Aim Different access routes to inpatient-equivalent home treatment (IEHT) were examined. Methods Baseline differences were examined using exploratory group comparisons, treatment effects by type of admission using regression analysis. Results Of 200 St & auml;B users, 144 (72%) were admitted directly to IEHT, while 56 (28%) were transferred. Direct admissions showed a higher prevalence of affective disorders, while transfers more often had schizophrenia. There were no relevant differences in terms of treatment effects. Conclusion Access to IEHT treatment is used flexibly, treatment outcomes do not differ significantly. Outreach services should be designed even more flexible.

AIM:Different access routes to inpatient-equivalent home treatment (IEHT) were examined. METHODS:Baseline differences were examined using exploratory group comparisons, treatment effects by type of admission using regression analysis. RESULTS:Of 200 StäB users, 144 (72%) were admitted directly to IEHT, while 56 (28%) were transferred. Direct admissions showed a higher prevalence of affective disorders, while transfers more often had schizophrenia. There were no relevant differences in terms of treatment effects. CONCLUSION:Access to IEHT treatment is used flexibly, treatment outcomes do not differ significantly. Outreach services should be designed even more flexible.

This part of the AKtiV Study focuses on treatment satisfaction of patients and their relatives within Inpatient Equivalent Home Treatment (IEHT) and regular treatment. Stress of relatives and job satisfaction and workload of employees in IEHT is also considered. Relevant Parameters were collected via established as well as newly adapted questionnaires at the end of treatment. Patients and relatives in IEHT are significantly more satisfied. The stress experienced by relatives is reduced in both forms of treatment. Employees in IEHT are generally very satisfied, although there is no correlation with the satisfaction of relatives and patients. Known limitations of satisfaction surveys must be taken into account. In general these results encourage the expansion and continuous development of this new form of treatment in Germany.

Zusammenfassung Hintergrund Risikofaktoren für die psychische Gesundheit sind häufig in sozioökonomischen, geschlechter- und migrationsspezifischen Ungleichheiten begründet. Diese sowie die Ausprägung der Depressivität, Ängstlichkeit und Somatisierung von Beschäftigten wurden in der vorliegenden Studie untersucht. Methoden Im Rahmen der friaa-Studie („Frühe Intervention am Arbeitsplatz“) wurden psychisch belastete Beschäftigte an 5 Standorten in Deutschland zu soziodemografischen, arbeits-, migrations- und gesundheitsbezogenen Inhalten befragt. Mittels Regressionsanalysen wurde der Zusammenhang dieser Faktoren mit Depressivität (Patient-Health-Questionnaire-9, PHQ-9), Ängstlichkeit (Generalized Anxiety Disorder-2, GAD-2) und Somatisierung (Somatic Symptom Scale-8, SSS-8) an der gesamten Stichprobe sowie bei Personen mit Migrationshintergrund (MH) untersucht. Bei Letzteren wurden zusätzlich die Akkulturation (Frankfurter Akkulturationsskala, FRAKK) und das Belastungsempfinden gegenüber Migrationsanforderungen (Demands of Immigration Scale, DIS) berücksichtigt. Ergebnisse Die 550 Beschäftigten (12 % mit MH) wiesen im Durchschnitt eine klinisch relevante Depressivität (M = 13,0, SD = 5,1) (PHQ-9 ≥ 10), Ängstlichkeit (M = 3,5, SD = 1,7) (GAD ≥ 3) sowie Somatisierung (M = 13,0, SD = 5,8) (SSS-8 ≥ 12) auf. Das weibliche Geschlecht war mit höheren Werten für Ängstlichkeit und Somatisierung assoziiert. Höheres Alter und Nachtschichtarbeit hingen mit stärkerer Somatisierung zusammen. Diskussion Die Ergebnisse bestätigen die hohe psychische Belastung der Beschäftigten in dieser Stichprobe aus Deutschland. Um deren psychische Gesundheit aufrechtzuerhalten, sollten Unterstützungsmaßnahmen insbesondere für vulnerable Gruppen wie Frauen, ältere Beschäftigte und Nachtschichtarbeitende angeboten werden.

