Depression in primary care and the role of evidence-based guidelines: cross-sectional data from primary care physicians in Germany

Background: Depression is the most common mental health burden worldwide. Primary care physicians (PCPs) play a key role in the care provision for people with depression. The first objective of the present study was to examine the health care situation of depression in primary care, focusing on the cooperation between PCPs and mental health specialists. Secondly, we aimed at examining the role of the German S3 Guideline for Unipolar Depression in the primary care provision. Methods: Data of N = 75 PCPs were analysed from a cross-sectional online survey. Analysis of descriptive information on the current status of primary health care and depression was conducted. Further, to examine factors that are related to the usage of guidelines, multiple regression was performed. Results: Only 22.1% of PCPs described the quality of cooperation with ambulatory mental health specialist as good. The most frequent problems in the cooperation were of structural nature (49.3%, long waiting list, few therapy units, as well as barriers in the communication and the information exchange). With regard to the role of the guideline, 65% of PCPs reported never or seldom using the guideline and 31.7% of PCPs perceived the guideline as not useful at all. In addition, perceived usefulness of the S3 guideline was positively associated with the usage of the guideline. Results of the logistic regression revealed a significant association between the usage of the German S3 Guideline for Unipolar Depression and rating of perceived usefulness of the guideline (OR: 4.771; 95% CI: 2.15-10.59; p < 0.001). Conclusion: This study highlights the central role of PCPs and demonstrates major barriers in the outpatient health care provision of depression. Present findings suggest a strong need for collaborative health care models to resolve obstacles resulting from fragmented mental health care systems. Finally, reported perceived barriers in the implementation of the German S3 Guideline for Unipolar Depression indicate the urge to involve PCPs in the development of evidence-based guidelines, in order to ensure a successful implementation and usage of guidelines in clinical practice

Safety and Healthcare Resource Utilization in Patients Undergoing Left Atrial Appendage Closure—A Nationwide Analysis

Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. The aim of this study was to analyze outcomes of peri-procedural safety and healthcare resource utilization in 11,240 adult patients undergoing LAAC in the United States between 2016 and 2019. Primary outcomes (safety) were in-hospital ischemic stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolization and mortality. Secondary outcomes (resource utilization) were adverse discharge disposition, hospital length of stay (LOS) and costs. Logistic and Poisson regression models were used to analyze outcomes by adjusting for 10 confounders. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (p = 0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality (0.14%) remained stable. Hospital LOS decreased by 17% (0.78-0.87, p < 0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, p = 0.005) between 2016 and 2019, while hospital costs did not significantly change (p = 0.2). Female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]) while multi-morbid patients had higher risks of major bleeding (p < 0.001) and mortality (p = 0.031), longer hospital LOS (p < 0.001) and increased treatment costs (p = 0.073). Significant differences in all outcomes were observed between male and female patients across US regions. In conclusion, LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients

