Karola Mergenthal

Background: The high number of mental disorders poses challenges for health care systems. In 2020, digital health applications (DHAs) were introduced in Germany as a new form of health care financed by the statutory health insurance. They aim to detect, monitor, treat, or alleviate disease, injury, or disability. DHAs for mental disorders (DHA-MD) intend to improve outpatient care for patients with mental disorders. However, evidence on general practitioners’ (GPs’) perspectives on DHA-MD and their prescribing behavior is limited. Objective: This study aimed to analyze GPs’ perspectives on DHA-MD and their prescribing behavior in the care of patients with mental disorders. Methods: A mixed methods study was conducted (January-October 2024), including a Germany-wide online survey and qualitative interviews with GPs and medical assistants (MAs). Sampling was conducted in collaboration with German research practice networks, which distributed the study invitation to their affiliated GPs. The questionnaire as well as the interview guides for GPs and MAs was developed by the study team according to the Consolidated Framework for Implementation Research. Descriptive analyses of prescribing behavior and perceived need (measured on an 11-point scale) for DHA-MD were conducted, followed by multivariate regression analyses to identify predictors of prescribing behavior and perceived need for DHA-MD. The interviews with GPs and MAs were analyzed using qualitative content analysis according to Mayring. Results: A sample of 149 GPs participated, and 12 GPs as well as 5 MAs were interviewed. The median prescription frequency of DHA-MD per quarter was 1, whereas the median estimated need was 3. Working in a half digitized and half paper-based practice (odds ratio 5.133, 95% CI 1.695‐15.542) as well as working in a completely digitized practice (odds ratio 3.006, 95% CI 1.296‐6.969) positively predicted the prescribing behavior. The duration of GPs’ medical practice ( b =−0.057; P =.01) negatively predicted the perceived need, while working in a group practice ( b =0.980; P =.02) positively predicted the perceived need for DHA-MD. In the interviews, GPs and MAs reported that they valued DHA-MD as a temporary or supplementary option for bridging waiting times for psychotherapy and considered their effectiveness to be highly dependent on indication and patient adherence. Reported barriers of GPs according to DHA-MD included lacking knowledge about DHA-MD, missing effectiveness studies, and difficulties integrating them into existing care processes. Conclusions: GPs are reluctant to prescribe DHA-MD, as the need is considered to be low and their use is primarily seen as a temporary or supplementary treatment option rather than a stand-alone intervention. There are significant reasons for rejection and barriers that hinder prescription in primary care. Addressing these barriers and involving GPs as well as patients in future research are essential for the development of DHA-MD.

Background: Since 2020, psychotherapists in Germany have been allowed to prescribe digital health applications for mental disorders (DHA-MDs). DHA-MDs were supposed to foster digitalization and improve access to mental health services. However, prescriptions of DHA-MDs are less frequent than expected. Objective: We aimed to investigate which characteristics of psychotherapists predicted perceived need for and prescribing of DHA-MDs among German psychotherapists. Methods: This study was a cross-sectional survey conducted in Germany. We contacted psychotherapists between January 2024 and April 2024 via professional associations, training institutes, or the social media platform X (formerly known as Twitter). We sent questionnaires to 1000 psychotherapy practices randomly selected from the registry of the National Association of Statutory Health Insurance Physicians. We assessed the characteristics of the psychotherapists, asked them to rate the perceived need for DHA-MDs on an 11-point scale, and documented their prescribing behavior. Linear and logistic regression analyses were performed to predict perceived need and prescribing, respectively. Results: A total of 321 psychotherapists participated. Perceived need was estimated as low (mean 2.1, SD 2.1). Among the 271 (84.4%) psychotherapists with valid data, 83 (30.6%) prescribed a DHA-MD to at least 1 patient in a regular quarter. As compared to a behavioral approach, a psychodynamic (b=–1.63; P<.001) or systemic psychotherapy approach (b=–1.48; P=.005) and higher age (b=–0.03; P=.007) negatively predicted the perceived need, while being a physician (vs psychologist; b=0.73; P=.02) and a psychotherapeutic and psychopharmacological treatment focus (vs psychotherapeutic alone; b=1.31; P=.04) positively predicted the perceived need. For prescribing DHA-MDs, odds were lower for psychotherapists with a psychodynamic, systemic, or other approach (vs behavioral approach; odds ratio [OR] 0.30, 95% CI 0.14-0.64). The odds were higher for psychotherapists with more than a half service mandate (vs less than or equal to a half service mandate; OR 2.99, 95% CI 1.50-5.97), working in a group practice or medical care center (vs single practice; OR 2.39, 95% CI 1.04-5.53), and being located in a rural community or small town (OR 2.74, 95% CI 1.27-5.94) or a medium-sized town (OR 2.67, 95% CI 1.21-5.92) compared to a large city. Conclusions: Professional group, psychotherapy approach, age, the size of service mandate, treatment focus, practice type, and community size predicted perceived need for and prescribing of DHA-MDs among psychotherapists. Our findings may inform stakeholders and decision-makers in health care and politics about where DHA-MDs have already been implemented in the landscape of mental health services.

