Study protocol for a randomised controlled trial evaluating an evidence-based, stepped and coordinated care service model for mental disorders (RECOVER)

INTRODUCTION

Healthcare systems around the world are looking for solutions to the growing problem of mental disorders. RECOVER is the synonym for an evidence-based, stepped and cross-sectoral coordinated care service model for mental disorders. RECOVER implements a cross-sectoral network with managed care, comprehensive psychological, somatic and social diagnostics, crisis resolution and a general structure of four severity levels, each with assigned evidence-based therapy models (eg, assertive community treatment) and therapies (eg, psychotherapy). The study rationale is the investigation of the effectiveness and efficiency of stepped and integrated care in comparison to standard care.

METHODS AND ANALYSIS

The trial is conducted in accordance to the Standard Protocol Items: Recommendations for Interventional Trials Statement. The study aims to compare the RECOVER model with treatment as usual (TAU). The following questions are examined: Does RECOVER reduce healthcare costs compared with TAU? Does RECOVER improve patient-relevant outcomes? Is RECOVER cost-effective compared with TAU? A total sample of 890 patients with mental disorders will be assessed at baseline and individually randomised into RECOVER or TAU. Follow-up assessments are conducted after 6 and 12 months. As primary outcomes, cost reduction, improvement in symptoms, daily functioning and quality of life as well as cost-effectiveness ratios will be measured. In addition, several secondary outcomes will be assessed. Primary and secondary outcomes are evaluated according to the intention-to-treat principle. Mixed linear or logistic regression models are used with the direct maximum likelihood estimation procedure which results in unbiassed estimators under the missing-at-random assumption. Costs due to healthcare utilisation and productivity losses are evaluated using difference-in-difference regressions.

ETHICS AND DISSEMINATION

Ethical approval from the ethics committee of the Hamburg Medical Association has been obtained (PV5672). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications.

TRIAL REGISTRATION NUMBER AND REGISTRY NAME

ClinicalTrials.gov (NCT03459664), RECOVER PROTOCOL VERSION: 19 March 2020 (V.3.0).

Information and decision-making needs of psychiatric patients: the perspective of relatives

Background

Mental illness may strongly affect relatives’ lives. Therefore, it is important to empower relatives by providing health information according to their preferences.

Methods

An online cross-sectional survey was conducted using a purpose-designed questionnaire on online health information and decision-support needs.

Results

Prevalent reasons for online health information search of the 185 participating relatives were the need for general information and the insufficiency of the information given by the health care provider. The most difficult treatment decisions concerned the treatment setting (inpatient or outpatient) as well as the psychopharmacological treatment.

Discussion

Since psychiatric patients’ relatives report extensive information and decision-support needs, it is essential to address their needs in health information material. Assessment of relatives’ needs when developing health information materials is recommended.

Information and Decision-Making Needs Among People with Anxiety Disorders: Results of an Online Survey

BACKGROUND

People with anxiety disorders are faced with treatment decisions considerably affecting their life. Patient decision aids are aimed at enabling patients to deliberate treatment options based on individual values and to participate in medical decisions.

OBJECTIVE

This is the first study to determine patients' information and decision-making needs as a pre-requisite for the development of patient decision aids for anxiety disorders.

METHODS

An online cross-sectional survey was conducted between January and April 2013 on the e-health portal http://www.psychenet.de by using a self-administered questionnaire with items on internet use, online health information needs, role in decision making and important treatment decisions. Descriptive and inferential statistical as well as qualitative data analyses were performed.

RESULTS

A total of 60 people with anxiety disorders with a mean age of 33.3 years (SD 10.5) participated in the survey. The most prevalent reasons for online health information search were the need for general information on anxiety disorders, the search for a physician or psychiatrist and the insufficiency of information given by the healthcare provider. Respondents experienced less shared and more autonomous decisions than they preferred. They assessed decisions on psychotherapy, medication, and treatment setting (inpatient or outpatient) as the most difficult decisions.

CONCLUSION

Our results confirm the importance of offering patient decision aids for people with anxiety disorders that encourage patients to participate in decision making by providing information about the pros and cons of evidence-based treatment options.

