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1.  Drug Treatment Patterns of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents in Germany: Results from a Large Population-Based Cohort Study 
Despite a substantial increase in total methylphenidate (MPH) prescriptions in Germany over the last 20 years, and the introduction of modified release MPH (MR MPH) and atomoxetine (ATX), remarkably little is known about treatment patterns of attention- deficit/hyperactivity disorder (ADHD) in individual patients.
Usage patterns of ADHD drugs in children and adolescents in Germany were analyzed using data from one large German health insurance including >7,200,000 members. Of those, 6210 ADHD patients newly diagnosed in 2005 were followed for a maximum of 4 years. Kaplan–Meier estimates were calculated for onset and discontinuation of ADHD drug treatment. Predictors of time until drug treatment initiation were assessed by Cox regression.
During follow-up, 52.0% of ADHD subjects (53.4% of boys, 47.5% of girls) received ADHD drug treatment. The majority of them (91.6%) were started on MPH, with immediate release MPH (IR MPH) being the initial treatment choice in 75.3%. In these subjects, change to drug treatment with MR MPH in the first year occurred in 48% by switch or addition. Significant predictors of drug treatment were behavioral and emotional disorders (HR=1.13; 95% CI 1.03–1.24) and a diagnosis of ADHD with conduct disorder (HR=1.21, 95% CI 1.12–1.32), whereas young age showed a protective effect. After 6, 12, and 24 months of treatment initiation, 22.4%, 43.4%, and 66.3% of treated girls, and 17.8%, 36.1%, and 54.1% of treated boys had discontinued ADHD treatment.
Drug treatment of ADHD was relatively common in Germany and more frequent in boys than in girls. IR MPH was the predominant treatment choice at treatment initiation. Approximately 20% of treated subjects discontinued drug treatment within the first 6 months, with girls stopping drug treatment earlier than boys. The reasons for early drug discontinuation need to be further explored.
PMCID: PMC3523251  PMID: 23234588
2.  Prevalence and gender patterns of mental health problems in German youth with experience of violence: the KiGGS study 
BMC Public Health  2013;13:628.
Research examining mental health in violence-affected youth in representative samples is rare. Using data from the nationally representative German Health Interview and Examination Survey for Children and Adolescents (KiGGS) this study reports on gender-specific prevalence rates and associations of a broad range of internalizing and externalizing mental health problems: emotional problems, conduct problems, ADHD, disordered eating, somatic pain and substance use in youth variously affected by violence. While internalizing is generally more common in girls and externalizing in boys, observations of prior non-normative studies suggest reverse associations once an individual is affected by violence. The occurrence of such “gender cross-over effects” is therefore examined in a representative sample.
The sample consisted of 6,813 adolescents aged 11 to 17 from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS): Applying multivariate logistic regression analyses, associations between each type of violence history and mental health indicator were determined for perpetrators, victims, and perpetrating victims of youth violence. Moderating effects of gender were examined by using product term interaction.
Victim status was associated primarily with internalizing problems, while perpetrators were more prone to externalizing problems. Perpetrating victims stood out with respect to the number and strength of risk associations with all investigated mental health indicators. However, the risk profiles of all violence-affected youth included both internalizing and externalizing mental health problems. Gender cross-over effects were found for girls and boys: despite lower overall prevalence, girls affected by violence were at far higher risk for conduct problems and illicit drug use; by contrast, somatic pain, although generally lower in males, was positively associated with perpetrator status and perpetrating victim status in boys. All violence-affected youth exhibited significantly higher rates of cumulative mental health problems.
The results highlight the importance of violence for the mental health of youth. They reveal a particular vulnerability as a function of gender. Implications for policy making, clinical practice and research are discussed.
PMCID: PMC3727956  PMID: 23819775
Youth violence; Mental health; Emotional problems; Conduct problems; ADHD; Disordered eating behaviors; Somatic problems; Substance use; Gender; Representative study
3.  U-Shaped Development: An Old but Unsolved Problem 
Even today the investigation of U-shaped functions in human development is of considerable importance for different domains of Developmental Psychology. More and more scientific researchers focus their efforts on the challenge to describe and explain the phenomenon by identifying those skills and abilities being affected. The impact of U-shaped functions on diagnostic decision-making and on therapeutic treatment programs highlights the importance of understanding the nature of non-monotonic development. The present article therefore addresses the relevant questions of how U-shaped functions are defined in theory, in which developmental domains such non-monotonic growth curves are suggested to occur, and which implications there are for future methodology and diagnostic practice. Finally, it is recommended to clearly identify those interactions between proximal and distal subcomponents which are expected to contribute to a U-shaped development.