Zusammenfassung: Theoretischer Hintergrund: Der Einsatz Digitaler Gesundheitsanwendungen für psychische Erkrankungen (PsyDiGA) wird kontrovers diskutiert. Fragestellung: Für wen und in welchem Behandlungskontext sind PsyDiGA (nicht) geeignet? Methode: Bundesweit niedergelassene Psychotherapeut_innen erhielten einen Fragebogen, der stratifiziert nach Verschreibungserfahrung mit PsyDiGA ausgewertet wurde. Zusätzlich analysierten wir leitfadenbasierte Interviews mittels qualitativer Inhaltsanalyse. Ergebnisse: Es lagen 321 Fragebögen sowie 16 Interviews vor. PsyDiGA seien geeignet für Patient_innen mit eingeschränkter Mobilität und ungeeignet bei Personen älter als 65 Jahre. Die Befragten lehnten PsyDiGA als primäre Behandlungsmethode ab, während dem Einsatz zur Überbrückung von Wartezeiten mehrheitlich zugestimmt wurde. Psychotherapeut_innen mit und ohne Verschreibungserfahrung von PsyDiGA unterschieden sich zum Teil deutlich hinsichtlich ihres Antwortverhaltens. Aus den Interviews ergaben sich die Notwendigkeit von persönlichem Kontakt, die Berücksichtigung psychischer Belastung sowie Technikaffinität als Kriterien für (fehlende) Eignung. Schlussfolgerungen: Die Verschreibung von PsyDiGA scheint abhängig von der therapeutischen Orientierung sowie der Abwägung zwischen Notwendigkeit und Möglichkeiten zu persönlicher Kontaktaufnahme zu sein.

BACKGROUND The high number of mental disorders poses challenges for healthcare systems. In 2020, digital health applications (DHA) were introduced in Germany as a new form of healthcare financed by the statutory health insurance. They aim to detect, monitor, treat, or alleviate disease, injury, or disability. DHA for mental disorders (DHA-MD) intend to improve outpatient care for patients with mental disorders. However, evidence on general practitioners (GP) perspectives on DHA-MD and their prescribing behavior is limited. OBJECTIVE The aim of this study was to analyze GPs’ perspectives on DHA-MD and their prescribing behavior in the care of patients with mental disorders. METHODS A mixed methods study was conducted (January - October 2024), including a Germany-wide online survey and qualitative interviews with GPs and medical assistants (MA). Sampling was conducted in collaboration with German research practice networks, which distributed the study invitation to their affiliated GPs. The questionnaire as well as the interview guides for GPs and MAs were developed by the study team according to the Consolidated Framework for Implementation Research. Descriptive analyses of prescribing behavior and perceived need (measured on an 11-point scale) for DHA-MD were conducted, followed by multivariate regression analyses to identify predictors of prescribing behavior and perceived need for DHA-MD. The interviews with GPs and MAs were analyzed using qualitative content analysis according to Mayring. RESULTS A sample of 149 GPs participated, 12 GPs and 5 MA were interviewed. The median prescription frequency of DHA-MD per quarter was 1 whereas the median estimated need was 3. Working in a half digitized/half paper-based practice (OR = 5.133, 95% CI [1.695 – 15.542]) as well as working in a completely digitized practice (OR = 3.006, 95% CI [1.296 - 6.969]) positively predicted the prescribing behavior. The duration of GPs’ medical practice (b = -.057, P = .013) negatively predicted the perceived need, while working in a group practice (b = .980, P = .02) positively predicted the perceived need for DHA-MD. In the interviews, GPs and MAs reported they valued DHA-MD as a temporary or supplementary option for bridging waiting times for psychotherapy and considered their effectiveness to be highly dependent on indication and patient adherence. Reported barriers of GPs according to DHA-MD included lacking knowledge about DHA-MD, missing effectiveness studies, and difficulties integrating them into existing care processes. CONCLUSIONS GPs are reluctant to prescribe DHA-MD, as the need is considered to be low and their use is primarily seen as a temporary or supplementary treatment option rather than a standalone intervention. There are significant reasons for rejection and barriers that hinder prescription in primary care. Addressing these barriers and involving GPs as well as patients in future research is essential for the development of DHA-MD.

