["Good dying"--definition and current state of research]. / Was ist "gutes Sterben"? Begriffsklärung und Stand der Forschung.

The advances of modern medicine did not only result in prolongation of life expectancy, but also led to a shift from dying at home to dying in public institutions. In western countries most people die at advanced age in medical facilities. Hence, the question regarding the conditions, which should be provided by society and especially medicine, to allow terminally ill people to experience "good dying" is substantial. For this purpose, an examination of patients', family members' and health care providers' understanding of the term " good dying" is required. The present paper aims at shedding light on the term "good dying" and to summarize the current state of research. Therefore, the attributes of "good dying" will be described from the perspectives of patients, family members and health care providers, which are discussed and examined in current medical-sociological research. These attributes can be illustrated on three dimensions: Quality of life at the end of life (e. g. pain relief, mental well-being), quality of dying (e. g. avoiding prolonged dying, autonomy, presence of relatives) and quality of health care at the end of life (e. g. patient-oriented health care, positive communication between health care providers and patients, availability of guidelines). Although the attributes of "good dying" are described in detail in the existing literature, further studies have to clarify the relevance and impact of these attributes as predictors of "good dying".

Inpatient and outpatient costs in patients with coronary artery disease and mental disorders: a systematic review.

BACKGROUND: To systematically review in- and outpatient costs in patients with coronary artery disease (CAD) and comorbid mental disorders. METHODS: A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included which allowed a comparison of in- and outpatient health care costs (assessed either monetarily or in terms of health care utilization) of CAD patients with comorbid mental disorders (mood, anxiety, alcohol, eating, somatoform and personality disorders) and those without. Random effects meta-analyses were conducted and results reported using forest plots. RESULTS: The literature search resulted in 7,275 potentially relevant studies, of which 52 met inclusion criteria. Hospital readmission rates were increased in CAD patients with any mental disorder (pooled standardized mean difference (SMD) = 0.34 [0.17;0.51]). Results for depression, anxiety and posttraumatic stress disorder pointed in the same direction with heterogeneous SMDs on a primary study level ranging from -0.44 to 1.26. Length of hospital stay was not increased in anxiety and any mental disorder, while studies on depression reported heterogeneous SMDs ranging from -0.08 to 0.82. Most studies reported increased overall and outpatient costs for patients with comorbid mental disorders. Results for invasive procedures were non-significant respectively inconclusive. CONCLUSIONS: Comorbid mental disorders in CAD patients are associated with an increased healthcare utilization in terms of higher hospital readmission rates and increased overall and outpatient health care costs. From a health care point of view, it is requisite to improve the diagnosis and treatment of comorbid mental disorders in patients with CAD to minimize incremental costs.

Are depression and anxiety determinants or indicators of quality of life in breast cancer patients?

Depression and anxiety are associated with a decline of health-related quality of life (QoL) in breast cancer patients, and the present study aims to investigate the longitudinal relationship of depression and anxiety with QoL in breast cancer patients. Depression and anxiety (HADS) as well as QoL (EORTC QLQ-C30) were assessed at baseline and six-month follow-up in 118 breast cancer patients and analysed using cross-lagged partial correlation analysis (CLPC). There were significant partial correlations between depression and anxiety at baseline and physical functioning, emotional functioning and "global health and QoL" at six-month follow-up (range of pr = -0.197 and -0.392; p < 0.05). "Global health and QoL" at baseline was significantly correlated with depression and anxiety at follow-up (pr = -0.207 and -0.327; p < 0.05). Cognitive functioning at baseline was significantly associated with anxiety at follow-up (pr = -0.248; p < 0.01). CLPC analysis of two models (depression and anxiety determining QoL vs. QoL determining depression and anxiety) did not show significant results. Hence, in breast cancer patients, depression and anxiety are closely related to QoL and the observed correlations suggest a complex interrelation in which depression and anxiety have to be regarded as indicators of QoL rather than determinants.

Psychological and pharmacological interventions for depression in patients with diabetes mellitus and depression.

