Introduction The number of people with peripheral arterial disease (PAD) increased by almost 25% between 2000 and 2010. The economic burden on healthcare systems caused by PAD will continue to rise because of the aging population and a further increase in risk factors. The aim of the study was to examine the cost-effectiveness of the 12-month patient-centered ‘Telephone Health Coaching and Remote Exercise Monitoring for Peripheral Artery Disease’ (TeGeCoach) program in a randomized controlled trial. Methods This is a cost-effectiveness analysis based on a two-arm, parallel-group, open-label, pragmatic, randomized-controlled clinical trial conducted by three German statutory health insurance funds with follow-up assessments after 12 and 24 months. Claims data for the calculation of costs and questionnaire data for the quantification of quality-adjusted life years (QALYs) based on the EQ5D-5L were used. From a healthcare payer’s perspective, cost-effectiveness was examined over 24 months follow-up using intention-to-treat (ITT) and modified ITT (mITT) and per protocol (PP) approaches. Results Assuming intervention costs of €672, the point estimates for the ITT analysis over 24 months showed non-significantly higher costs in the IG of €2003 and non-significantly higher QALYs of 0.02 compared to the control group. At a willingness to pay (WTP) threshold of €50,000, the probability of the TeGeCoach being cost-effective was 30%. Under the same assumptions, the mITT and the PP approach resulted in probabilities for cost-effectiveness of 79% and, 95%, respectively. Conclusion As demonstrated by the PP- and mITT-analysis, the treatment of PAD by TeGeCoach might be cost-effective under favorable assumptions. However, applying the stricter criteria represented by the ITT scenario, TeGeCoach couldn’t demonstrate its cost-effectiveness. Therefore, before TeGeCoach should be used in healthcare practice, it is necessary to adapt the program implementation. The effectiveness of these adjustments should then be verified in further studies.

Aims We will first examine whether seeking help for depression and schizophrenia from mental health professionals is nowadays more accepted among the German public than it used to be 30 years ago. Next, we will explore whether changes in help-seeking preferences between 1990 and 2020 are specific to mental health professions or are part of changes in attitudes to professional help-seeking in general. Finally, we will study whether a temporal relationship does exist between the advent of awareness-raising and anti-stigma campaigns after the turn of the millennium and changes in the acceptance of mental health care. Methods In 1990 ( n = 2044), 2001 ( n = 4005), 2011 ( n = 1984) and 2020 ( n = 2449) methodologically identical population-based surveys were conducted in Germany. After presentation of an unlabelled case vignette depicting someone with either schizophrenia or depression, we asked about help-seeking recommendations for the person described. Results The German public's readiness to recommend seeking help from mental health professionals has markedly grown over the past 30 years. In contrast, in the eyes of the public, turning to a general practitioner has become only slightly more, consulting a priest even less advisable than it used to be three decades ago. Seeing a naturopath is seen with markedly less disapproval today compared to 1990, but explicit recommendation of this helping source has not increased correspondingly in. The most pronounced increase in the German public's propensity to recommend seeking help from mental health professionals occurred already in the 1990s, i.e. before efforts to heighten public awareness had started. Conclusions Today, the German public is more in favour of mental health professionals than it used to be three decades ago. This seems to be a specific trend, and not to reflecting an increasing propensity towards professional help-seeking in general. Our findings counter the narrative that mental health communication efforts and initiatives have created more favourable attitudes towards mental health care among the public, since the observed changes in attitudes have preceded any campaigns. Instead, we tend to interpret the rise of the popularity of mental health professionals as a reflection of general cultural changes that have taken place over the past decades in Germany, as in other western countries.

