The economic burden of inpatient care of depression in Poznan (Poland) and Kiel (Germany) in 2016
The economic burden of inpatient care of depression in Poznan (Poland) and Kiel (Germany) in 2016
Tomasz Zaprutko 0 1
Robert GoÈ der 1
Krzysztof Kus 0 1
Wiktor Paøys 1
Filip Rybakowski 1
Elżbieta Nowakowska 0 1
0 Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences , Poznan , Poland , 2 Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universitat zu Kiel , Kiel, Germany , 3 Department of Adult Psychiatry, Karol Jonscher Clinical Hospital, Poznan University of Medical Sciences , Poznan , Poland
1 Editor: Tomasz Bochenek, Jagiellonian University , POLAND
Depression is a global health problem associated with a significant public health burden and costs. Although studies on costs of diseases are being considered as an increasingly important factor for health policies, information concerning costs of inpatient care of depression is still insufficient. Thus, the main aim of this study was to evaluate costs of hospitalization of patients treated in 2016 in psychiatric clinics in Poznan (Poland) and in Kiel (Germany) and to analyze treatment used in these centers. The study was conducted from September 2017 to February 2018. 545 hospital records were considered (187 in Poznan and 358 in Kiel). Eventually, 490 hospital records were included, 168 in Poland and 322 in Germany. In general, the costs were calculated based on the patients' sex and diagnosis (F32 and F33) separately and, subsequently, the outcomes were added and multiplied by the length of hospital stay, giving the cost of hospitalization. The annual cost of inpatient care of depression in 2016 was EUR 491,067.19 (x EUR 2923:02) in Poznan and EUR 2,847,991.00 x EUR 8844:69 in Kiel. In Poznan, hospitalization was underfunded reaching EUR 183,042.55 (37.27% of total costs in Poznan). In Poznan, the most frequently prescribed medicine was quetiapine, followed by olanzapine and venlafaxine, whereas in Kiel it was venlafaxine, followed by mirtazapine and promethazine. Although non-pharmacological therapies were commonly used in both centers, in Kiel this type of treatment was better structured. The study confirms the degree of the economic burden of inpatient care of depression. The underfunding of mental health revealed, emphasizes the need for urgent amendment of organization and funding of mental health care in Poland. Patients in Poznan were hospitalized on average 10 days longer than in Kiel, thus a reduction of length of hospitalization in Poznan seems possible. Although pharmacotherapy seemed to be comprehensive in both centers, there were some differences between Poznan and Kiel. Access to non-pharmacological therapies during outpatient care was limited in Poznan, however, compared to Kiel.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: The project was supported by a grant
(503-19-03316440-30055-10596) from the
National Science Centre, Poland. The funders had
no role in study design, data collection and
analysis, decision to publish, or preparation of the
Competing interests: The authors have declared
that no competing interests exist.
Depression is one of the most common, highly prevalent, and burdensome disorders
worldwide [1±3], affecting people of any age [
]. According to the World Health Organization
(WHO) data, depression is expected to become the second leading cause of disability or early
death by 2020 [
]. The disease is characterized by a pertinaciously low mood with loss of
interest in everyday activities [
], and might be associated with personal and public stigma [
contributes to exacerbation of comorbid conditions such as hypertension or diabetes, for
]. Moreover, untreated depression increases the risk of self-harm and suicide, and
approximately two-thirds of suicide completers or attempters have major depressive episodes
at the time of the suicidal act [
Nevertheless, depression not only causes personal suffering but also produces significant
economic burden both for the patients and the whole society being a major worldwide public
health problem [
]. Total costs of the disorder can be broken down into direct (e.g.
inpatient and outpatient care, pharmacotherapy) and indirect costs (mainly related to the
productivity loss) [
]. In Europe, the total annual costs of depression were estimated at EUR 118
billion in 2004, with EUR 42 billion and 76 billion in direct and indirect costs, respectively
]. These values were confirmed in a later study conducted by Olesen et al. [
indicated that major depression was among the most expensive disorders in relation to the total
costs of brain disorders in 2010. In the United States, however, the economic burden of
depression was USD 83 billion, with USD 26.1 billion allocated in direct costs and USD 56.9
billion in indirect costs [
]. Considering results from Asia likewise, Okumura and Higuchi
] evaluated economic burden of depression in Japan with total costs estimated at USD 11
billion, with USD 4.1 billion in direct costs and USD 6.9 billion in indirect costs.