Cognitive-behavioral management training of depressive symptoms among inpatient orthopedic patients with chronic low back pain and depressive symptoms: A 2-year longitudinal study

BACKGROUND AND OBJECTIVES

Co-existing depressive symptoms aggravate the chronic course of pain and may interfere with successful rehabilitation.

OBJECTIVE

To examine the psychosocial rehabilitation success of a standard rehabilitation program with a supplemental cognitive-behavioral management training of depressive symptoms compared to the standard rehabilitation alone among patients with chronic low back pain (CLBP) and depressive symptoms.

METHODS

Effects on psychological measures (depressive symptoms, anxiety, and somatization) were evaluated prior to, 6, 12, and 24 months after rehabilitation among N = 84 consecutively admitted patients with CLBP and depressive symptoms, aged from 34–59 years. Furthermore, self-reported days of sick leave were determined.

RESULTS

Favorable effects on depressive symptoms and anxiety persisted up to the 24-month follow-up assessment and incremental effects of the new program on depressive symptoms and anxiety were found at the 6-month follow-up assessment. Days of sick leave were decreased 6 months after rehabilitation and frequencies of clinical levels of psychological symptoms at the 24-month follow-up assessment were attenuated in the intervention group.

CONCLUSIONS

The long-term psychological rehabilitation success among patients with CLBP and depressive symptoms was improved by the newly developed program, whose clinical significance was also supported. Thus, significant factors for the further development of CLBP were ameliorated.

Acceptance of the German e-mental health portal www.psychenet.de: an online survey

Background. Taking into account the high prevalence of mental disorders and the multiple barriers to the use of mental health services, new forms of fostering patient information, involvement, and self-management are needed to complement existing mental health services. The study aimed at investigating acceptance regarding design and content of the e-mental health portal www.psychenet.de.

Methods. An online cross-sectional survey was conducted between May 2013 and May 2015 using a self-administered questionnaire including items on perceived ease of use, perceived usefulness, attitude towards using, and perceived trust. Effects of different participants’ characteristics on the portals’ acceptance were analyzed.

Results. The majority of the N = 252 respondents suffered from mental disorders (n = 139) or were relatives from persons with mental disorders (n = 65). The portal was assessed as “good” or “very good” by 71% of the respondents. High levels of agreement (89–96%) were shown for statements on the perceived ease of use, the behavioral intention to use the portal, and the trustworthiness of the portal. Lower levels of agreement were shown for some statements on the perceived usefulness of the portals’ content. There were no effects of different participants’ characteristics on the perceived ease of use, the perceived usefulness, the attitude towards using the website and the perceived trust.

Discussion. This survey provides preliminary evidence that the e-mental health portal www.psychenet.de appears to be a usable, useful and trustworthy information resource for a broad target group. The behavioral usefulness of the portals’ content might be improved by integrating more activating patient decision aids.

Changes in beliefs and attitudes toward people with depression and schizophrenia - results of a public campaign in Germany

We examined the impact of a mental health awareness campaign on public attitudes. The campaign was embedded in the project psychenet - Hamburg Network for Mental Health. Beliefs and attitudes were examined before and after specific awareness measures in Hamburg (intervention region) and Munich (control region). Analyses were based on representative surveys (2011: N=2014; 2014: N=2006). Vignettes with symptoms suggestive of depression respectively schizophrenia were presented, followed by questions on social distance, beliefs and emotional reactions. Analyses of variance tested variations between regions over time and differences between those aware of the campaign and those not aware. In 2014, 7.3% (n=74) of the Hamburg respondents were aware of the psychenet campaign. Regarding the total sample, there were minor changes in attitudes. Differentiated according to campaign awareness among Hamburg respondents, those who were aware showed less desire for social distance toward a person with depression. Moreover, respondents aware of the campaign stated less often that a person with schizophrenia is in need of help. The campaign had small impact on attitudes. A substantial change in ingrained attitudes toward persons with mental health problems is difficult to achieve with interventions targeting the general public.