BACKGROUND Since 2020, psychotherapists in Germany have been allowed to prescribe digital health applications for mental disorders (DHA-MDs). DHA-MDs were supposed to foster digitalization and improve access to mental health services. However, prescriptions of DHA-MDs are less frequent than expected. OBJECTIVE We aimed to investigate which characteristics of psychotherapists predicted perceived need for and prescribing of DHA-MDs among German psychotherapists. METHODS This study was a cross-sectional survey conducted in Germany. We contacted psychotherapists between January 2024 and April 2024 via professional associations, training institutes, or the social media platform X (formerly known as Twitter). We sent questionnaires to 1000 psychotherapy practices randomly selected from the registry of the National Association of Statutory Health Insurance Physicians. We assessed the characteristics of the psychotherapists, asked them to rate the perceived need for DHA-MDs on an 11-point scale, and documented their prescribing behavior. Linear and logistic regression analyses were performed to predict perceived need and prescribing, respectively. RESULTS A total of 321 psychotherapists participated. Perceived need was estimated as low (mean 2.1, SD 2.1). Among the 271 (84.4%) psychotherapists with valid data, 83 (30.6%) prescribed a DHA-MD to at least 1 patient in a regular quarter. As compared to a behavioral approach, a psychodynamic (b=–1.63; P<.001) or systemic psychotherapy approach (b=–1.48; P=.005) and higher age (b=–0.03; P=.007) negatively predicted the perceived need, while being a physician (vs psychologist; b=0.73; P=.02) and a psychotherapeutic and psychopharmacological treatment focus (vs psychotherapeutic alone; b=1.31; P=.04) positively predicted the perceived need. For prescribing DHA-MDs, odds were lower for psychotherapists with a psychodynamic, systemic, or other approach (vs behavioral approach; odds ratio [OR] 0.30, 95% CI 0.14-0.64). The odds were higher for psychotherapists with more than a half service mandate (vs less than or equal to a half service mandate; OR 2.99, 95% CI 1.50-5.97), working in a group practice or medical care center (vs single practice; OR 2.39, 95% CI 1.04-5.53), and being located in a rural community or small town (OR 2.74, 95% CI 1.27-5.94) or a medium-sized town (OR 2.67, 95% CI 1.21-5.92) compared to a large city. CONCLUSIONS Professional group, psychotherapy approach, age, the size of service mandate, treatment focus, practice type, and community size predicted perceived need for and prescribing of DHA-MDs among psychotherapists. Our findings may inform stakeholders and decision-makers in health care and politics about where DHA-MDs have already been implemented in the landscape of mental health services. CLINICALTRIAL

Background/Objectives: Obesity and depression, in conjunction with multimorbidity, are interconnected conditions increasingly managed in general practitioner (GP) settings, yet these associations remain insufficiently studied in older patients. This study investigates the prevalence of depression across different body mass index (BMI) classes and includes age and gender differences in multimorbid older patients, offering a novel perspective on subgroup-specific patterns. Further the agreement between GP depression diagnoses and the Geriatric Depression Scale (GDS) is studied and patient-specific factors that may affect the agreement are explored, aiming to improve future diagnostics for vulnerable subgroups. Methods: Data were provided by the baseline assessment of the MultiCare Study, a prospective multicenter observational cohort of multimorbid patients aged 65+ years recruited from 158 GP practices across eight study centers in Germany. Data from 2568 study participants were analyzed based on GP-coded International Classification of Diseases (ICD) diagnoses, structured GP questionnaires, and patient questionnaires. Assessments included data on the BMI and depression (15 item version of the GDS). Agreement between GP diagnoses of depression and GDS assessment was measured using Cohen’s kappa. Four logistic regression models were used to examine the effects of patient-specific factors on the agreement of depression diagnosis (match or mismatch). Results: GPs diagnosed depression in 17.3% of cases, compared to the detection of depressive symptoms in 12.4% of the patients by GDS (cut-off ≥ 6 points). The highest prevalence rates were observed in patients with obesity class III (25.0% by GP; 21.7% by GDS). Women were significantly more likely to receive a depression diagnosis by a GP across most BMI classes (except obesity classes II and III). The detection of depressive symptoms by GDS was significantly more prevalent in older multimorbid obese patients (≥75 years), except for patients with obesity class III. The overall agreement between GP diagnosis and GDS assessment was weak (κ = 0.156, p < 0.001). The highest agreement was found for people with obesity class III (κ = 0.256, p < 0.05). Factors associated with a True Positive depression diagnosis (match by both GDS and GP) were female gender (odds ratio (OR) = 1.83, p < 0.05), widowhood (OR = 2.43, p < 0.01), limited daily living skills (OR = 3.14, p < 0.001), and a higher level of education (OR = 2.48, p < 0.01). A significantly lower likelihood of a False Negative depression diagnosis was found for patients with obesity class III. Conclusions: This study highlights the significant prevalence of depression among multimorbid older adults across different BMI classes, particularly in those with obesity class III. The weak diagnostic agreement between GP diagnosis and GDS assessment suggests a need for improved diagnostic practices in primary care. Implementing standardized screening tools and fostering collaboration with mental health specialists could enhance the identification and management of depression in this vulnerable population.

