Versorgungssituation älterer Menschen hinsichtlich ambulanter Richtlinien-Psychotherapie

Evidence for underuse and overuse of antidepressants in older adults: Results of a large population-based study

OBJECTIVES

Depression is common among elderly people. However, diagnosis and adequate treatment is frequently difficult. Research on underuse and overuse of antidepressants in elderly persons is scarce. This study investigates the utilization and appropriateness of pharmacological and psychological depression treatment in a large cohort of community-dwelling adults.

METHODS

A subsample of 3117 participants (aged 55-85 y) of the third follow-up (2008-2010) of the large population-based German ESTHER study was included. Depression was assessed using the eight-item Patient Health Questionnaire (PHQ-8). In the course of a home visit, study doctors collected complete information on medication. Logistic regression analyses were conducted to determine the relationship of depression with both underuse and overuse of antidepressants. The analyses were then adjusted for socioeconomic variables, psychosomatic comorbidities, and motivation to seek help.

RESULTS

One hundred sixty-three participants (5.2%; 95% confidence interval [CI], 4.5-6.1) fulfilled the criteria for major depression. Underuse of antidepressants was present in 126 depressed participants (77.3%; 70.1-83.5). Persons who were motivated to seek help, who had an established depression diagnosis, or who were taking more than five different medications had lower odds of underuse. Anxiety was associated with higher odds for underuse. Overuse of antidepressants (prescription without clinical indication) was found in 96 cases (41.7%; 35.3-48.4) of all antidepressant prescriptions.

CONCLUSIONS

Depression treatment in older adults is frequently insufficient; it appears to depend on diagnosis as well as the patients' motivation to seek help. Education regarding the diagnosis of depression in the elderly as well as guidelines for appropriate treatment is needed.

[Psychosomatic medicine in old age]

Approximately 25% of people over 65 years old suffer from psychiatric disorders but in cases of simultaneously occurring somatic diseases the prevalence is increased. Sickness, loss of important reference persons and life crises in older age often reactivate traumatic experiences from earlier life stages. It can be difficult to differentiate between psychological disorders and the psychological symptoms accompanying somatic illness. The biographic medical history and estimation of cognitive skills within a geriatric basis assessment should be standard in geriatric diagnostics. Psychological disorders are often overlooked or inadequately treated in older people. In the case of psychopharmacological treatment, effects on somatic sickness as well as drug-drug interactions have to be kept in mind. Psychotherapeutic approaches focusing on resources and social support particularly in group therapy seem to be very helpful.

Attitudes towards seeking mental health services among older adults: personal and contextual correlates

OBJECTIVES

Especially older adults underutilize professional mental health services. However, little is known about the factors associated with older adults' attitudes towards seeking mental health services (ATSMHS). We therefore investigated a wide range of contextual (e.g. physical access, residence) and personal (e.g. perceived social support, life satisfaction, openness to experience) predictors of ATSMHS in a sample of older community-dwelling adults in Germany. We predicted that representations of old age as well as perceptions of (younger) psychotherapists would be uniquely important for determining ATSMHS.

METHOD

A diverse sample of N = 156 older adults (Mage = 71.5 years, SD = 6.4, range: 60-92) completed questionnaire measures. We used hierarchical linear regression analyses to identify predictors of ATSMHS.

RESULTS

In the final saturated model, female gender, urban residence, personal and vicarious experience with psychotherapy, and higher perceived social support were each associated with more positive ATSMHS. In addition, more positive representations of old age and less negative perceptions of (younger) psychotherapists explained unique variance in ATSMHS over and above the other predictors. The overall model was significant and explained 49% of the variance in ATSMHS.

CONCLUSION

Our findings can be used to inform interventions to improve older adults' ATSMHS. Interventions that seek to improve older adults' representations of their own aging as well as of psychotherapists may be useful for reducing the treatment gap.

[Long-term outcome of inpatient psychotherapy in older patients]

OBJECTIVES

To compare long-term outcome of inpatient psychotherapy in an age-mixed setting for patients aged over 50 years or over 60 years at time of treatment compared to younger patients.

METHODS

At the beginning and the end of inpatient psychotherapy and at katamnesis 1 to 8 years later, patients were examined with self-assessment questionnaires (BSI, HADS, IIP). At katamnesis they also filled in a questionnaire designed to record improvement in symptoms, satisfaction with the inpatient treatment, and other psychotherapeutic and/or psychiatric treatments.

RESULTS

87 (34.3 %) of the 253 participants were 50 years or older, 48 (18.9 %) 60 years or older at time of inpatient treatment. At katamnesis there were no significant differences between the older and younger patients regarding treatment satisfaction, improvement of symptoms, psychometric scales, and further in- or outpatient psychotherapy.

DISCUSSION

Older patients can be treated as successfully as younger patients with inpatient psychotherapy in an age-mixed setting.

[Outcome and catamnesis of psychosomatic hospital treatment of 60+-year-old inpatients]

OBJECTIVES

The catamnesis study examined the effectiveness of inpatient psychotherapy of patients 60+ years of age 1 to 2 years after the treatment. The patients had been treated in the years 2007 and 2008.

METHOD

Systematic pre and post inpatient treatment data were available for all patients, collected according to Psy-BaDo. For the purpose of the catamnesis the patients received the complaint questionnaire SCL-90-R as self-evaluation questionnaire, based on a shortened form of the BSI. In addition, we also used a special catamnesis questionnaire developed by the inpatient Group Therapy Research Unit staff and revised at the Rhein-Klinik (Wuchner u. Hess 2005).

RESULTS

According to their self-assessments, most patients reported of having gained a "good" to "very good" benefit from the treatment. The effectiveness of the inpatient treatment was high both at the end of the treatment and at the time of the catamnesis (discharge d = 0.86; catamnesis d = 0.84).Nearly 70 % of the patients were also later treated by outpatient psychotherapy, 51 % were prescribed psychopharmacologic drugs and 33 % other forms of medicine.

DISCUSSION

The therapeutic framework for the treatment of older patients corresponded to the rules for psychosomatic medicine and psychotherapy. There is no need for any other fundamentally different concepts. After the follow-up outpatient treatments, older patients and the therapists expressed an increased acceptance of psychotherapy. The effectiveness of treatment in older patients may result from their good resources. The results of the catamnesis show encouraging findings for the psychosomatic treatment of older patients, also in the long term from 1,5 to 2 years.

Mental health quality, outcome measurement, and improvement in Germany

PURPOSE OF REVIEW

The German mental healthcare system is currently undergoing discussions regarding the assessment of mental healthcare quality and the identification of potentials for optimizing mental healthcare. Quality assurance projects play an important role in the optimization of the care for the mentally ill in Germany. This review describes the most recent results of quality assurance programs from Germany as identified by a systematic literature search covering the time span 1 January 2008 until 1 June 2009.

RECENT FINDINGS

The German mental healthcare system is characterized by a high degree of structural quality. Quality assurance research in German mental healthcare is multifaceted and several projects are underway to determine the cost-effectiveness of procedures in mental healthcare and the development of quality indicators.

SUMMARY

In Germany, mental healthcare research is a rapidly developing field. Potentials for improvements can be identified in the assessment of process and outcome quality, the regional distribution, and the coordination among service providers. More studies are needed to identify the best methods to assess quality in mental healthcare with a view to improve process and outcome quality.