Background Peripheral artery disease (PAD) is the third most prevalent atherosclerotic cardiovascular disease. In 2016, costs per patient associated with PAD exceeded even the health-economic burden of coronary heart disease. Although affecting over 200 million people worldwide, a clear consensus on the most beneficial components to be included in home-based exercise programs for patients with peripheral artery disease is lacking. The aim of the study was to examine the health care use and costs caused by the 12-month patient-centered ‘Telephone Health Coaching and Remote Exercise Monitoring for Peripheral Artery Disease’ (TeGeCoach) program in a randomized controlled trial. Methods This is a two-arm, parallel-group, open-label, pragmatic, randomized, controlled clinical trial (TeGeCoach) at three German statutory health insurance funds with follow-up assessments after 12 and 24-months. Study outcomes were medication use (daily defined doses), days in hospital, sick pay days and health care costs, from the health insurers’ perspective. Claims data from the participating health insurers were used for analyses. The main analytic approach was an intention-to-treat (ITT) analysis. Other approaches (modified ITT, per protocol, and as treated) were executed additionally as sensitivity analysis. Random-effects regression models were calculated to determine difference-in-difference (DD) estimators for the first- and the second year of follow-up. Additionally, existing differences at baseline between both groups were treated with entropy balancing to check for the stability of the calculated estimators. Results One thousand six hundred eighty-five patients (Intervention group (IG) = 806; Control group (CG) = 879) were finally included in ITT analyses. The analyses showed non-significant effects of the intervention on savings (first year: − 352€; second year: − 215€). Sensitivity analyses confirmed primary results and showed even larger savings. Conclusion Based on health insurance claims data, a significant reduction due to the home-based TeGeCoach program could not be found for health care use and costs in patients with PAD. Nevertheless, in all sensitivity analysis a tendency became apparent for a non-significant cost reducing effect. Trial registration NCT03496948 (www.clinicaltrials.gov), initial release on 23 March 2018

AIM: To date, to our knowledge there are no studies regarding attitudes and experiences of outpatient medical personnel during a pandemic. This study's aim was to evaluate the impact of the COVID-19 pandemic in March 2020 on German psychiatrists and neurologists. METHODS: An e-mail and fax-based short survey of 2,072 practice-based psychiatrists and neurologists was performed including Likert-type questions on personal burden and concerns, anticipated risk of infection, practice management as well as anxiety and sleep problems. RESULTS: 396 physicians returned the questionnaire (19 %). More than 60 % of the participants felt restricted strongly or very strongly, more than 30 % were strongly and very strongly concerned. They anticipated a high own risk of infection. However, 91 % did not report any contact with patients positively screened for COVID-19, which they were aware of. One third felt financially threatened and loss of business volume was anticipated. 18 % reported, that the pandemic triggers substantial anxiety. Sleep problems, which occur at least almost every night, were rarely reported (9 %). CONCLUSION: Practice-based psychiatrists and neurologists are negatively affected by the COVID-19 pandemic.

Objectives This study aims to investigate the public stigma towards informal caregivers of individuals aged 65 years and older in the German population.Method In an Online-Survey 1038 participants (18 years and older and living in Germany) were sampled using a quota-system based on the German micro census data. To assess public stigma towards informal caregiving for individuals aged 65 years and older, three aspects of stigma were assessed: 1) emotional reactions (adapted Emotional Reaction to Mental Illness Scale), 2) behavioral reactions (adapted Social Distance Scale), and 3) cognitive reactions (newly developed List of Cognitions regarding informal caregiving). Exploratory and confirmatory factor analyses were conducted for the development and adaptation of the three instruments, and their composite reliability is provided.Results Emotional reactions in terms of devaluing feelings and feelings of misery were low, while appreciative feelings were neither low nor high. Reported social distance was low. Agreement with cognitions towards informal care in terms of devaluing and accusative cognitions was on average low, but high regarding appreciative cognitions.Conclusion The results show that there is stigma towards informal caregiving for older individuals (65 years and older) in terms of emotional reactions, cognitions and social distance, although the magnitude of this stigma seems to be small. Knowledge regarding the occurrence and magnitude of stigma, as well as the processes that underlie this, is needed to prevent stigmatization and its negative outcomes, or at the very least, to enable the development of support for the affected individuals.

Depressive disorders are among the most widespread mental disorders in old age, with negative consequences for quality of life (QOL). Understanding QOL as a multidimensional construct, in this article we have a closer look on what specific aspects are affected by depression. We used a representative sample of the German population (n = 805) and one of individuals diagnosed with depression (n = 106) to compare QOL using the WHOQOL-BREF and the WHOQOL-OLD. Multivariate analysis showed that individuals diagnosed with depression exhibited lower QOL with regard to WHOQOL-BREF-dimensions physical health, psychological, social relationships and global QOL and with regard to WHOQOL-OLD-facets sensory abilities, past, present, and future activities and social participation. In addition, in the regression analysis, there were no significant differences between individuals with and without depression with regard to environment (WHOQOL-BREF), autonomy, death and dying, intimacy and overall (WHOQOL-OLD). Associations between depression and QOL in older age are selective in terms of which aspects of QOL are affected. From a methodological perspective, a multidimensional approach to QOL is recommended. From a clinical perspective, our research highlights those areas of QOL that are relevant for health professionals working with older people and that could be the focus of interventions.