Hintergrund: Arbeitsbezogene Selbstwirksamkeitserwartungen (aSW) gelten als Prädiktor für eine erfolgreiche Rückkehr an den Arbeitsplatz bei Arbeitnehmenden mit psychischen Störungen. Spezifische Interventionen zur Förde­rung der aSW existieren bislang jedoch nicht. In der vorliegenden Sekundäranalyse wurde untersucht, ob ein neu entwickeltes kognitiv-imaginatives aSW-Modul geeignet erscheint, (1) imaginative Bewältigungserfahrungen zu erzeugen, (2) reale Bewältigungsbestrebungen vorzuberei­ten (Verhaltensrelevanz; VR) und (3) die aSW zu adressieren. Methoden: Das aSW-Modul wurde im Rahmen einer ar­beitsplatzbezogenen Kurzzeitintervention durchgeführt und videographiert (N = 22). Die aSW und Indikatoren für imaginative Bewältigungserfahrungen (IB) sowie für die VR wurden anhand der Videoaufzeichnungen durch unabhängige Beurteiler:innen eingeschätzt. Zusätzlich erfolgten Selbstbeurteilungen der aSW vor Behandlungsbeginn und zum Zeitpunkt des aSW-Moduls. Ergebnisse: Alle IB-Indikatoren (Kooperation, Lebhaftigkeit, emotionale Beteiligung, kognitive Flexibilität) waren eher hoch ausgeprägt. Bezüglich der VR-Indikatoren zeigte sich, dass Erkenntnisgewinne mode­rat, Intentionen für Verhaltensänderungen eher hoch und die Identifikation von erfolgreichen Modellen gering ausgeprägt waren. Die Fremdberichte der aSW korrelierten mit der selbstberichteten aSW vor Behandlungsbeginn (r = 0,47, p = 0,025) und während des aSW-Moduls (r = 0,51, p = 0,014). Schlussfolgerung: Im aSW-Modul wurden (1) imaginative Bewältigungserfahrungen erzeugt, (2) Intentionen für Verhaltensänderungen gefördert und (3) selbstwirk­sam­keits­relevante Kognitionen aktiviert. Es erscheint geeignet zur kognitiv-motivationalen Vorbereitung von Bewältigungsbestrebungen. Forschungsbedarf besteht hinsichtlich der Effekte des Interventionsmoduls auf reale Bewältigungs­erfahrungen und die Entwicklung der aSW.

Zusammenfassung Einleitung Die Inanspruchnahme von Leistungen durch Arbeitnehmer:innen mit psychischen Belastungen sowie die damit verbundenen Kosten im Gesundheits- und Sozialsystem wurden bisher nicht systematisch in Studien erhoben bzw. nur indirekt erfasst. Diese Publikation hat zum Ziel, die Inanspruchnahme in dieser Zielgruppe zu dokumentieren, die Kosten im Gesundheits- und Sozialsystem erstmalig abzuschätzen und mögliche Einflussfaktoren der Kostenvarianz zu untersuchen. Methodik Als Teil einer Multicenter-Studie wurden Häufigkeiten der Inanspruchnahme sowie Kosten im Gesundheits- und Sozialsystem von 550 Arbeitnehmer:innen mit psychischen Belastungen erhoben. Die Inanspruchnahme von Leistungen wurde mit der deutschen Version des Client Sociodemographic Service Receipt Inventory (CSSRI) erhoben. Kosten wurden für 6 Monate berechnet. Mithilfe eines Regressionsmodells wurden Einflussfaktoren auf die Kosten überprüft. Ergebnisse Zu Studienbeginn betrugen die durchschnittlichen Gesamtkosten der vergangenen 6 Monate in der Stichprobe € 5227,12 (Standardabweichung € 7704,21). Das Regressionsmodell weist auf einen signifikanten Anstieg der Kosten mit zunehmendem Alter sowie bei Personen mit Depressionen, Verhaltensauffälligkeiten mit körperlichen Symptomen und anderen Diagnosen hin. Diskussion Die berechneten Kosten sind im Vergleich zu klinischen Stichproben ähnlich hoch. Des Weiteren sollte zukünftig untersucht werden, ob sich dieses Ergebnis durch die Analyse der Längsschnittdaten verändert und ob die Intervention einen Kosteneinfluss aufweist.