[Evaluation of a Public Campaign on Mental Disorders - Results from "psychenet"]

Objective: From 2011 to 2014, an information and awareness campaign was conducted in the framework of psychenet - Hamburg network for mental health. Evaluation is focused on two aspects: First, the reach of the campaign is examined. Second, effects of the campaign's key messages on public attitudes concerning mental disorders are analyzed. Methods: Analyses are based on two representative telephone surveys, conducted in Hamburg (intervention region) and Munich (control region) in 2011 prior (N = 2014) and 2014 post-campaign (N = 2006). Respondents were asked about their awareness of the psychenet campaign and to state their agreement or disagreement regarding attitudes and beliefs about mental disorders. Results: 7.3 % (74 of 1005) of the respondents from Hamburg were aware of psychenet. Compared to the other respondents, this subgroup displayed a stronger accordance with the campaign's key messages. However, regarding the total population over the course of time, differences in attitudes towards mental disorders were minor. Conclusion: Information and awareness campaigns seem to have minor effects on public attitudes towards mental disorders. Effects of specific campaign messages need to be examined more systematically.

[Improving Mental Health Literacy and Mental Illness Stigma in the Population of Hamburg]

Evidence shows that poor mental health literacy and stigmatization have negative consequences on mental health. However, studies on interventions to improve both are often heterogenic in methodology and results. The psychenet-campaign in Hamburg was developed and implemented in collaboration with patients and relatives and comprised multidimensional interventions focusing on education and contact to patients. The main goals were the improvement of mental health literacy and destigmatization and the long-term implementation within Hamburg's mental health care system.

[Development and Process Evaluation of the e-Mental Health Portal www.psychenet.de for the Hamburg Network for Mental Health]

OBJECTIVE

The purpose of this project was to develop a user-centered web-portal for empowerment in mental disorders.

METHODS

The development of the portal included mixed-methods techniques for needs assessment to identify user-relevant content. Exposure and use of the portal was investigated as part of a process evaluation.

RESULTS

psychenet.de informs about mental disorders and treatment option. Results of the process evaluation showed a highly accessed website, the portal was assessed as "good" or "very good" by 73 % of the respondents.

DISCUSSION

Using psychenet.de attempts to raise awareness, to inform about mental disorders, and to engage patients in the course of their treatment.

Psychenet.de: Development and process evaluation of an e-mental health portal

BACKGROUND

E-mental health interventions can have a positive impact on patient-reported and clinical outcomes. The purpose of this project was to develop a user-centered e-mental health portal.

METHODS

The development of the portal www.psychenet.de included mixed-methods techniques for needs assessment to identify user-relevant content. Furthermore, user-centered design techniques were applied by utilizing individual usability testing with cognitive task analysis. First, a basic version of the portal was created and introduced to the public by means of a media campaign. After the development of module-specific content, exposure and use of the portal was investigated as part of a process evaluation.

RESULTS

Relevant content identified by needs assessment covered both, overarching and diagnosis-specific topics. Results of the process evaluation showed a highly accessed website. During the first 18 months, 119,423 visits were tracked. The portal was predominantly accessed by Google searches (73.9%), while 17.6% of visits were related to direct traffic.

DISCUSSION

Serving as a complement to face-to-face consultations, www.psychenet.de attempts to inform about mental disorders, and engage patients in the course of their treatment. Results of the process evaluation confirm the high relevance and potential of the portal and can be used for further improvements and extensions in the future.

Information and decision-making needs among people with affective disorders - results of an online survey

BACKGROUND

Patient decision aids are one possibility for enabling and encouraging patients to participate in medical decisions.

OBJECTIVE

This paper aims to describe patients' information and decision-making needs as a prerequisite for the development of high-quality, web-based patient decision aids for affective disorders.

DESIGN

We conducted an online cross-sectional survey by using a self-administered questionnaire including items on Internet use, online health information needs, role in decision making, and important treatment decisions, performing descriptive and comparative statistical analyses.

PARTICIPANTS

A total of 210 people with bipolar disorder/mania as well as 112 people with unipolar depression participated in the survey.