Background: Availability of information at the interface of outpatient and inpatient care remains an important and inadequately resolved issue in Germany and beyond. As a vulnerable group with complex care needs, older patients, mostly multimorbid, are especially affected by the consequences. This trial tested the feasibility and implementability of a complex intervention which aimed at improving the availability of health information among patients and different healthcare providers. Methods: The prospective two-arm blinded pilot cRCT was accompanied by an explorative mixed-methods process evaluation. Over a period of six months in 2022, general practitioner (GP) practices in Germany with patients (≥ 65, multimorbid, polypharmacy) participated in testing the implementation of the intervention and the trial design (intervention (IG) vs control group (CG)). Here, the focus is on the feasibility and exploratory results of the primary (combined endpoint of hospitalisation, falls and mortality) and secondary outcome measures (improving GP practices’ and patients’ knowledge of health-related resource use (FIMA), as well as improving patients’ Health Literacy (HLQ-G) and Satisfaction with Medication Information (SIMS-D)). Data were analysed according to the intention to treat principle. Results: Twelve GP practices were randomised (6 per IG/CG). Of 159 patients invited, 93 were included in the analyses (52 IG/41 CG). At t0 and t1, only few self-reported data from patients (5 resp. 10) or from the GP questionnaire (resp. 0) were missing. At least one survey perspective was available for each patient at both survey times. Overall, there were few missing items in the questionnaires, so the scores could not be calculated in 4-18% of cases (primary combined endpoint 9%), and there were no single items with increased missing values (n = 0 to 7). The concordance of the hospitalisation data from patients and GP practices was about 80%. Exploratory analyses showed no effects of the intervention on primary or secondary outcome measures. Conclusions: The primary combined endpoint was feasible. The secondary outcomes and survey methods used also proved feasible for GP practices and older multimorbid patients, with low missing rates. However, there was no hint of the influence of the intervention in the study groups in the explorative analyses. Trial registration: The trial was registered in the DRKS German Clinical Trials Register: registration number DRKS00027649 (date: 19.01.2022); http://www.drks.de/DRKS00027649.