Although indirect costs represent the greatest share of the total costs of depression, direct
costs are the significant part of the economic burden, too, with costs of inpatient care indicated
as a significant [
] or even the most important contribution of direct costs generated by
patients with depression . In spite of this fact, there is still insufficient information
concerning the costs of hospitalization of depression [
10, 12, 15
]. Hence, the main aim of this
study was to investigate the costs of inpatient care of depression among patients hospitalized
in 2016 in Poznan (Poland) and in Kiel (Germany). Moreover, the study was also to compare
pharmacotherapy and non-pharmacological interventions used and to provide information
about funding and organization of mental health care in the study centers. Poznan, with a
population of approximately 550,000, is the capital of Greater Poland VoivodeshipÐPoland's
second largest province. Kiel, on the other hand, inhabited by a population of almost 250,000, is
the capital city of the Schleswig-Holstein land, the northernmost state of Germany
Material and methods
The study was conducted from September 2017 to February 2018. It evaluated costs of
inpatient care of depression in 2016, at the Department of Adult Psychiatry of the Karol Jonscher
Hospital of Poznan University of Medical Sciences (Poland) and at the Department of
Psychiatry and Psychotherapy of the University Hospital Schleswig-Holstein of Christian-Albrechts
University of Kiel (Germany).
Data were obtained from hospital records and from the hospital accounting departments.
Before the analysis all data were fully anonymized, thus the study conforms with the Act on
Protection of Personal Data. The costs were calculated based on the patients' sex and diagnosis
separately and, subsequently, the outcomes were added and multiplied by the length of
hospital stay (LOHS), giving the cost of hospitalization. The structure of hospital records in Poznan
2 / 14
allowed calculation of the costs of pharmacotherapy and diagnostic tests individually, and the
results were presented as a percentage share of total costs.
In Kiel, however, all individual components (including hospital stay, pharmacotherapy, and
diagnostic tests) up to the daily value of the procedure are covered, thus the cost of
hospitalization in Kiel was not the direct result of multiplying LOHS and base rate of tariff per day, which
was established by the health care payer. To evaluate the cost of inpatient care, each
hospitalization was calculated separately in cooperation with the financial department of the hospital in
Kiel. What is important, in Kiel the evaluation of the percentage contribution of e.g.
pharmacotherapy would not have been possible because the hospital records present pharmacotherapy
using international names or brand names marked frequently ªfor exampleº alternately,
allowing the use of originators or any generic brands.
To analyze and compare pharmacotherapy, each medicine used was registered. Such
detailed and meticulous analysis identified medications most frequently used in the study
centers. For non-pharmacological interventions, however, hospital records, as well as freely
available schedule of these therapies, were analyzed to compare the scope and types of
nonpharmacological treatment in Poznan and Kiel.
Inclusion criteria were as follows: a diagnosed depression (in the study, two diagnosis codes
were applicable: depressive episodeÐF32 and recurrent depressive disorderÐF33) based on
the International Classification of Diseases, Tenth Revision (ICD-10), and adult age of the
patients (>18 years old). Patients were excluded from the study, however, if their LOHS
was 3 days (this criterion was established because there were patients admitted to the
hospital on Friday evening and discharged or transferred to another department on Monday
morning) and if they left the hospital against medical advice.
In the study, 545 hospital records (all patients hospitalized in 2016 in Poznan and in Kiel)
were taken into consideration (187 in Poznan and 358 in Kiel). However, based on the
inclusion and exclusion criteria of the study, 490 hospital records were eventually included, n = 168
in Poland (106 womenÐW and 62 menÐM; 70 diagnosed with F32 and 98 diagnosed with
F33) and n = 322 in Germany (191 W and 131 M; 121 diagnosed with F32 and 201 diagnosed
with F33). Results are presented as total costs of inpatient care of depression in Poznan and in
Kiel and as average values associated with sex and diagnosis.
Due to the different currencies in Poland (PLN) and Germany (EUR), money values were
converted from PLN to EUR at the average EUR exchange rate in 2016 published by the
National Bank of Poland (EUR 1 = PLN 4.3625). Monetary values presented in the study are
roundings of calculated amounts resulting from the conversion of monetary units into the
common European currency. Moreover, results presented in EUR should make this paper
clear and useful for the readers.
Furthermore, the study was approved by the Bioethics Committee of Poznan University of
Medical Sciences and the Ethics Committee of Christian-Albrechts University in Kiel, as well
as by hospital decision-makers in both Poznan and Kiel.
The data are shown as x ± SEM (plus the median and lower/upper quartile). Data distribution
pattern was normal (like the Gaussian function). Statistically significant results (p<0.05) were
demonstrated for homogenous groups using 2-ways Anova test and post-hoc Tukey test.