Preoperative depression and hospital length of stay in surgical patients

Einleitung: Bei operativen Patienten wurde bislang die Assoziation von Depressivität und Krankenhausverweildauer vor allem in der kardiovaskulären Chirurgie untersucht. Sehr selten sind Studien aus anderen chirurgischen Fachgebieten. In dieser Studie soll untersucht werden, ob klinisch relevante Depressivität bei Patienten diverser chirurgischer Gebiete mit der Krankenhausverweildauer assoziiert ist. In der Analyse sollen wesentliche somatische Einflussfaktoren auf die Krankenhausverweildauer berücksichtigt werden. Methodik: In dieser prospektiven Beobachtungsstudie wurden 2.624 operative Patienten aus der Anästhesieambulanz der Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin der Charité - Universitätsmedizin Berlin eingeschlossen. Vor der Prä- medikationsvisite wurde eine computergestützte Lebensstilbefragung durchgeführt, die unter anderem verschiedene psychosoziale Selbstbeurteilungsfragebögen beinhaltete. Es wurden zur Erfassung von Depressivität drei standardisierte Screeninginstrumente eingesetzt: Allgemeine Depressionsskala (ADS-K), World Health Organization 5-Item Well-Being Index (WHO-5) und Two-Item Patient Health Questionnaire (PHQ-2). Sechs Monate nach der Operation wurden aus elektronischen Datenverwaltungssystemen der Klinik ergänzende peri- und postoperative somatische Patientencharakteristika entnommen. Ergebnisse: Patienten mit klinisch relevanter Depressivität auf der ADS-K (n=296; Median: 5 Tage, Interquartilbereich: 3-8 Tage) zeigten eine statistisch signifikant höhere Krankenhausverweildauer (p<0,001) als Patienten ohne klinisch relevante Depressivität (n=2.328; Median: 4 Tage, Interquartilbereich: 2-6 Tage). In der multivariaten binär-logistischen Regression mit der abhängigen Variable Krankenhausverweildauer (kleiner oder gleich Median versus über dem Median) zeigte die klinisch relevante Depressivität (gemessen mit der ADS-K) eine statistisch unabhängige Assoziation mit der Krankenhausverweildauer (OR: 1,822 [95% CI 1,360–2,441], p<0,001) bei gleichzeitiger Berücksichtigung von Alter, Geschlecht, Klassifikation der American Society of Anesthesiologists, Charlson Comorbidity Index, chirurgischem Fachgebiet und Operationsschwere aus dem Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity. Unabhängig vom Erhebungsinstrument der Depressivität hat sich in den jeweiligen Regressionsmodellen die klinisch relevante Depressivität als signifikanter Prädiktor für die Krankenhausverweildauer herausgestellt (ADS-K p<0,001, WHO-5 p=0,003, PHQ-2 p=0,023). Darüber hinaus konnte in einem erweiterten Regressionsmodell gezeigt werden, dass klinisch relevante Depressivität ein unabhängiger statistisch signifikanter Prädiktor (p<0,001) für erhöhte Krankenhausverweildauer bleibt, wenn weitere soziodemographische Charakteristika sowie klinische Risikofaktoren für Depressivität (Partnerschaftsstatus, Erwerbstätigkeitsstatus, Schulbildung, Body Mass Index, Raucherstatus, alkoholkonsumbezogene Störungen und Drogenkonsum) berücksichtigt werden. Schlussfolgerung: Die Assoziation zwischen klinisch relevanter Depressivität und erhöhter Krankenhausverweildauer ist signifikant unabhängig von Alter, Geschlecht, Schwere der somatischen Komorbidität, Schwere der Operation und chirurgischem Fachgebiet. Patienten mit klinisch relevanter Depressivität haben ein 82% höheres Risiko für einen längeren Krankenhausaufenthalt als Patienten ohne klinisch relevante Depressivität. Ein möglicher Behandlungsansatz wäre die Einführung eines multimodalen psychosozialen Stufenkonzepts in die Routineversorgung operativer Patienten, das es ermöglicht, klinisch relevante Depressivität im Rahmen einer Screeninguntersuchung zu erkennen und belasteten Patienten adäquate psychotherapeutische und psychiatrische Interventionen anzubieten.Background: Until now the association between depression and hospital length of stay has rarely been examined in surgical patients outside of cardiovascular surgery. The purpose of this study was to investigate whether clinically relevant preoperative depression shows an independent association with hospital length of stay in patients from various surgical fields, after adjusting for age, gender and important somatic factors. Methods: In this prospective observational study, a total of 2.624 surgical patients were included at the preoperative assessment clinics of the Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Germany. Data were collected before the preoperative anesthesiological examination within a computer-assisted psycho- social self-assessment including three screening instruments for depression: Center for Epidemiologic Studies Depression Scale (CES-D), World Health Organization 5-Item Well- Being Index (WHO-5) and Two-Item Patient Health Questionnaire (PHQ-2). Data on peri- and postoperative somatic parameters were obtained from the hospital’s electronic patient management system six months after the preoperative assessment. Results: The hospital length of stay of patients with clinically relevant depression on the CES-D (n=296; median: 5 days, interquartile range: 3-8 days) was significantly longer (p<0,001) than for patients without depression (n=2.328; median: 4 days, interquartile range: 2-6 days). A multivariate logistic regression model with the binary dependent variable hospital length of stay (below or equal to the median versus above the median) showed that the significant association between depression and hospital length of stay persisted (OR: 1,822 [95% CI 1,360–2,441], p<0.001) when simultaneously including the covariates age, gender, classification of the American Society of Anesthesiologists, Charlson Comorbidity Index, surgical field and operative severity rating from the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity. Independent of the screening instruments, depression was a significant predictor for hospital length of stay (CES-D p<0,001, WHO-5 p=0,003, PHQ-2 p=0,023). Furthermore, it was shown in an expanded regression model that the association between depression and hospital length of stay (p<0.001) remained independent even when including other sociodemographic characteristics and clinical risk factors for depression (partnership status, employment status, education, Body Mass Index, smoking status, alcohol use disorders and drug use). Conclusion: Data suggest that the association of depression and hospital length of stay is independent of the impact of age, gender, and the somatic factors surgical field, preoperative physical health, severity of medical comorbidity and extent of surgical procedure. The risk of having a hospital length of stay above the median was 82% higher in patients with clinically relevant depression than in patients without clinically relevant depression. Therefore a multimodal psychosocial stepped care approach of depression therapy might be integrated in routine care of surgical patients

Social networks of men who have sex with men engaging in chemsex in Germany: differences in social resources and sexual health

Abstract Meyer’s minority stress model posits that sexual minority communities can act as protective factors for individuals within the sexual minority. Given that existing evidence on this proposition is inconclusive, a social network approach was employed to capture diversity in the social environment of individuals involved in chemsex that might account for variations in social resources and sexual health. This study examined the social networks of men who have sex with men (MSM) involved in sexualised drug use, using data from a cross-sectional online survey. Utilising cluster analysis, four distinct social network types were identified based on network composition: MSM-diverse, partner-focused, family-diverse, and chemsex-restricted. In terms of social resources, the four network types did not exhibit significant differences in social support. However, individuals with a chemsex-restricted social network reported stronger social influence related to chemsex and less social engagement outside of chemsex. Contrary to initial expectations, the four network types did not differ in chemsex-related consequences or sexual satisfaction. MSM engaged in chemsex for over 5 years reported more chemsex-related consequences and lower sexual satisfaction, particularly those with a family-diverse social network. Additionally, indicators of network quality, such as perceived emotional closeness, reciprocity with network members, and overall satisfaction with the network, were more influential in predicting sexual health outcomes than social resources. The findings of the study suggest that the social environment of MSM engaged in chemsex plays a role in shaping their experiences. Insufficient inclusion in a sexual minority community is potentially associated with an elevated risk of poor sexual health. These findings underscore the importance of tailoring interventions to address the diverse needs of individuals exposed to different social environments