Objectives: This study aimed to investigate the association between familiarity with caregiving and public stigma towards informal caregivers of older individuals. Material and methods: The sample for this Online-Survey was identified using a quota-system based on German micro census data (N=1037; aged 18 years and older, living in Germany). Familiarity with caregiving was assessed by asking whether the participant has experience in or has friends or relatives with experience in informal or professional caregiving for individuals aged 65 years or older. Public caregiver stigma was assessed by analyzing the emotional, behavioral and cognitive reactions towards caregivers as described in a vignette. Results: Adjusted regressions analyses indicated that experience in providing informal care was associated with increased appreciative feelings and statements, and decreased social distance. Experience in providing professional care was associated with increased devaluing statements. Having friends or relatives who have experience in informal caregiving was associated with decreased social distance. Having friends or relatives who have experience in professional caregiving was associated with decreased devaluing feelings, increased appreciative feelings and decreased social distance. Conclusions: Results indicate that familiarity with caregiving, through one's own informal care experience or through contact with informal or professional caregivers, reduced public stigma towards informal caregivers. Moreover, experience with informal care or contact with professional caregivers increased appreciation of informal caregivers. However, increased negative stigmatizing statements were indicated among participants with experience in professional caregiving. Fostering contact and cooperation between informal caregivers and non-caregivers, as well as with professional caregivers may help reduce stigmatizing reactions.

Background: In recent years there is a growing interest in public beliefs about mental disorders. Numerous representative population-based studies have been conducted around the globe, also in European countries bordering on the Mediterranean Sea. However, relatively little is known about public beliefs in countries in Northern Africa. Objective: To fill this gap by comparing public beliefs about mental disorders in Tunisia and Germany, focusing on causal beliefs, help-seeking recommendations and treatment preferences. Methods: Representative national population-based surveys have been conducted in Tunisia in 2012 (N = 811) and in Germany in 2011 (N = 1852), using the same interview mode and the same fully structured interview starting with a vignette depicting a person suffering from either schizophrenia or depression. Results: In Tunisia, the public was more likely to adopt psychosocial and to reject biogenetic explanations than in Germany. Correspondingly, psychological treatments were more frequently recommended and biological ones more frequently advised against. There was also a strong inclination to share religious beliefs and to recommend seeking religious advice. Tunisians tended much more than Germans to hold moralistic views and to blame the afflicted person for his or her illness. In Tunisia, the public tended less to differentiate between schizophrenia and depression than in Germany. Conclusion: Marked differences between Tunisia and Germany exist in public beliefs about the causes of mental disorders and their treatment, which correspond to differences in cultural orientations prevailing in these countries. Mental health professionals need to be sensitive to the particular cultural context in which they operate, in order to be able to reach those they intend to care for.

Aim To date, to our knowledge there are no studies regarding attitudes and experiences of outpatient medical personnel during a pandemic. This study's aim was to evaluate the impact of the COVID-19 pandemic in March 2020 on German psychiatrists and neurologists. Methods An e-mail and fax-based short survey of 2,072 practice-based psychiatrists and neurologists was performed including Likert-type questions on personal burden and concerns, anticipated risk of infection, practice management as well as anxiety and sleep problems. Results 396 physicians returned the questionnaire (19 %). More than 60% of the participants felt restricted strongly or very strongly, more than 30% were strongly and very strongly concerned. They anticipated a high own risk of infection. However, 91% did not report any contact with patients positively screened for COVID-19, which they were aware of. One third felt financially threatened and loss of business volume was anticipated. 18% reported, that the pandemic triggers substantial anxiety. Sleep problems, which occur at least almost every night, were rarely reported (9 %). Conclusion Practice-based psychiatrists and neurologists are negatively affected by the COVID-19 pandemic.