PMCID: PMC3664325  PMID: 23750146
U-shaped functions; developmental psychology; diagnostic decision-making; test development; non-monotonic development
4.  Comparative psychometric analyses of the SCL-90-R and its short versions in patients with affective disorders 
BMC Psychiatry  2013;13:104.
Despite the widespread application of Symptom Checklist 90-R (SCL-90-R), its psychometric weaknesses have repeatedly been noted. This study aimed to comparatively assess the psychometric properties of the SCL-90-R scales and the scales of its short versions Brief Symptom Inventory (BSI), Symptom Checklist-27 (SCL-27), Brief Symptom Inventory-18 (BSI-18), Symptom Checklist-14 (SCL-14), and Symptom Checklist short version-9 (SCL-K-9) in patients with affective disorders.
The data of 2,727 patients within the main treatment group of affective disorders were assessed according to the DSM-IV. Patients completed the SCL-90-R and Beck Depression Inventory (BDI).
There were no significant differences regarding the internal consistency of the SCL-90-R scales and the scales of the short versions. The dimensional structure was only supported for the short versions BSI-18, SCL-14 and SCL-K-9. The assessment of convergent validity revealed high correlations. With regard to the discriminant validity, there were medium correlations. With regard to the sensitivity of change, no significant differences between the scales were found.
In summary, the scales of the short versions show mostly satisfactory psychometric properties in comparison to the scales of the SCL-90-R. The results support the application of the short versions as screening instruments, especially the BSI-18, and more economic variants of the SCL-90-R covering a wide range of psychopathological symptoms.
PMCID: PMC3626675  PMID: 23537095
SCL-90-R; Short versions; Psychometric; Affective disorder; Symptom severity
5.  Comorbidities in ADHD children treated with methylphenidate: a database study 
BMC Psychiatry  2013;13:11.
Methylphenidate (MPH) is the most common drug treatment of attention deficit / hyperactivity disorder (ADHD) in children. Treatment with MPH is contraindicated in the presence of certain psychiatric, cerebro- and cardiovascular conditions. We assessed MPH treatment prevalence and incidence and the frequency of comorbid conditions related to these contraindications in new MPH users compared to a control group without ADHD and ADHD medication.
We used health care data for the years 2004 to 2006 from the German Pharmacoepidemiological Research Database (GePaRD) which includes about 18% of the German population. MPH treatment prevalence and incidence was assessed based on at least one MPH prescription in the given year. In MPH users, the prevalence of psychiatric and other comorbidities was assessed in the quarter of the first MPH prescription and the three preceding quarters, whereas in controls it was assessed in the earliest four quarters of continuous insurance time starting at 01.01.2004 or the start of insurance if this was later. Differences in the presence of comorbid diagnoses between MPH users and controls were tested by logistic regression.
In 2005, 1.5% of all children and adolescents aged 3 to 17 years (2.3% of males and 0.6% of females) received MPH in Germany. The proportion of children with a record of a psychiatric comorbidity in any of the nine ICD categories of diagnoses was substantially higher in new MPH users (83%) compared to controls (20%). Cerebro- and cardiovascular comorbidities were rare in general. Still, among new MPH users, 2% of males and females had a diagnosis of a pre-existing cardiovascular disorder but only 1.2% of controls.
Besides MPH treatment prevalence we first publish age-specific incidence rates for Germany. A high proportion of children who were started on MPH had a record of a psychiatric comorbidity preceding the first prescription. Cerebro- and cardiovascular conditions were rare in the studied age range, but still higher among children who received MPH than in the control group. Results show that in a substantial subgroup of patients, comorbidities require a thorough weighting of possible risks of MPH medication against the risks of untreated ADHD.
PMCID: PMC3544568  PMID: 23294623
6.  Developmental trauma disorder: pros and cons of including formal criteria in the psychiatric diagnostic systems 
BMC Psychiatry  2013;13:3.
This article reviews the current debate on developmental trauma disorder (DTD) with respect to formalizing its diagnostic criteria. Victims of abuse, neglect, and maltreatment in childhood often develop a wide range of age-dependent psychopathologies with various mental comorbidities. The supporters of a formal DTD diagnosis argue that post-traumatic stress disorder (PTSD) does not cover all consequences of severe and complex traumatization in childhood.