BackgroundOnly two-thirds of patients admitted to psychiatric wards return to their previous jobs. Return-to-work interventions in Germany are investigated for their effectiveness, but information regarding cost-effectiveness is lacking. This study investigates the cost-utility of a return-to-work intervention for patients with mental disorders compared to treatment as usual (TAU). MethodsWe used data from a cluster-randomised controlled trial including 166 patients from 28 inpatient psychiatric wards providing data at 6- and 12-month follow-ups. Health and social care service use was measured with the Client Sociodemographic and Service Receipt Inventory. Quality of life was measured with the EQ-5D-3L questionnaire. Cost-utility analysis was performed by calculating additional costs per one additional QALY (Quality-Adjusted Life Years) gained by receiving the support of return-to-work experts, in comparison to TAU. ResultsNo significant cost or QALY difference between the intervention and control groups has been detected. The return-to-work intervention cannot be identified as cost-effective in comparison to TAU. ConclusionsThe employment of return-to-work experts could not reach the threshold of providing good value for money. TAU, therefore, seems to be sufficient support for the target group.

Zusammenfassung Ziel Die quasi-experimentelle AKtiV-Studie untersucht die Wirksamkeit der stationsäquivalenten Behandlung (StäB). Diese Arbeit beschreibt die demographischen und klinischen Parameter der Teilnehmenden zum Studieneinschluss und vergleicht deren Indexbehandlungen. Methodik Über einen Zeitraum von 12 Monaten wurden 200 StäB-Nutzende in die Interventionsgruppe (IG) und 200 stationär behandelte Personen in die Kontrollgruppe (KG) eingeschlossen. Die Vergleichbarkeit der beiden Gruppen wurde mittels Propensity-Score Matching (PSM) Verfahren sichergestellt. Ergebnisse Zusätzlich zu den PSM-Variablen unterschieden sich alle weiteren erhobenen Charakteristika zwischen der Interventionsgruppe (IG) und der Kontrollgruppe (KG) zum Zeitpunkt der Studieneinschreibung nicht signifikant voneinander. Die Dauer der Indexbehandlung war in der IG signifikant länger (M=37,2 Tage) als in der KG (M=27,9 Tage; p<0,001). Schlussfolgerung Die Ähnlichkeit der beiden Gruppen erlaubt einen Vergleich und somit die Untersuchung der Auswirkungen von StäB auf längerfristige Outcomes.

Zusammenfassung Dieses Teilprojekt der AKtiV-Studie untersucht die Behandlungszufriedenheit von Patient*innen und Angehörigen und deren Belastungserleben in stationsäquivalenter und vollstationärer Behandlung. Zusätzlich wird die Arbeitszufriedenheit und -belastung von StäB Mitarbeitenden berücksichtigt. Relevante Parameter wurden über etablierte sowie neu adaptierte Fragebögen am Behandlungsende erhoben. Patient*innen und Angehörige in StäB sind signifikant zufriedener. Das Belastungserleben der Angehörigen reduziert sich in beiden Behandlungsformen. StäB Mitarbeitende sind allgemein sehr zufrieden, wobei kein Zusammenhang mit der Zufriedenheit von Angehörigen und Patient*innen besteht. In der Diskussion der Ergebnisse sind die bekannten Limitationen von Zufriedenheitsbefragungen zu beachten. Dennoch ermutigen die Ergebnisse dazu, diese für Deutschland neue Behandlungsform weiterzuentwickeln und zu verbreiten.