The psychological burden of COVID-19 on the desire for parenthood in minoritized sexual identities: a study on depressive symptoms and family planning in Germany

Abstract Background The COVID-19 pandemic continues to spread across the globe and is associated with significant clinical and humanitarian burden. The desire for parenthood has been described to be positively correlated with psychological well-being: An unfulfilled wish for parenthood is associated with impaired mental health, and the wish for parenthood is a predictor for the development of depressive symptoms. While higher rates of anxiety and depression have been reported in individuals with minoritized sexual identities (compared to heterosexual individuals) during the COVID-19 pandemic, the specific impact of the pandemic and its social restriction measures on this population is poorly understood. Methods From April to July 2020, we conducted an anonymous cross-sectional survey online among N = 2463 adults living in Germany. We screened for depressive symptoms (Patient Health Questionnaire-4; PHQ-4) and assessed individuals’ desire for parenthood during the pandemic, and motives for or against the desire for parenthood (Leipzig questionnaire on motives for having a child, Version 20; LKM-20), with the aim of identifying differences between individuals with minoritized sexual identities and heterosexual individuals. Results Compared to heterosexual individuals (n = 1304), individuals with minoritized sexual identities (n = 831) indicated higher levels of depressive symptoms. In our study sample the majority of all participants (81.9%) reported no change in the desire for parenthood since the COVID-19 pandemic. Conclusion The findings underline the unmet need for social, psychological and medical support in regard to family-planning and the desire for parenthood during a pandemic. Furthermore, future research should explore COVID-19-related psychological consequences on individuals’ desire for parenthood and building a family

A GWAS top hit for circulating leptin is associated with weight gain but not with leptin protein levels in lithium-augmented patients with major depression

Lithium-treated patients often suffer from weight gain as a common adverse event. In an earlier investigation, we found an impact of two single-nucleotide polymorphisms (rs10487506 and rs2278815) at the leptin gene on weight gain but not on leptin protein levels in serum under lithium augmentation. A recent genome-wide association study identified a polymorphism at the leptin gene locus (rs10487505) associated with circulating leptin protein levels. To characterize potential effects of this variant in acute major depressive disorder, we investigated body mass indices from 180 lithium-augmented patients and serum concentrations of leptin protein from 89 patients using linear mixed model analyses and rs6979832, a proxy SNP of rs10487505. Body mass index was measured before and after 4 weeks of lithium augmentation, in a subsample also after 4 and 7 months. Leptin serum levels were measured before and during lithium augmentation. G-allele homozygotes of rs6979832 had a significantly lower body mass index increase during observation compared to A-allele hetero- and homozygotes. However, we found no influence on leptin serum levels. Joint analyses of rs6979832 with the previously investigated polymorphisms rs10487506 and rs2278815, and expressed quantitative trait data, suggest a complex interplay between SNP alleles at the leptin locus. These results strongly support our earlier findings that common genetic variation at the leptin gene locus may be involved in lithium augmentation-associated weight gain in major depressive disorder

Well-being during COVID-19 pandemic: A comparison of individuals with minoritized sexual and gender identities and cis-heterosexual individuals.

BackgroundPreliminary empirical data indicates a substantial impact of the COVID-19 pandemic on well-being and mental health. Individuals with minoritized sexual and gender identities are at a higher risk of experiencing such negative changes in their well-being. The objective of this study was to compare levels of well-being among cis-heterosexual individuals and individuals with minoritized sexual and gender identities during the COVID-19 pandemic.MethodsUsing data obtained in a cross-sectional online survey between April 20 to July 20, 2020 (N = 2332), we compared levels of well-being (WHO-5) across subgroups (cis-individuals with minoritized sexual identities, individuals with minoritized gender identities and cis-heterosexual individuals) applying univariate (two-sample t-test) and multivariate analysis (multivariate linear regression).ResultsResults indicate overall lower levels of well-being as well as lower levels of well-being in minoritized sexual or gender identities compared to cis-heterosexual individuals. Further, multivariate analyses revealed that living in urban communities as well as being in a relationship were positively associated with higher levels of well-being. Furthermore, a moderation analysis showed that being in a relationship reduces the difference between groups in terms of well-being.ConclusionAccess to mental healthcare for individuals with minoritized sexual and gender identities as well as access to gender-affirming resources should be strengthened during COVID-19 pandemic. Healthcare services with low barriers of access such as telehealth and online peer support groups should be made available, especially for vulnerable groups