Traumatized individuals are difficult to treat, but clinical experience has shown that they tend to benefit from specific trauma therapy. A main argument against inclusion of formal DTD criteria into existing diagnostic systems is that emphasis on the etiology of the disorder might force current diagnostic systems to deviate from their purely descriptive nature. Furthermore, comorbidities and biological aspects of the disorder may be underdiagnosed using the DTD criteria.
Here, we discuss arguments for and against the proposal of DTD criteria and address implications and consequences for the clinical practice.
PMCID: PMC3541245  PMID: 23286319
Comorbidity; Developmental psychopathology; Developmental trauma disorder (DTD); Dissociation, Post-traumatic stress disorder (PTSD)
7.  Validation of the Fibromyalgia Survey Questionnaire within a Cross-Sectional Survey 
PLoS ONE  2012;7(5):e37504.
The Fibromyalgia Survey Questionnaire (FSQ) assesses the key symptoms of fibromyalgia syndrome. The FSQ can be administrated in survey research and settings where the use of interviews to evaluate the number of pain sites and extent of somatic symptom intensity and tender point examination would be difficult. We validated the FSQ in a cross-sectional survey with FMS patients. In a cross-sectional survey, participants with physician diagnosis of FMS were recruited by FMS-self help organisations and nine clinical institutions of different levels of care. Participants answered the FSQ (composed by the Widespread Pain Index [WPI] and the Somatic Severity Score [SSS]) assessing the Fibromyalgia Survey Diagnostic Criteria (FSDC) and the Patient Health Questionnaire PHQ 4. American College of Rheumatology 1990 classification criteria were assessed in a subgroup of participants. 1,651 persons diagnosed with FMS were included into analysis. The acceptance of the FSQ-items ranged between 78.9 to 98.1% completed items. The internal consistency of the items of the SSS ranged between 0.75–0.82. 85.5% of the study participants met the FSDC. The concordance rate of the FSDC and ACR 1990 criteria was 72.7% in a subsample of 128 patients. The Pearson correlation of the SSS with the PHQ 4 depression score was 0.52 (p<0.0001) and with the PHQ anxiety score was 0.51 (p<0.0001) (convergent validity). 64/202 (31.7%) of the participants not meeting the FSDC criteria and 152/1283 (11.8%) of the participants meeting the FSDC criteria reported an improvement (slightly too very much better) in their health status since FMS-diagnosis (Chi2 = 55, p<0.0001) (discriminant validity). The study demonstrated the feasibility of the FSQ in a cross-sectional survey with FMS-patients. The reliability, convergent and discriminant validity of the FSQ were good. Further validation studies of the FSQ in clinical and general population settings are necessary.
PMCID: PMC3360780  PMID: 22662163
8.  The German fibromyalgia consumer reports – a cross-sectional survey 
Consumer surveys provide information on effectiveness and side effects of medical interventions in routine clinical care. A report of fibromyalgia syndrome (FMS) consumers has not been carried out in Europe.
The study was carried out from November 2010 to April 2011. Participants diagnosed with FMS rated the effectiveness and side effects of pharmacological and non-pharmacological FMS interventions on a 0 to 10 scale, with 10 being most efficacious (harmful). The questionnaire was distributed by the German League for people with Arthritis and Rheumatism and the German Fibromyalgia Association to their members and to all consecutive FMS patients of nine clinical centers of different levels of care.
1661 questionnaires (95% women, mean age 54 years, mean duration since FMS diagnosis 6.8 years) were analysed. The most frequently used therapies were self-management strategies, prescription pain medication and aerobic exercise. The highest average effectiveness was attributed to whole body and local warmth therapies, thermal bathes, FMS education and resting. The highest average side effects were attributed to strong opioids, local cold therapy, gamma-amino-butyric acid analogues (pregabalin and gabapentin), tramadol and opioid transdermal systems.
The German fibromyalgia consumer reports highlight the importance of non-pharmcological therapies in the long-term management of FMS, and challenges the strong recommendations for drug therapies given by FMS-guidelines.