RESULTS

Both groups specified general information search as their most relevant information need and decisions on treatment setting (inpatient or outpatient) as well as decisions on pharmacological treatment as the most difficult treatment decisions. For participants with unipolar depression, decisions concerning psychotherapeutic treatment were also especially difficult. Most participants of both groups preferred shared decisions but experienced less shared decisions than desired.

DISCUSSION AND CONCLUSION

Our results show the importance of information for patients with affective disorders, with a focus on pharmacological treatment and on the different treatment settings, and highlight patients' requirements to be involved in the decision-making process. Since our sample reported a chronic course of disease, we do not know if our results are applicable for newly diagnosed patients. Further studies should consider how the reported needs could be addressed in health care practice.

Information and decision-making needs among people with mental disorders: a systematic review of the literature

BACKGROUND

Assessment of users' information and decision-making needs is one key step in the development of decision-support interventions.

OBJECTIVE

To identify patients' information and decision-making needs as a pre-requisite for the development of high-quality web-based patient decision aids (PtDAs) for common mental disorders.

SEARCH STRATEGY

A systematic MEDLINE search for papers published until December 2012 was conducted, and reference lists of included articles and relevant reviews were searched.

INCLUSION CRITERIA

Original studies containing data on information or decision-making needs of adults with depression, anxiety disorders, somatoform disorders, alcohol-related disorders and schizophrenia were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed using a standardized form, and data synthesis was conducted using a theory-based deductive approach by two independent reviewers. Studies were quality assessed using the Mixed Methods Appraisal Tool.

MAIN RESULTS

Twelve studies were included focusing on information needs or the identification of decisions patients with depression and schizophrenia were facing. No studies were found for the other mental disorders. Overall, seven information needs categories were identified with the topics 'basic facts', 'treatment' and 'coping' being of major relevance. Six decision categories were identified of which decisions on 'medication' and 'treatment setting' were most often classified.

CONCLUSIONS

This review reveals that patients with schizophrenia and depression show extensive information and decision-making needs. The identified needs can initially inform the design of PtDAs for schizophrenia and depression. However, there is an urgent need to investigate information and decision-making needs among patients with other mental disorders.

[Long-term effects of a cognitive-behavioral intervention on pain coping among inpatient orthopedic rehabilitation of chronic low back pain and depressive symptoms]

Beneficial effects on psychological measures in orthopedic inpatient rehabilitation of patients with chronic low back pain (CLBP) and co-exist-ing depressive symptoms have been shown only for multidisciplinary approaches that incorporate psychotherapeutic interventions. Aim of this study was to verify these findings for pain coping outcomes (pain-related psychological disability, pain-related coping). Short-, mid-, and long-term effects of a standard pain management program that was either solely provided or combined with a supplemental cognitive-behavioral depression management were examined in a consecutive sample of n=84. Patients in both groups showed long-term beneficial effects in pain coping measures. Thus, the standard rehabilitation revealed specific and long-term effects on pain coping. However, further evidence suggests that diagnosis-specific psychotherapeutic treatment elements are required to improve psychological symptoms.

Long-term effects of a cognitive-behavioral training program for the management of depressive symptoms among patients in orthopedic inpatient rehabilitation of chronic low back pain: a 2-year follow-up

The aim of the present study was to investigate the 2-year outcome of a cognitive-behavioral training program for the management of depressive symptoms for patients with chronic low back pain (CLBP) and co-existing depressive symptoms compared with the standard rehabilitation. Therefore, a quasi-experimental 3 × 2 × 5 (treatment condition × gender × time) repeated measures design with five assessment points (pre-treatment, post-treatment, 6-, 12-, and 24-month follow-up) was employed among N = 153 patients with CLBP, aged 33-62 years. Patients were consecutively assigned to one of three treatment conditions: patients with no or mild depressive symptoms were treated with the standard rehabilitation (CG) and patients with moderate or severe depressive symptoms were either treated with the standard rehabilitation (CG(depr)) or the standard rehabilitation plus cognitive-behavioral management of depressive symptoms (IG(depr)). Patients in the IG(depr) significantly improved in mental health up to the 6-month follow-up and in anxiety and depressive symptoms up to the 24-month follow-up. Only short- or mid-term improvements were found in the CG(depr). In conclusion, the new cognitive-behavioral training program augmented the long-term rehabilitation success in this highly strained subgroup of patients with CLBP and depressive symptoms.

