Depression treatment in Germany – using claims data to compare a collaborative mental health care program to the general practitioner program and usual care in terms of guideline adherence and need-oriented access to psychotherapy

Abstract

Background Societies strive for fast-delivered, evidence-based and need-oriented depression treatment within budget constraints. To explore potential improvements, selective contracts can be implemented. Here, we evaluate if the German collaborative psychiatry-neurology-psychotherapy contract (PNP), which extends the gatekeeping-based general practitioner (GP) program, improved guideline adherence or need-oriented and timely access to psychotherapy compared to usual care (UC). Methods We conducted a retrospective observational cohort study based on health insurance claims data. After we identified patients with depression who were on sick leave due to a mental disorder in 2015, we applied entropy balancing to adjust for selection effects and employed chi-squared tests to compare guideline adherence of the received treatment between PNP, the GP program and UC. Subsequently, we applied an extended cox regression to assess need-orientation by comparing the relationship between accumulated sick leave days and waiting times for psychotherapy across health plans. Results N = 23,245 patients were included. Regarding guideline adherence, we found no significant differences for most severity subgroups; except that patients with a first moderate depressive episode received antidepressants or psychotherapy more often in UC. Regarding need-orientation, we observed that the effect of each additional month of sick leave on the likelihood of starting psychotherapy was increased by 6% in PNP compared to UC. Irrespective of the health plan, we found that within the first 12 months only between 24.3 and 39.7% (depending on depression severity) received at least 10 psychotherapy sessions or adequate pharmacotherapy. Conclusions The PNP contract strengthens the relationship between sick leave days and the delay until the beginning of psychotherapy, which suggests improvements in terms of need-oriented access to care. However, we found no indication for increased guideline adherence and – independent of the health plan – a gap in sufficient utilization of adequate treatment options.

Effectiveness of a coordinated ambulatory care program for patients with mental disorders or multiple sclerosis: results of a prospective non-randomized controlled trial in South Germany

“…One further reason might result from problems with the use of guideline-based care: Although the intervention group potentially had free access to different health services related to the PNP contract, this did not ensure that all patients of the intervention group actually received or used PNP treatment, nor did it verify the extent and appropriateness (e.g., guideline-based recommendations) of the treatments provided in the PNP intervention group. Results based on health insurance fund data indicate, that a relevant proportion of patients with depression in the GP and PNP program were still untreated or insufficiently treated during the first 12 months after sick leave (37). Although waiting times for acute and severely ill cases were lower in the PNP program compared to the control groups, it is not clear whether access to care is actually facilitated for participants of the PNP program.…”

Improving mental health care in depression: A call for action

“…Many subjects with major depressive disorder initially present to their general practitioner (GP) [7]. One study found that GPs correctly diagnosed depression in only 47.3% (95% CI, 41.7 to 53.0%) of cases [8].…”

Development and psychometric evaluation of a questionnaire for the assessment of depression in primary care: a cross-sectional study

“…20 Hence, it is particularly important to improve the diagnosis and care of patients with depression and to optimise treatment processes. 21 It is crucial to identify and treat people with depression in the early stages of their illness to prevent chronicity. 22 In addition, proactive management of subthreshold depression can also protect affected individuals from developing major depression.…”