BACKGROUND: Depression occurs frequently in patients with diabetes mellitus and is associated with a poor prognosis. OBJECTIVES: To determine the effects of psychological and pharmacological interventions for depression in patients with diabetes and depression. SEARCH METHODS: Electronic databases were searched for records to December 2011. We searched CENTRAL in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, ISRCTN Register and clinicaltrials.gov. We examined reference lists of included RCTs and contacted authors. SELECTION CRITERIA: We included randomised controlled trials (RCTs) investigating psychological and pharmacological interventions for depression in adults with diabetes and depression. Primary outcomes were depression and glycaemic control. Secondary outcomes were adherence to diabetic treatment regimens, diabetes complications, death from any cause, healthcare costs and health-related quality of life (HRQoL). DATA COLLECTION AND ANALYSIS: Two review authors independently examined the identified publications for inclusion and extracted data from included studies. Random-effects model meta-analyses were performed to compute overall estimates of treatment outcomes. MAIN RESULTS: The database search identified 3963 references. Nineteen trials with 1592 participants were included. Psychological intervention studies (eight trials, 1122 participants, duration of therapy three weeks to 12 months, follow-up after treatment zero to six months) showed beneficial effects on short (i.e. end of treatment), medium (i.e. one to six months after treatment) and long-term (i.e. more than six months after treatment) depression severity (range of standardised mean differences (SMD) -1.47 to -0.14; eight trials). However, between-study heterogeneity was substantial and meta-analyses were not conducted. Short-term depression remission rates (OR 2.88; 95% confidence intervals (CI) 1.58 to 5.25; P = 0.0006; 647 participants; four trials) and medium-term depression remission rates (OR 2.49; 95% CI 1.44 to 4.32; P = 0.001; 296 participants; two trials) were increased in psychological interventions compared to usual care. Evidence regarding glycaemic control in psychological intervention trials was heterogeneous and inconclusive. QoL did not improve significantly based on the results of three psychological intervention trials compared to usual care. Healthcare costs and adherence to diabetes and depression medication were examined in only one study and reliable conclusions cannot be drawn. Diabetes complications and death from any cause have not been investigated in the included psychological intervention trials.With regards to the comparison of pharmacological interventions versus placebo (eight trials; 377 participants; duration of intervention three weeks to six months, no follow-up after treatment) there was a moderate beneficial effect of antidepressant medication on short-term depression severity (all studies: SMD -0.61; 95% CI -0.94 to -0.27; P = 0.0004; 306 participants; seven trials; selective serotonin reuptake inhibitors (SSRI): SMD -0.39; 95% CI -0.64 to -0.13; P = 0.003; 241 participants; five trials). Short-term depression remission was increased in antidepressant trials (OR 2.50; 95% CI 1.21 to 5.15; P = 0.01; 136 participants; three trials). Glycaemic control improved in the short term (mean difference (MD) for glycosylated haemoglobin A1c (HbA1c) -0.4%; 95% CI -0.6 to -0.1; P = 0.002; 238 participants; five trials). HRQoL and adherence were investigated in only one trial each showing no statistically significant differences. Medium- and long-term depression and glycaemic control outcomes as well as healthcare costs, diabetes complications and mortality have not been examined in pharmacological intervention trials. The comparison of pharmacological interventions versus other pharmacological interventions (three trials, 93 participants, duration of intervention 12 weeks, no follow-up after treatment) did not result in significant differences between the examined pharmacological agents, except for a significantly ameliorated glycaemic control in fluoxetine-treated patients (MD for HbA1c -1.0%; 95% CI -1.9 to -0.2; 40 participants) compared to citalopram in one trial. AUTHORS' CONCLUSIONS: Psychological and pharmacological interventions have a moderate and clinically significant effect on depression outcomes in diabetes patients. Glycaemic control improved moderately in pharmacological trials, while the evidence is inconclusive for psychological interventions. Adherence to diabetic treatment regimens, diabetes complications, death from any cause, health economics and QoL have not been investigated sufficiently. Overall, the evidence is sparse and inconclusive due to several low-quality trials with substantial risk of bias and the heterogeneity of examined populations and interventions.

Indirect costs in patients with coronary artery disease and mental disorders: a systematic review and meta-analysis.

OBJECTIVES: The aim of the present study was to systematically review the association of comorbid mental disorders with indirect health care costs in patients with coronary artery disease (CAD). MATERIALS AND METHODS: A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included, which allowed for a comparison of indirect health care costs between CAD patients with comorbid mental disorders and CAD patients without mental disorders. RESULTS: The literature search revealed 4962 potentially relevant studies, out of which 13 primary studies met the inclusion criteria. Depression was investigated most often (N = 10), followed by anxiety disorders (N = 3) and any mental disorder not further specified (N = 3). All studies focused on return to work as indirect cost outcome. CAD patients with depression showed diminished odds for return to work, compared to CAD patients without depression (OR = 0.37; 95% CI: 0.27-0.51). The findings for comorbid anxiety and any mental disorder were inconsistent. Indirect health care costs were exclusively assessed by a patient self-report (N = 13). CONCLUSIONS: There is strong evidence for diminished odds of return to work in CAD patients with comorbid depression, highlighting the need for integrated CAD and depression care. With regard to other comorbid mental disorders, however, the evidence is sparse and inconclusive.

Collaborative care for depression in medically ill patients.

