Ten years ago, on November 10, 2009, football goalkeeper Robert Enke took his own life. Enke struggled with major depression. His death opened up a debate about the disease, encouraging the sick to seek help. Since then, emergency centers have been set up to serve people in acute crises. However, there is still a lack of offers. Health Minister Jens Spahn wants to oppose new treatment options: The Bundestag on Thursday passed the Digital Care Act, which aims to integrate mental health applications into health insurance funding. Whether application help can be discussed.
More than four million Germans have depression. Has anything changed in dealing with the disease?
"The Enke case has triggered something," says psychiatrist Iris Hauth, chief physician at the Psychiatry, Psychotherapy and Psychosomatics Department of the Berlin-Weissensee Alexian Hospital and a member of the German Society of Psychiatry, Psychotherapy, Psychosomatics and Neurology (DGPPN).
A sign of increased awareness of mental illness is the number of sick days. Since 2006, the number of failures associated with mental illness has steadily increased, to decrease last year. Mental illness is the third leading cause of sickness, as indicated by DAK's 2019 health report. Excluding sick days per 1,000 insureds, in 2007 employees dropped 422 days, in 2017 there were already 920 days. Depression is by far the most common diagnosis when a worker becomes ill due to mental discomfort.
These numbers are by no means more depressing – the proportion of people with depression remains constant, experts say. Basically, a quarter of all adults suffer from a mental illness that requires treatment for a year.
What is changing is the social acceptance of depression. If we compare the attitude of the population in 2011 with that of 1990, as did psychiatrists Georg Schomerus and Matthias Angermeyer of the University of Leipzig in one study, it turns out: Knowledge about mental illness has grown in recent decades, one Generally, it is good that can treat with medication and psychotherapy. In addition, it proves to be a little more open to contact with people suffering from depression. Respondents in 2011 expressed a little more compassion and helpfulness and slightly less bias than in 1990.
What do you know about the causes of depression?
In the meantime, it is undisputed that biology plays a key role in the development of depression, along with environmental factors. "We know there is some genetic vulnerability and we suspect multiple loci," says Iris Hauth. In 2018, an international research consortium was able to identify 44 such risk variants. Significant, especially stressful life events or even chronic stress, according to the biopsychosocial model of the disease, cause these genes to become active and adversely affect the availability of important neurotransmitters in the brain.
In recent years, workplace stress has come to the fore especially as such a trigger. Therefore, treatment with a psychotherapy procedure and (especially in the case of severe depression) also with medication must often be accompanied by changes in daily life in order to be successful. In many cases, such changes should start much earlier. "We now know a lot about how to maintain fitness," says Iris Hauth. "But what's missing is a basic knowledge of mental balance and that should be taught in school."
What can I do alone?
Build resilience! Meanwhile, in the words and topics of many counselors, psychological resistance is crucial if something goes wrong. Their pillars are optimism, accepting situations, giving up on sacrifice, orientation to the solution, sociability, a sense of self-efficacy, realistic self-assessment and visions for the future. The bad news: Many of these factors are predetermined by genes and education. The good news: Even with adults, nothing is lost. Christian Peter Dogs, a leading German resistance researcher and author, told in Planet Wissen his own biography that was characterized by neglect and drug use. He says: Solving crises alone makes us resilient, in addition to our daily mindfulness and healthy everyday life with social contacts and movement. But we can help not only ourselves but our environment to become resilient. "Gratitude is the best way to become resilient," says Dogs, especially when it comes to working together in the workplace. The movement of attention also wants to have a prophylactic effect: by pausing several times a day and exercises where the focus is on breathing and body condition from head to toe, users should take better care of these methods. Psychotherapists also work with similar methods because depression often involves a disturbed, uncomfortable relationship with oneself. This should be broken down by taking care of yourself: For example, it is an exercise to write a list of nice, healthy activities and include them in your daily life.
Where can I get help?
In acute depressive episodes, a crisis service or telephone counseling can help you in your first interview. The appointment service can arrange appointments with psychotherapists or psychiatrists for an initial evaluation. However, this does not mean that those affected will be spared seeking medical treatment – those who do not pay privately must expect strenuous pursuits and long waiting times.
In the national average, patients waited a total of 19.9 weeks in 2017, i.e., nearly five months for a paid approved psychotherapist. In acute cases, each district in Berlin has at least one psychiatric emergency department and offers inpatient and outpatient care at district hospitals.
Specialized clinics with a stay of four weeks to several months help with long-term illness. Low-threshold exchanges may also be self-help groups, which can be found in Berlin on the website of the self-help contact center. Most importantly: Shame, talk to trusted people in an emergency, even make friends or relatives phone.
Do you have dark thoughts? If you're not feeling well or thinking about killing yourself, try talking to other people. These can be friends or relatives. But there are also plenty of help offers you can turn to. Berlin Crisis Service is anonymous, free and available for an entire hour. Phone numbers vary by district, you can find the correct extension for your district here.
Furthermore, there is from Telefonseelsorge offer chat for help. There is also the possibility of consulting via e-mail. Registration takes place – also anonymous and free – on the site. Information can be found at: www.telefonseelsorge.de
What does treatment look like today?
Psychotherapy and treatment are the two most common methods. In mild and moderate depression, psychotherapies often alone, in severe cases, usually help the serotonin reuptake inhibitors to keep the happiness hormone levels in the body stable, releasing enough energy for daily life.
However, these medicines can only be prescribed by doctors; psychological psychotherapists are not entitled to it. There are currently three outpatient funded psychotherapy procedures: behavioral therapy, in-depth psychology, and analytical psychotherapy. The fourth method in the league will be systemic therapy. Physical and perceptual activities such as art therapy, autogenic training, sports activities, baths and group therapies are used to stay in the patient.
However, these offers are far from all those in need: An analysis by the Robert Koch Foundation shows that two-thirds of people with depression do not seek psychiatric or psychotherapy help within a year – indicating persistent stigma on the one hand and major obstacles such as waiting time.
What about apps and online offers?
The "Digital Supply Act" (DVG) provides that insured persons will in the future be entitled to "low-risk digital health applications" such as online self-management support. Professional societies generally welcome this. However, DGPPN and the German Psychological Society criticize in a statement issued in July this year that the draft law makes no distinction between health promotion applications and online therapeutic interventions in the event of illness.
"Both should be available over-the-counter, in part, directly from the health insurance company. Treatment without a previous visit to the doctor could overlook diagnoses and endanger the patient's well-being," the medical associations complain. The Stiftung Warentest rating confirmed the positive effects for four of the eight depression-tested applications, but the other four dropped. They are certainly not a substitute for professional help, but can serve as an introduction, bridging, and accompaniment.
On the other hand, it looks like internet therapy, like video telephony or direct news: Several studies confirm that internet psychotherapy has a similar effect to therapy in a classic armchair or on the couch, writes "Ärzteblatt". As a regular psychotherapy, this method is not allowed, since the long-distance treatment ban is applied in Germany. This is why psychotherapists often offer "internet counseling".
Health insurance companies and associations have long called for the lifting of the long-distance treatment ban. "It limits us, with further offers to eliminate supply problems in the rural region," Manon Austenat-Wied, a representative of the country's technical health insurance (TK) in Mecklenburg-Vorpommern, said in a message.