BackgroundIf people with episodic mental-health conditions lose their job due to an episode of their mental illness, they often experience personal negative consequences. Therefore, reintegration after sick leave is critical to avoid unfavorable courses of disease, longer inability to work, long payment of sickness benefits, and unemployment. Existing return-to-work (RTW) programs have mainly focused on "common mental disorders" and often used very elaborate and costly interventions without yielding convincing effects. It was the aim of the RETURN study to evaluate an easy-to-implement RTW intervention specifically addressing persons with mental illnesses being so severe that they require inpatient treatment. MethodsThe RETURN study was a multi-center, cluster-randomized controlled trial in acute psychiatric wards addressing inpatients suffering from a psychiatric disorder. In intervention wards, case managers (RTW experts) were introduced who supported patients in their RTW process, while in control wards treatment, as usual, was continued. ResultsA total of 268 patients were recruited for the trial. Patients in the intervention group had more often returned to their workplace at 6 and 12 months, which was also mirrored in more days at work. These group differences were statistically significant at 6 months. However, for the main outcome (days at work at 12 months), differences were no longer statistically significant (p = 0.14). Intervention patients returned to their workplace earlier than patients in the control group (p = 0.040). ConclusionsThe RETURN intervention has shown the potential of case-management interventions when addressing RTW. Further analyses, especially the qualitative ones, may help to better understand limitations and potential areas for improvement.

AIM:The quasi-experimental AKtiV study investigates the effects inpatient-equivalent home treatment (IEHT). This paper describes the study population based on demographic and clinical parameters at baseline and compares the index treatment.METHODS:Over a period of 12 months 200 IEHT users were included in the intervention group (IG) and 200 inpatients were included in the control group (CG). The comparability of the two groups was ensured by propensity score matching (PSM).RESULTS:In addition to the PSM variables, IG and CG did not differ significantly from each other variables at study inclusion. The duration of the index treatment was significantly longer in the IG (M=37.2 days) compared to the CG (M=27.9 days; p<0.001).CONCLUSION:The similarity of the two groups enables comparisons over 12 months, investigating IEHT effects on long-term outcomes.

Background Children of families with a parent with a mental illness have an increased risk of developing social and mental health problems resulting in decreased quality of life. Therefore, children and adolescents living in families with a parent with mental illness are regarded as a target group for preventive interventions. To date, only a few economic evaluation studies for interventions directed at preventing the intergenerational transmission of mental health problems exist. In this investigation we estimated the cost utility of an intervention for the support of children and adolescents with a parent having a mental illness from the perspective of the German health and social care system. Methods We randomly assigned a total of 214 families with 337 children and adolescents to the intervention (INT) group (108/170) or the control (TAU) group (106/167). Families in the intervention group received on average eight intervention sessions (50–90 min) over 6 months. We estimated total cost of illness by means of the Children and Adolescent Mental Health Service Receipt Inventory (CAMHSRI) over 24 months. For the estimation of Quality-Adjusted Live Years (QALYs) we applied the KIDSCREEN-10. For estimating the incremental cost-utility of the intervention compared to treatment as usual we used the net-benefit approach. Results We estimated the annual cost of illness amounting to € 3784.59 (SD € 8581.11) in the TAU group and € 3264.44 (SD € 9431.89) in the INT group. The annual cost difference between INT and TAU was € − 516.14 (SE 1124.95) which was not significant ( p ≤ 0.05). We estimated the average QALY to be 0.759 (SD 0.073) in the TAU group and 0.763 (SD 0.072). The QALY difference between INT and TAU was 0.0037 (SE 0.0092) which was not significant ( p ≤ 0.05). The incremental cost utility ratio (ICUR) indicated that the gain of one additional year in full health by means of the intervention was associated with the saving of € 139.49. However, the stochastic insecurity of the ICUR did not allow a unique decision about the cost-utility of the intervention. Conclusions More information on the economic value of the intervention for families with a parent with mental illness in comparison to treatment as usual in Germany is needed. Trial registration : ClinicalTrials.gov, identifier NCT02308462; German Clinical Trials Register: DRKS00006806.