Due to a multitude of reasons Randomized Control Trials on the basis of so-called "routine data" provided by insurance companies cannot be conducted. Therefore the estimation of "causal effects" for any kind of treatment is hampered since systematic bias due to specific selection processes must be suspected. The basic problem of counterfactual, which is to evaluate the difference between two potential outcomes for the same unit, is discussed. The focus lies on the comparison of the performance of different approaches to control for systematic differences between treatment and control group. These strategies are all based on propensity scores, namely matching or pruning, IPTW (inverse probability treatment weighting) and entropy balancing. Methods to evaluate these strategies are presented. A logit model is employed with 87 predictors to estimate the propensity score or to estimate the entropy balancing weights. All analyses are restricted to estimate the ATT (Average Treatment Effect for the Treated) Exemplary data come from a prospective controlled intervention-study with two measurement occasions. Data contain 35 857 chronically ill insurants with diabetes, congestive heart failure, arteriosclerosis, coronary heart disease or hypertension of one German sickness fund. The intervention group was offered an individual telephone coaching to improve health behavior and slow down disease progression while the control group received treatment as usual. Randomization took place before the insurants' consent to participate was obtained so assumptions of an RCT are violated. A weighted mixture model (difference-in-difference) as the causal model of interest is employed to estimate treatment effects in terms of costs distinguishing the categories outpatient costs, medication costs, and total costs. It is shown that entropy balancing performs best with respect to balancing treatment and control group at baseline for the first three moments of all 87 predictors. This will result in least biased estimates of the treatment effect.

BACKGROUND:To analyze whether probable panic disorder (PD) is associated with health care costs in older age over time.METHODS:Data regarding individuals aged 65 and over were derived from two waves of the ESTHER cohort study (nt1  = 2,348, nt2  = 2,090). Probable PD was assessed using the panic screening module from the Patient Health Questionnaire. Health care costs were obtained through monetary valuation of self-reported health care use data. Fixed effects regressions analyzed the association between transitions in probable PD status and change in health care costs, while adjusting for potential confounders.RESULTS:On a descriptive level, study participants with a positive PD screening displayed higher three-month health care costs compared to those without (incremental costs: € 259 for t1 , € 1,544 for t2 ). Transitions in probable PD were associated with an approximate increase of 65% in outpatient health care costs (β = 0.50, p < .05). There was no significant association between probable PD transition and change in any other cost category.CONCLUSIONS:Using longitudinal data, our results highlight the economic consequences of probable PD in older adults. Future research should address whether reducing PD in older adults may reduce the associated economic burden and analyze underlying mechanisms.

Background. There is currently a gap in the research literature regarding the occurrence and magnitude of public stigma towards informal caregiving. However, the investigation of stigma towards informal care is highly relevant, given the negative consequences that stigmatization can have. Therefore, this study aims to investigate the public stigma towards informal caregiving for individuals older than 65 years in the German population.Methods. 1038 members of the adult population (18 years and older) living in Germany participated in an online-survey. They were sampled using a quota-system based on the German micro census data. To assess public stigma towards informal caregiving for individuals older than 65 years, the following three aspects of stigma were assessed: 1) emotional reactions (adapted version of the Emotional Reaction to Mental Illness Scale), 2) behavioral reactions (extended version of the Social Distance Scale), and 3) cognitive reactions (newly developed list of Cognitions regarding informal care). Exploratory and confirmatory factor analyses were conducted for the development and adaptation of the three instruments, and their composite reliability is provided.Results. Emotional reactions in terms of devaluing feelings and feelings of misery were low, while appreciative feelings were neither low nor high. Reported social distance was low. Agreement with cognitions towards informal care in terms of devaluing and accusative cognitions was on average low, but high regarding appreciative cognitions.Conclusions. The results show that there is stigma towards informal caregiving for older individuals (65 years and older) in terms of emotional reactions, cognitions and social distance, although the magnitude of this stigma seems to be small. Knowledge regarding the occurrence and magnitude of stigma, as well as the processes that underlie this, is needed to prevent stigmatization and its negative outcomes, or at the very least, to enable the development of support for the affected individuals.