PURPOSE OF REVIEW: Depression is common in medically ill patients and associated with a negative prognosis. Recent findings indicate that single interventions have little effect on outcomes in these patients. Alternatively, complex interventions based on a collaborative care model are promising. This review summarizes recent findings regarding collaborative care in medically ill patients with comorbid depression. RECENT FINDINGS: Recent trials provide evidence for a significantly beneficial effect on depression outcomes with moderate effect sizes regarding depressive symptoms [standardized mean differences (SMDs): -0.46 to -0.74, n = 5] and depression response [odds ratios (ORs): 1.29 to 4.75, n = 6]. Psychosocial quality of life (SMDs: 0.09 to 0.54, n = 5) and satisfaction with care (ORs: 2.55-7.43, n = 3; SMDs: 0.05 and 0.2, n = 1) were increased in intervention patients compared with usual care, whereas physical quality of life (SMDs: -0.17 to 0.06) was not. The evidence regarding medication adherence and somatic, disease-specific outcomes is sparse and conclusions cannot be drawn so far. SUMMARY: Collaborative care interventions are efficacious in medically ill patients with depression. However, there is no data concerning their cost-effectiveness. Furthermore, as trials on collaborative care comprise a heterogeneous set of components, the most effective characteristics should be identified. Moreover, these interventions should be adapted to other healthcare systems than the United States.

Direct and indirect costs in persons with chronic back pain and comorbid mental disorders--a systematic review.

OBJECTIVE: Direct inpatient and outpatient healthcare costs as well as indirect costs (e.g. productivity losses) are hypothesized to be increased in chronic back pain (CBP) patients with mental disorders. The aim of this systematic review is to examine this hypothesis by comparing costs in CBP patients with and without mental disorders. METHODS: A comprehensive literature search (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS) was conducted. All studies were included which allowed for a comparison of direct and indirect costs between CBP patients with and without mental disorders. RESULTS: Of 2283 potentially relevant articles, 10 studies fulfilled the inclusion criteria. Total healthcare costs (SMD=0.16 [SE=0.06]; n=1), CBP-related healthcare costs (SMD=0.21 [0.06]; n=1), CBP-related primary care visits (OR=1.6 [95%-CI:1.2-2.3]; n=1), CBP-related specialty care visits (OR=1.4 [1.0-2.0];n=1), CBP-related radiologic procedures (OR=1.6 [1.0-2.5]; n=1) and mental health visits (OR=8.1 [7.3-9.1]; n=2) were increased in CBP patients with depression. The incidence of new surgeries was increased in CBP patients with PTSD (OR=4.2 [1.6-10.8]; n=1). Pain-related healthcare use (n=1) in CBP patients with both depression and anxiety and CBP-related hospital admissions (n=1) in CBP patients with depression were not increased. Regarding indirect costs results were inconsistent for both return to work rates (n=3) and work absence (n=2). CONCLUSION: The results indicate increased direct but not indirect costs in CBP patients with mental disorders. However, the evidence is limited due to the low number of studies per outcome. This is all the more problematic, since the adequate allocation of healthcare resources will become a major topic of health care policy due to limited resources.

Psychological and pharmacological interventions for depression in patients with coronary artery disease.

BACKGROUND: Depression occurs frequently in patients with coronary artery disease (CAD) and is associated with a poor prognosis. OBJECTIVES: To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression. SEARCH STRATEGY: CENTRAL, DARE, HTA and EED on The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ISRCTN Register and CardioSource Registry were searched. Reference lists of included randomised controlled trials (RCTs) were examined and primary authors contacted. No language restrictions were applied. SELECTION CRITERIA: RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression were included. Primary outcomes were depression, mortality and cardiac events. Secondary outcomes were healthcare costs and health-related quality of life (QoL). DATA COLLECTION AND ANALYSIS: Two reviewers independently examined the identified papers for inclusion and extracted data from included studies. Random effects model meta-analyses were performed to compute overall estimates of treatment outcomes. MAIN RESULTS: The database search identified 3,253 references. Sixteen trials fulfilled the inclusion criteria. Psychological interventions show a small beneficial effect on depression compared to usual care (range of SMD of depression scores across trials and time frames: -0.81;0.12). Based on one trial per outcome, no beneficial effects on mortality rates, cardiac events, cardiovascular hospitalizations and QoL were found, except for the psychosocial dimension of QoL. Furthermore, no differences on treatment outcomes were found between the varying psychological approaches. The review provides evidence of a small beneficial effect of pharmacological interventions with selective serotonin reuptake inhibitors (SSRIs) compared to placebo on depression outcomes (pooled SMD of short term depression change scores: -0.24 [-0.38,-0.09]; pooled OR of short term depression remission: 1.80 [1.18,2.74]). Based on one to three trials per outcome, no beneficial effects regarding mortality, cardiac events and QoL were found. Hospitalization rates (pooled OR of three trials: 0.58 [0.39,0.85] and emergency room visits (OR of one trial: 0.58 [0.34,1.00]) were reduced in trials of pharmacological interventions compared to placebo. No evidence of a superior effect of Paroxetine (SSRI) versus Nortriptyline (TCA) regarding depression outcomes was found in one trial. AUTHORS' CONCLUSIONS: Psychological interventions and pharmacological interventions with SSRIs may have a small yet clinically meaningful effect on depression outcomes in CAD patients. No beneficial effects on the reduction of mortality rates and cardiac events were found. Overall, however, the evidence is sparse due to the low number of high quality trials per outcome and the heterogeneity of examined populations and interventions.