PMCID: PMC3444387  PMID: 22607517
Fibromyalgia syndrome; Consumer reports; Drugs; Non-pharmacological therapies
9.  MIPAS-Family—evaluation of a new multi-modal behavioral training program for pediatric headaches: clinical effects and the impact on quality of life 
The Journal of Headache and Pain  2010;11(3):215-225.
Several meta-analyses have demonstrated that the combination of electrical muscle activity and Temperature Biofeedback could be regarded as gold standard in chronic pediatric headaches. However, these techniques seem to be uneconomical and furthermore they are not directed to improve the social competence as well as resolve possible impairments in daily activities of the child. Therefore, multi-modal behavioral techniques have been proposed, but no studies comparing these with the gold standard were conducted. The present study compared the impact of a new multi-modal behavioral education and training program—MIPAS-Family—with a combined Biofeedback treatment, evaluating clinical efficacy as well as the effect on the quality of life (QoL) of children with chronic headaches. Thirty-four children and adolescents with recurrent headache, ranging from 7 to 16 years, were randomly assigned to the MIPAS-Family (N = 19) or the Biofeedback (N = 15) condition. All patients were diagnosed by the criteria of the International Headache Society. The children and their parents completed headache diaries, diaries of daily living activities and a QoL questionnaire (KINDL®). Both groups showed significant improvements concerning the headache intensity and headache duration. We found no significant differences in the main headache parameters between both treatments. After the treatments, the children were less disturbed by their headaches in the domains school, homework, and leisure time. In conclusion, MIPAS-Family is as effective as Biofeedback but it is more cost-effective and addresses the whole family and the daily activities.
PMCID: PMC3451914  PMID: 20376520
Pediatric headaches; Biofeedback; MIPAS-Family Program; Education; Behavioral medicine
10.  Developmental psychopathology: Attention Deficit Hyperactivity Disorder (ADHD) 
BMC Psychiatry  2009;9:58.
Attention Deficit/Hyperactivity Disorder (ADHD), formerly regarded as a typical childhood disorder, is now known as a developmental disorder persisting over the lifespan. Starting in preschool-age, symptoms vary depending on the age group affected.
According to the variability of ADHD-symptoms and the heterogeneity of comorbid psychiatric disorders, a broad review of recent studies was performed. These findings were summarized in a developmental psychopathological model, documenting relevant facts on a timeline.
Based on a genetic disposition and a neuropsychological deregulation, there is evidence for factors which persist across the lifespan, change age-dependently, or show validity in a specific developmental phase. Qualitative changes can be found for children in preschool-age and adults.
These differences have implications for clinical practice as they can be used for prevention, diagnostic proceedings, and therapeutic intervention as well as for planning future studies. The present article is a translated and modified version of the German article "Entwicklungspsychopathologie der ADHS", published in Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 56, 2008, S. 265-274.
PMCID: PMC2751746  PMID: 19761584
11.  Development and evaluation of a cancer-related fatigue patient education program: protocol of a randomized controlled trial 
BMC Nursing  2008;7:12.
Cancer-related fatigue (CRF) and its impact on patients' quality of life has been an increasing subject of research. However, in Germany there is a lack of evidence-based interventions consistent with the multidimensional character of fatigue. The objective of this study is to develop and evaluate a self-management program for disease-free cancer patients to cope with CRF.
Based on evidence extracted from a literature review, a curriculum for the self-management program was elaborated. The curriculum was reviewed and validated by an interdisciplinary expert group and the training-modules will be pretested with a small number of participants and discussed in terms of feasibility and acceptance.
To determine the efficacy of the program a randomised controlled trial will be carried out: 300 patients will be recruited from oncological practices in Bremen, Germany, and will be allocated to intervention or control group. The intervention group participates in the program, whereas the control group receives standard care and the opportunity to take part in the program after the end of the follow-up (waiting control group). Primary outcome measure is the level of fatigue, secondary outcome measures are quality of life, depression, anxiety, self-efficacy and physical activity. Data will be collected before randomisation, after intervention, and after a follow-up of 6 months.
Because there are no comparable self-management programs for cancer survivors with fatigue, the development of the curriculum has been complex; therefore, the critical appraisal by the experts was an important step to validate the program and their contributions have been integrated into the curriculum. The experts appreciated the program as filling a gap in outpatient cancer care.
If the results of the evaluation prove to be satisfactory, the outpatient care of cancer patients can be broadened and supplemented.
Trial Registration
ClinicalTrials NCT00552552
PMCID: PMC2491613  PMID: 18651943

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