BackgroundPrevious studies have shown that higher education may reduce dementia risk and promote a better cognitive functioning in older age.ObjectiveThe study investigated to what extent higher education leads to compression of cognitive morbidity, and thus a shorter lifetime affected by cognitive impairment and dementia, in individuals aged 75 years and older living in Germany.MethodsOur sample included n = 742 individuals of the population‐based Leipzig Longitudinal Study of the Aged (LEILA75+; 1998‐2013), who were free of dementia at baseline. The impact of higher education on compression of cognitive morbidity was studied by analyzing the association between education and (1) cognitive functioning over the study period and age at dementia onset, (2) age at death, and (3) the cumulative lifetime cognitive morbidity.ResultsIndividuals with more years of education had a higher cumulative cognitive functioning over the lifetime period 75 to 100 years (weighted for survival probability), but not a later age of dementia onset nor a later age at death.ConclusionOur results suggest, in individuals aged 75 years and older, higher education only compresses cognitive morbidity prior to dementia onset. Findings may be specific to countries where education is not a necessary requirement for access to good quality health care services.

BACKGROUND:Little is known specifically about the association between generalized anxiety symptoms or panic and health care costs in older age. The aim of this study was to examine the association between generalized anxiety symptoms, panic and health care costs in people aged 65 and over. METHODS:Cross-sectional data from the 8-year follow-up of a large, prospective cohort study, the ESTHER study, was used. Individuals aged 65 and over, who participated in the study's home assessment, were included in this analysis (n = 2348). Total and sectoral costs were analyzed as a function of either anxiety symptoms, probable panic disorder, or a panic attack, while controlling for selected covariates, using Two Part and Generalized Linear Models. Covariates were chosen based on Andersen's Behavioral Model of Health Care Use. RESULTS:There was no significant association between either of the anxiety or panic measures and total health care costs. Stratified by health care sectors, only the occurrence of a panic attack was significantly associated with incurring costs for outpatient non-physician services (OR: 1.99; 95% CI: 1.15-3.45) and inpatient services (OR: 2.14; 95% CI: 1.07-4.28). Other illness-related factors, such as comorbidities and depressive symptoms, were associated with health care costs in several models. LIMITATIONS:This was a cross-sectional study relying on self-reported data. CONCLUSION:This study points to an association between a panic attack and sector-specific health care costs in people aged 65 and over. Further research, especially using longitudinal data, is needed.

Objective to investigate how frailty and frailty symptoms affect healthcare costs in older age longitudinally. Methods data were gathered from a prospective cohort study in Saarland, Germany (two waves with 3-year interval, n = 1,636 aged 57-84 years at baseline). Frailty was assessed by the five Fried frailty criteria. Frailty was defined as having at least three criteria, the presence of 1-2 criteria as 'pre-frail'. Healthcare costs were quantified based on self-reported healthcare use in the sectors of inpatient treatment, outpatient treatment, professional nursing care and informal care as well as the provision of pharmaceuticals, medical supplies and dental prostheses. Results while the onset of pre-frailty did not increase (log) total healthcare costs after adjusting for potential confounders including comorbidity, progression from non-frailty to frailty was associated with an increase in total healthcare costs (for example, costs increased by ~54 and 101% if 3 and 4 or 5 symptoms were present, respectively). This association of frailty onset with increased healthcare costs was in particular observed in the inpatient sector and for informal nursing care. Among the frailty symptoms, the onset of exhaustion was associated with an increase in total healthcare costs, whereas changes in slowness, weakness, weight loss and low-physical activity were not significantly associated with an increase in total healthcare costs. Conclusions our data stress the economic relevance of frailty in late life. Postponing or reducing frailty might be fruitful in order to reduce healthcare costs.

In 2005, 15 years after the introduction of the diagnosis in DSM-III, a telephone survey in Germany revealed that the public was still unfamiliar with the term bipolar disorder. Only 5.3% of those questioned knew at the time that it denotes a mental illness. In the meantime, efforts have been made to spread the concept among the public. In the media there has been increasing mention of the disorder. Another telephone survey in 2017 showed that familiarity with the diagnostic term has grown substantially. 54.0% of respondents now connected the term bipolar disorder with a mental illness.