Hintergrund: In der allgemeinmedizinischen Forschung in Deutschland haben sich in den letzten Jahren zunehmend partizipative Forschungsansätze etabliert. Bei dieser Art der Forschung werden die Sichtweisen und das Erfahrungswissen relevanter Interessensgruppen, sogenannte Stakeholder, die bisher oftmals nur Forschungsobjekt waren, aktiv in den Forschungsprozess eingebunden. Im Bereich der Allgemeinmedizin sind neben hausärztlichen Praxisteams (Hausärzt:innen, Medizinische Fachangestellte, weitere Professionen) insbesondere Patient:innen sowie Bürger:innen relevante Stakeholder, durch deren aktive Beteiligung die Relevanz und Machbarkeit von Forschungsprojekten gesteigert werden kann. Zielsetzung: Mit dieser erfahrungsbasierten Handreichung sollen Wissenschaftler:innen zur aktiven Beteiligung von Stakeholdern an Forschung ermutigt und der Einsatz partizipativer Forschungsansätze weiter gefördert werden. Dabei legt diese Handreichung den Fokus bewusst auf die Besonderheiten allgemeinmedizinischer Forschung und der in diesem Kontext relevanten Stakeholder. Die Handreichung soll Hilfestellungen geben, wie ein Einstieg gelingen kann und was es bei der Planung und Umsetzung von Beteiligungsaktivitäten mit Patient:innen, Bürger:innen, Hausärzt:innen und Medizinischen Fachangestellten zu berücksichtigen gilt. Methode: Die Eckpunkte für diese Handreichung wurden im Rahmen eines Forschungssymposiums der Initiative Deutscher Forschungspraxennetze DESAM-ForNet erarbeitet, das im April 2024 in Frankfurt am Main stattfand. Bei dem Forschungssymposium kamen 35 Wissenschaftler:innen, Studienassistent:innen und weitere interessierte Mitarbeitende aus allgemeinmedizinischen Forschungspraxennetzen und anderen Institutionen zusammen, um sich zu der Frage „Wie gelingt aktive Forschungsbeteiligung von Patient:innen, Bürger:innen, Hausärzt:innen und Medizinischen Fachangestellten an der allgemeinmedizinische Forschung?“ auszutauschen. Hierfür diskutierten die Teilnehmenden in zwei World Cafés zu den Themen (1) Partizipation planen und umsetzen sowie (2) Besonderheiten der Stakeholder. Die erarbeiteten Inhalte wurden jeweils auf Moderationskarten gesammelt und thematisch geclustert. Auf Grundlage dieser Erfahrungssammlung arbeiteten die Teilnehmenden des Symposiums im Nachgang in kleinen Autor:innengruppen die einzelnen Kapitel der Handreichung aus. Im Sinne der Beteiligung wurde die Handreichung vor Finalisierung durch zwei Patient:innen, zwei Hausärzt:innen und zwei Medizinische Fachangestellte geprüft und kommentiert. Ergebnisse: Mit Fokus auf der allgemeinmedizinischen Forschung gibt die Handreichung einen umfassenden Überblick über die Zielsetzungen und Gründe aktiver Forschungsbeteiligung, mögliche Methoden, Aspekte der Planung und Organisation von Beteiligungsaktivitäten sowie Ansätze und Instrumente für deren Evaluation. Darüber hinaus beleuchtet sie Besonderheiten der drei zentralen Stakeholdergruppen Patient:innen/Bürger:innen, Hausärzt:innen und Medizinischen Fachangestellte im Hinblick auf Diversität, geeignete Beteiligungsformate, zielgruppengerechte Ansprache, Erwartungsmanagement sowie passende Anreize für die Beteiligung. Da die Inhalte überwiegend erfahrungsbasiert und dadurch limitierend bezüglich der Übertragbarkeit auf andere Kontexte sind, wir die Handreichung durch eine Sammlung an Verweisen auf weitere hilfreicher Ressourcen wie Handbücher, Glossare und Checklisten ergänzt. Schlussfolgerung: Diese Handreichung zur aktiven Beteiligung von Stakeholdern an allgemeinmedizinischer Forschung spiegelt die Erfahrungen der Autor:innengruppe wider. Sie soll auf diese Weise möglichst anwendungsorientierte und passgenaue Anregungen für den Kontext Allgemeinmedizin geben und noch mehr Kolleg:innen ermutigen, Stakeholder aktiv an Forschung zu beteiligen.

Introduction: Patient and public involvement is vital for high‐quality research. Integrating patients' and providers' perspectives early in research enhances the feasibility and relevance of study results. Within our family practice‐based research network ForN, we established a standing patient advisory board (PAB) to include patients with diverse conditions and experiences. In this paper, we aim to describe the establishment and functioning of a standing PAB in family medicine research from patients' and researchers' perspectives.Methods: After each PAB meeting, patients and researchers were asked to name anonymously positive and challenging moments in a feedback form with open questions. Researchers were also asked to reflect on how they implemented the discussion content in their research projects. The responses from both groups were transferred to MAXQDA 2018 and analyzed separately using thematic analysis.Results: We analyzed 40 feedback forms from patients and 14 feedback forms from researchers. The dominant theme in the patients' feedback was ‘exchange’: They positively emphasized the ‘exciting and open discussions’ and the exchange of perspectives with one another and researchers. The clarity of the researchers' presentations and the research topics were appreciated. Researchers also positively highlighted the open atmosphere of the discussions. Presenting their research to the PAB helped most researchers reflect on their research topics from patients' perspectives and implement changes. However, researchers also mentioned several barriers to the implementation of PAB members’ feedback.Conclusion: The establishment of a standing PAB in family practice research is feasible and productive both from patients' and researchers' perspectives.Patient or Public Contribution: This study reports the evaluation of the establishment of a standing PAB in family practice research. Board members are involved in the design of studies, the co‐production of interventions and information material, and the interpretation of data.