Health care costs in persons with asthma and comorbid mental disorders: a systematic review.

OBJECTIVE: The aim of this study was to systematically review the impact of comorbid mental disorders on health care costs in adult persons with asthma. METHOD: A comprehensive search for studies investigating adult persons (≥18 years) with asthma was conducted. All studies were included, which allowed a comparison of health care utilization and costs between asthma patients with mental disorders and asthma patients without. RESULTS: The literature search revealed 1977 potentially relevant studies. Eighteen primary studies (20 publications) fulfilled the inclusion criteria. Mood disorders (n=14) and anxiety disorders (n=9) were studied most often. Increased rates of hospitalizations (odds ratio range, 0.9-6.1; n=7), emergency department visits (odds ratio range, 1.8-17.2; n=7) and general practitioner visits (standardized mean difference range, 0.1-1.1; n=6) were found in asthma patients with mental comorbidity. Indirect costs of work absence were investigated in two studies pointing in the same direction of increased costs. Evidence is sparse regarding other outcomes due to a lack of primary studies. CONCLUSION: The present systematic review highlights a meaningful impact of comorbid mental disorders on health care utilization and costs in adult patients with asthma. Thus, psychodiagnostic routines and appropriate mental health treatments are needed to reduce health care costs in asthma care.

Quality of life in medically ill persons with comorbid mental disorders: a systematic review and meta-analysis.

BACKGROUND: This systematic review aims to investigate the association between comorbid mental disorders and quality of life (QoL) in patients with chronic medical diseases. METHODS: Studies investigating adults with diabetes mellitus, coronary artery disease, asthma, chronic back pain and colorectal cancer were included. Two reviewers independently extracted data and assessed methodological criteria. Effect sizes for QoL scores were analyzed in random-effects meta-analyses. Subgroup and sensitivity analyses were conducted. RESULTS: The database search identified 7,291 references and 65 primary studies were included. Medically ill persons with comorbid mental disorders showed a significantly decreased overall (d = -1.10; 95% CI = -1.34 to -0.86), physical (d = -0.64; 95% CI = -0.74 to -0.53) and psychosocial (d = -1.18; 95% CI = -1.42 to -0.95) QoL compared to persons without mental disorders. Subgroup analyses did not reveal significant differences between the examined medical diseases or mental disorders. CONCLUSION: The review provides evidence of a substantially reduced psychosocial and physical QoL in medically ill patients with comorbid mental disorders. This patient-reported outcome highlights the importance of recognizing and treating comorbid mental disorders in the medically ill.

Health care utilisation and quality of life in individuals with diabetes and comorbid mental disorders.

OBJECTIVE: To investigate the association of comorbid mental disorders with health care utilisation and quality of life (QoL) in persons with diabetes (PWD). METHOD: Data were drawn from the German National Health Interview and Examination Survey (GNHIES). Mental disorders in PWD (n=146) were assessed by means of a standardised clinical interview for mental disorders (M-CIDI). Health care utilisation was assessed by using self-report questionnaires and QoL by using the SF-36. RESULTS: Controlling for age and sex, mental comorbidity was significantly associated with reduced QoL scores on all SF-36 subscales, except for "bodily pain". The frequency of physician visits was (insignificantly) higher in PWD with mental disorders compared to PWD without (20.7 vs. 14.4). Among PWD with mental disorders (n=40), only seven individuals reported mental health specialist visits. Mental comorbidity was not associated with hospitalisation days, disability days or utilisation of diabetes-related preventive services. CONCLUSIONS: Comorbid mental disorders were found to be associated with lowered psychosocial and physical aspects of QoL in a nationally representative sample of PWD. Associations with health care utilisation were less consistent. The low rate of mental health specialist visits in PWD with comorbid mental disorders may indicate an under-use of appropriate health care services.