Dementia Score (CAIDE) ≥9). Adherence to the components nutrition, enhancement of physical and social activities and cognitive training was analyzed in two ways, first continual within the intervention group (n = 378, mean age = 69.1 years, 52.7% female) and second as dichotomous split (75% adherence) and in reference to the control group (received infomaterial and regular health advice; n = 441, mean age = 69 years, 53% female). Generalized linear regression models were then run on the health outcomes functioning in everyday activities, quality of life, depressive symptoms, and social inclusion. Results Health-related quality of life and depressiveness were improved in participants with better adherence to nutritional counselling and enhancement of physical and social activities. Better adherence to social activities was relevant for function in everyday activities. Effects of high adherence to cognitive training was found for improvements in depressiveness when comparing it to the control group. No effect was found on social inclusion when considering the particular components. Conclusions The extent of adherence to most components influenced health-related outcomes such as health-related quality of life and depressiveness. With this study, the effectiveness of AgeWell.de can be understood in greater depth. Trial Registration German Clinical Trial Register (DRKS; ID: DRKS00013555).

Recruitment through general practitioners (GPs) is a key challenge in primary care trials. Understanding how individual, practice, and regional characteristics affect recruitment and perceived workload could help optimize participation strategies. This study aims to identify barriers and facilitators to patient recruitment within the AgeWell.de dementia prevention trial. We analysed publicly available data on GPs participating in the AgeWell.de trial, including their sociodemographic characteristics, practice structures, and socioeconomic indicators of their practice locations, alongside recruitment and survey data. We used correlation analysis and uni- and multivariable regression models to explore determinants of study engagement in terms of recruitment performance and perceived workload. Among 120 participating GPs, a total of 1,173 patients were recruited, though contributions varied widely. The top 20 Trail registration: German Clinical Trials Register (DRKS; trial identifier: DRKS00013555); Date of Registration: 2017-12-07.

Theoretical background: Mental disorders in childhood and adolescence are as common as in adulthood and are precursors of mental disorders in adulthood. There is an urgent need for low-threshold, population-based prevention and early intervention measures to reach all children and adolescents. Objective: The aim is to develop a concept combining evidence-based interventions and implementation factors that improve conditions for young people in urban areas and their living environments and lead to a long-term increase in mental health and a reduction of mental disorders. Method: Based on a literature review and interdisciplinary expert workshops, we developed measures and strategies for the prevention and early intervention of mental disorders in a participatory manner with stakeholders and experts in the field. Results: The Urban Mental Health (UMH) concept is a comprehensive and low-threshold intervention strategy implemented by professionals, teachers, and everyday helpers in the urban environments where children, adolescents, and young adults live, such as schools, kindergartens as well as counseling and youth-welfare institutions. The ongoing evaluation of all UMH components provides a learning system that allows adapting the UMH concept to different institutions and conditions. Discussion and conclusion: The UMH concept takes a holistic, community-based, and participatory approach. A coalition of stakeholders from politics, science, and practice ensures a sustainable implementation of the UMH concept across the country.

BackgroundHealthy dietary patterns have been linked to reduced risks for cardiovascular diseases and dementia, making nutrition an essential part of a comprehensive approach for dementia prevention. Knowledge about factors associated with a healthy diet in people with increased dementia risk is scarce.ObjectiveTo analyze dietary habits and associated factors in older adults with increased dementia risk in Germany.MethodsWe used baseline-data of the AgeWell.de-trial (n = 1001, %female = 52.2, Mage = 69.0, SD = 4.9). Nutrition was assessed using a composite score, comprising 11 components covered by national recommendations for a healthy diet (range = 0-11 points). Linear regressions assessed associations of sociodemographic, social, health-related and psychological factors with consumption of a healthy diet. Further, we assessed stages of change based on the transtheoretical model of behavior change.ResultsConsumption of a healthy diet was moderate (Median = 4, IQR = 2). Female sex (b = 0.64, 95% CI: 0.41, 0.88), higher levels of motivation for healthy eating (b = 0.22, 95% CI: 0.10, 0.34) and higher self-efficacy (b = 0.33, 95% CI: 0.20, 0.46) were linked to a healthy diet. Regarding the stages of behavior change, the majority were in the maintenance stage (45.2%), followed by the contemplation (21.5%) and precontemplation (21.2%) stages.ConclusionsResults suggest room for improvement regarding a healthy diet in our sample. Lifestyle-based interventions in older adults should be tailored towards current levels of motivation and self-efficacy of participants. Including modules targeting motivation and self-efficacy might help maximize intervention effectiveness.