BACKGROUND:In the growing population of the elderly, drug-related problems are considered an important health care safety issue. One aspect of this is the prescription of potentially inappropriate medication (PIM) which is considered to increase health care costs.OBJECTIVE:Using data from the Health Economics of Potentially Inappropriate Medication (HEPIME) study, we aimed to analyze how the number of prescribed substances moderates the association of PIM use as defined by the German PRISCUS list and health care costs applying a longitudinal perspective.METHODS:An initial number of 6,849,622 insurants aged 65+ of a large German health insurance company were included in a retrospective matched cohort study. Based on longitudinal claims data from the four separate quarters of a 12-month pre-period, 3,860,842 individuals with no exposure to PIM in 2011 were matched to 508,212 exposed individuals. Exposure effects of PIM use on health care costs and the number of prescribed substances were measured based on longitudinal claims data from the four separate quarters of the 12-month post-period.RESULTS:After successful balancing for the development of numerous matching variables during the four quarters of the pre-period, exposed individuals consumed 2.1 additional prescribed substances and had higher total health care costs of 1,237 € when compared to non-exposed individuals in the 1st quarter of the post-period. Controlling for the number of prescribed substances, the difference in total health care costs between both study groups was 401 €. The average effect of one additionally prescribed substance (other than PIM) on total health care costs was increased by an amount of 137 € for those being exposed to a PIM. In quarters 2-4 of the post-period, the differences between both study groups tended to decrease sequentially.CONCLUSIONS:PIM use has an increasing effect on the development of health care costs. This cost-increasing effect of PIM use is moderated by the number of prescribed substances.

Zusammenfassung: Im Rahmen des WHOQOL-OLD-Projektes wurde die Lebensqualität (LQ) sowohl von älteren pflegenden Angehörigen Demenzkranker als auch von nichtpflegenden älteren Menschen (60 Jahre und älter) mit Hilfe des WHOQOL-BREF und WHOQOL-OLD erfasst. Außerdem wurden Komorbidität sowie bei den Pflegenden zusätzliche Informationen zur Pflege erhoben. Es zeigten sich deutliche Unterschiede hinsichtlich der LQ. So bewerteten die pflegenden Angehörigen ihre LQ signifikant schlechter als Personen ihres Alters, die keinen Angehörigen pflegen. Diese deutlich schlechtere Bewertung ihrer LQ kann hauptsächlich auf die im Rahmen der Pflege entstehende Belastung zurückgeführt werden.

BACKGROUND:Self-guided computerized cognitive behavior therapy (cCBT) has the potential to be a feasible alternative to current first-step treatment approaches for depression. Yet, research regarding the effectiveness and acceptability of self-guided cCBT as an adjunct element of GP care is controversial. METHODS:Primary care patients with symptoms of mild to moderately severe depression (N = 647) were recruited from 112 GP practices within a cluster randomized controlled trial. GPs were randomized to groups that provided either cCBT (internet intervention) plus treatment as usual (TAU) or TAU alone. Primary outcomes were self-reported depression severity according to the Beck Depression Inventory (BDI-II) and Patient Health Questionnaire (PHQ-9). Intention to treat (ITT) and per protocol (PP) analysis was performed. RESULTS:ITT analyses showed significant between group differences in depressive symptoms for BDI-II in favor of the intervention group, corresponding to a small effect size (6 weeks: d = 0.36, 95% CI 0.19 to 0.53, P < .001; 6 months: d = 0.41, 95% 0.22 to 0.59, P < .001). The number needed to treat (NNT) at six months was 6.2. PHQ-9 analyses was solely significant at six months (d = 0.26, 95% CI 0.08 to 0.44, P < .05, NNT = 9.2). PP analyses highly agree with these findings. LIMITATIONS:The initial response rate with regard to the recruitment of GP practices for the trial was low. CONCLUSIONS:The results suggest that cCBT is effective in reducing depressive symptoms in mildly to moderately severe depressed primary care patients. Efforts should be made to raise awareness about the potential of such freely accessible treatment options among GPs and patients.

Zusammenfassung Ziel Analyse der Entwicklung der psychiatrischen Einstellungsforschung in Deutschland. Methode Historischer Überblick auf der Basis systematischer Reviews. Ergebnisse Die Einstellung der Bevölkerung zu psychisch Kranken und zur Psychiatrie wurde ursprünglich aus soziologischer Perspektive untersucht, später dominierte die sozialpsychologische bzw. individualpsychologische Perspektive. Schlussfolgerung Auch wenn dieser Ansatz wichtige Einblicke in die dem Stigma zugrunde liegenden Prozesse erlaubte, erscheint es an der Zeit die individuelle Perspektive durch eine gesellschaftliche zu ergänzen.