INTRODUCTION:The integration of a web-based computer-adaptive patient-reported outcome test (CAT) platform with persuasive design optimised features including recommendations for action into routine healthcare could provide a promising way to translate reliable diagnostic results into action. This study aims to evaluate the effectiveness and cost-effectiveness of such a platform for depression and anxiety (RehaCAT+) compared with the standard diagnostic system (RehaCAT) in cardiological and orthopaedic health clinics in routine care. METHODS AND ANALYSIS:A two-arm, pragmatic, cluster-randomised controlled trial will be conducted. Twelve participating rehabilitation clinics in Germany will be randomly assigned to a control (RehaCAT) or experimental group (RehaCAT+) in a 1:1 design. A total sample of 1848 participants will be recruited across all clinics. The primary outcome, depression severity at 12 months follow-up (T3), will be assessed using the CAT Patient-Reported Outcome Measurement Information System Emotional Distress-Depression Item set. Secondary outcomes are depression at discharge (T1) and 6 months follow-up (T2) as well as anxiety, satisfaction with participation in social roles and activities, pain impairment, fatigue, sleep, health-related quality of life, self-efficacy, physical functioning, alcohol, personality and health economic-specific general quality of life and socioeconomic cost and benefits at T1-3. User behaviour, acceptance, facilitating and hindering factors will be assessed with semistructured qualitative interviews. Additionally, a smart sensing substudy will be conducted, with daily ecological momentary assessments and passive collection of smartphone usage variables. Data analysis will follow the intention-to-treat principle with additional per-protocol analyses. Cost-effectiveness analyses will be conducted from a societal perspective and the perspective of the statutory pension insurance. ETHICS AND DISSEMINATION:The study will be conducted according to the Declaration of Helsinki. The Ethics Committee of Ulm University, has approved the study (on 24 February 2021 ref. 509/20). Written informed consent will be obtained for all participants. Results will be published via peer-reviewed journals. TRIAL REGISTRATION NUMBER:DRKS00027447.

IMPORTANCE The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear. OBJECTIVE To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group. INTERVENTIONS The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees. MAIN OUTCOMES AND MEASURES The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021. RESULTS Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the 51-1+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T 6068 pound ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T 14 pound 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone. CONCLUSIONS AND RELEVANCE This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.

BACKGROUND:Unemployment is associated with a high risk of experiencing mental illness. This can lead to stigmatisation, reduced quality of life, and long-term costs like increased healthcare expenditure and productivity losses for society as a whole. Previous research indicates evidence for an association between unemployment and higher mental health service costs, but there is insufficient information available for the German healthcare system.AIM OF THE STUDY:This study aims to identify costs and cost drivers for health and social service use among unemployed people with mental health problems in Germany.METHODS:A sample of 270 persons participated at baseline and six-month-follow-up. Healthcare and social service use was assessed using the Client Socio-Demographic and Service Receipt Inventory. Descriptive cost analysis was performed. Associations between costs and potential cost drivers were tested using structural equation modelling.RESULTS:Direct mean costs for 12 months range from EUR 1265.13 (somatic costs) to EUR 2206.38 (psychiatric costs) to EUR 3020.70 (total costs) per person. Path coefficients indicate direct positive effects from the latent variable mental health burden (MHB) on stigma stress, somatic symptoms, and sick leave.DISCUSSION:The hypothesis that unemployed people with mental health problems seek help for somatic symptoms rather than psychiatric symptoms was not supported. Associations between MHB and costs strongly mediated by sick leave indicate a central function of healthcare provision as being confirmation of the inability to work.IMPLICATIONS FOR HEALTH POLICIES:Targeted interventions to ensure early help-seeking and reduce stigma remain of key importance in reducing long-term societal costs.IMPLICATIONS FOR FURTHER RESEARCH:Future research should explore attitudes regarding effective treatment for the target group.