[Psychosocial factors in chronic low back pain in orthopaedic inpatient rehabilitation. An analysis using the axes of the Mainz Pain Staging System]

BACKGROUND

The aim of this study was to investigate the criterion validity of the Mainz Pain Staging System (MPSS), considering the four axes of the MPSS separately.

METHODS AND DESIGN

Psychological and pain-related impairments were analysed depending on the stage of axis (I, II, III) for each single axis of the MPSS in a consecutive sample of 280 patients with chronic low back pain in orthopaedic inpatient rehabilitation. In addition, the distribution of frequency of clinically significant symptoms in depression, anxiety and somatisation were examined depending on the stage of axis.

RESULTS

For all axes, an increasing stage was associated with greater psychological and pain-related impairments. Particularly patients assigned to stage III on axis 1 (temporal aspects) and 2 (spatial aspects) and patients assigned to stage II on axis 3 (drug intake) and 4 (utilisation of the health care system) showed enhanced psychosocial impairments and more frequently had clinically relevant symptoms in psychological variables.

CONCLUSION

Findings confirm the criterion validity of the MPSS for chronic low back pain. In addition, results support the significance of psychosocial factors for the further development of chronicity.

Effects of gender and cognitive-behavioral management of depressive symptoms on rehabilitation outcome among inpatient orthopedic patients with chronic low back pain: a 1 year longitudinal study

Psychological factors have been found to be of major importance for the transition from acute to chronic low back pain (CLBP). Although some evidence has been provided that depressive symptoms occur secondarily to CLBP, psychological treatment modules that specifically address depressive symptoms are not yet included in German inpatient rehabilitation programs. In this study, a standard rehabilitation program for patients with CLBP and depressive symptoms was compared to a standard rehabilitation, into which a cognitive-behavioral management training of depressive symptoms was integrated. Moreover, treatment effects of this multidisciplinary standard rehabilitation program delivered to patients with either no or only mild depressive symptoms were investigated. As a further aim of the present study, gender effects on rehabilitation outcomes were examined. Short-, mid-, and long-term effects on individual global improvement as well as pain-related, psychological, and work-related measures were evaluated among N = 199 consecutively admitted patients with CLBP, aged from 24 to 62 years. The standard rehabilitation program had no persisting effects on psychological outcomes among patients with no and mild depressive symptoms. Patients with moderate and severe depressive symptoms in the standard rehabilitation program did not benefit with clinical importance at the 6- and 12-month follow-up assessments, but did show clinically significant improvements in psychological outcome measures at the 6-month follow-up assessment when the supplemental psychological component was applied. Additionally, days of sick leave decreased in the intervention group in the mid-term when compared to the baseline. Females benefited more in mental health than males. However, due to regression effects at the 12-month follow-up assessment, booster sessions are highly recommended. The results presented here support the notion that a more adequately tailored rehabilitation program seems to improve rehabilitation success and prevent further development of CLBP among this high-risk subpopulation.

[Gender differences in psychosocial variables in inpatient orthopedic rehabilitation of chronic low back pain]

As females are more often affected by chronic low back pain and psychological impairments than males, it can be assumed that females are more prone to develop chronic pain and have a special need for psychological treatment in orthopedic rehabilitation of chronic low back pain. In realizing a one-factorial design, effects of gender on psychosocial measures were examined in a consecutive sample of N=431 patients with chronic low back pain prior to rehabilitation. Females showed more psychological strain and pain-related impairments than males. Furthermore, the development of chronicity was more advanced in women than men. Evidence suggests increased needs for psychosocial interventions in females compared to males in inpatient orthopedic rehabilitation of chronic low back pain. Additionally, the necessity of a tailored allocation to specific psychological interventions in the rehabilitation of chronic low back pain is emphasized.