Background Children of parents with mental illness have a higher risk of developing mental health problems when compared with the general population. Therefore, families with parents with mental illness are a suitable target group for selective prevention. In order to plan and evaluate the health economic consequences of preventive interventions for this target group, data on the societal costs related to parenthood under the condition of mental disorders are needed. To date, within Germany there has been a lack of research evaluating the costs of mental health treatment and use of social services by children and adolescents with parents with mental illness. Methods As part of a multicentre randomised controlled trial, use and costs of health and social services were assessed for a sample of 332 children and adolescents with parents with mental illness in six regions of Germany. Service use at baseline was assessed by the German version of the Children and Adolescent Mental Health Service Receipt Inventory. Costs were calculated for 12 months based on diagnosis and service user status and described separately. Cost drivers were identified by means of a two-part regression model. Results Total mean costs for 12 months for the total sample amount of € 3736.35 (95% CI: € 2816.84–4813.83) per person. Children with a psychiatric diagnosis generated a total of € 5691.93 (95% CI: € 4146.27–7451.38) of costs per person, compared to € 1245.01 (95% CI: € 657.44–1871.49) for children without a psychiatric diagnosis. The logit part indicates significant odds ratios for individual functioning and diagnosis of the child as well as for family functioning. The linear part reveals that increasing individual functioning in the child is related to decreasing costs. Conclusions Children of families with parents with mental illness use a broad spectrum of mental health care, school-based support and youth welfare services even if they are not yet diagnosed as having a mental disorder. Further research should examine whether these institutions are sufficiently qualified and interlinked to meet the support needs of this vulnerable group. Trial registration The study was registered at the 07/10/2014 before the start of data collection (04/11/2014) at the German clinical trials register (Deutsches Register Klinischer Studien, DRKS, nr: DRKS00006806, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00006806 ).

Background: More than half of the unaccompanied young refugees (UYRs) resettled in Europe report elevated levels of posttraumatic stress symptoms (PTSS) and comorbid symptoms. Earlier studies have highlighted the effectiveness of the trauma-focused preventive group intervention ‘Mein Weg’ (English ‘My Way’), and the feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) for UYRs. Both interventions are deemed to be empirically supported treatments (ESTs). However, UYRs seldom receive ESTs or, in fact, any treatment at all. In view of the high need and the limited treatment resources available, a stepped-care approach is indicated but has not been evaluated so far. The purpose of this trial is to compare the stepped-care approach BETTER CARE with usual care enhanced with screening and indication (usual care+). Methods: In a cluster randomized controlled trial involving N = 540 UYRs living in up to N =54 child and youth welfare service (CYWS) facilities, BETTER CARE will be compared with usual care+. We will randomize clusters comprising a CYWS facility with at least one eligible psychotherapist. BETTER CARE consists of step 1) screening and indication and either step 2) preventive trauma-focused group intervention ‘Mein Weg’ delivered by trained CYWS staff or step 3) TF-CBT delivered by trained community therapists and supported by trained translators if necessary. Participants will be assessed 6 and 12 months after randomization. The primary outcome is the severity of PTSS after 12 months. Secondary outcomes are depressive and anxiety symptoms, quality of life, and proxy reported PTSS. Furthermore, drug use, health costs, benefits and long-term effects on integration/acculturation will be assessed. Discussion: The trial will directly integrate a stepped-care approach into existing structures of the German child welfare and (mental) health system. It could, therefore, serve as a blueprint for how to implement ESTs for UYRs. If successful, screening, prevention and intervention will be sustainably implemented in CYWS in southern Germany. Trial registration : German Clinical Trials Register, ID: DRKS00017453. Registered December 11 th , 2019. URL: https://www.drks.de/drks_web/setLocale_EN.do