The mean age of patients in Poznan was 52.84 years. In Kiel, patients were a bit younger than
in Poznan and the average age was 50.77. In terms of length of hospital stay, patients in Poznan
3 / 14
were hospitalized on average more than 10 days longer than in the German hospital.
Nevertheless, the shortest hospitalization included in both centers was 4 days regardless of the sex and
diagnosis. On the other hand, the longest hospitalization in Poznan lasted 173 days (M; F33)
and in Kiel 298 days (W; F33). In both centers, there were more W (106 in Poznan and 191 in
Kiel) than M hospitalized (62 in Poznan and 131 in Kiel).
The annual cost of inpatient care of depression in 2016 was EUR 491,067.19
(x EUR 2923:02) in Poznan and EUR 2,847,991.00 (x EUR 8844:69) in Kiel. The cost
for W was EUR 312,300.62 (x EUR 2946; 23) and EUR 1,782,064.00 (x EUR 9330:18)
in Poznan and Kiel, respectively. For M, it was EUR 178,766.57 (x EUR) in Poznan and
EUR 1,065,927.00 (x EUR 8136:85) in Kiel. The results of that task are presented in Tables
1, 2 and 3.
In terms of diagnosis-related costs of inpatient care, the results were as follows. In
Poznan, the cost of F32 was EUR 191,143.02 (x EUR 2730:62) and of F33 ±EUR 299,924.17
(x EUR 3060:45). In Kiel, meanwhile, it was EUR 904,222.00 (x EUR 7472:91) and EUR
1,943,769.00 (x EUR 9670:49) respectively. The results of that task are presented in Tables 4
Although all components of the total cost (cost of hospital stay, pharmacotherapy and
diagnostic tests) were included into the value of the daily medical procedure in both centers, the
structure of hospital records in Poznan allowed a separate evaluation the cost of
pharmacotherapy and diagnostic tests. The value of pharmacotherapy used was EUR 7,853.95, which
corresponds to 1.60% of total costs in Poznan. The cost of medicines used generated by W was
EUR 5,428.56 (F32 ±EUR 1,959.00 and F33 ±EUR 3,469.56) and by MÐEUR 2,425.39 (F32 ±
EUR 716.61 and F33±1,708.78). Values per patient are depicted in Tables 1 and 4.
The cost of diagnostic tests was EUR 12,320.45, which corresponds to 2.51% of total costs of
hospitalization in Poznan. The value generated by W was EUR 7,888.59 (F32 ±EUR 3,009.97
and F33 ±EUR 4,878.62) and by MÐEUR 4,431.86 (F32 ±EUR 1,659.37 and F33 ±EUR
2,772.49). Values per patient are depicted in Tables 1 and 4.
In both centers, there was a tariff rate per day established by the healthcare payer. In
Poznan, it was EUR 39.54 decreasing to EUR 27.68 per person per day for each day of
hospitalization exceeding 70 days. Nevertheless, this value was insufficient from the hospital's point of
view, with the costs per day (including hospital stay, pharmacotherapy, and diagnostic tests)
amounting to EUR 55.80 at the men's ward, EUR 62.95 at the women's ward, and EUR 69.94
at the mixed ward. The difference in the pricing of tariff rate per day by the hospital and the
healthcare payer allowed us to evaluate the degree of underfunding of mental health care at the
Detailed analysis of values of tariff rates per day found that inpatient care of depression was
underfunded in Poznan by as much as EUR 183,042.55, which corresponds to 37.27% of total
cost at the Polish hospital. This results from the daily value of procedure funded by the Polish
healthcare payer which leads to the underfunding from the very first day of hospitalization and
exacerbates the problem in case of hospitalizations lasting more than 70 days.
In Kiel, however, the base tariff rate per day was EUR 259.71 regardless of the patient's sex
and the ward of hospital stay. In spite of the fact that the value of daily rate differed between
particular cases of hospitalization, the final cost of each hospitalization was indicated as
sufficient to cover all expenses related to inpatient care; thus, in Germany there was no
Apart from the economic burden, it might be interesting to analyze treatment schedules
used in Poznan and in Kiel. Although treatment in both centers could be defined as
comprehensive, there were some differences in this respect. In terms of pharmacotherapy used, the
most frequently used substances in Poznan were quetiapine (used by 53.57% of patients),
4 / 14
3060.45 ± 189.76 3146.91 ± 214.40 2904.21 ± 369.31
(M: 2901.51 ~ L/U Q:1538.76/4266.57) (M: 3287.36 ~ L/U Q:1841.34/4406.46) (M: 2077.28 ~ L/U Q:1447.80/4126.69)
NS (p = 0.7680) vs W NS (p = 0.5438) vs. W
NS (p = 0.6876) vs M
olanzapine (used by 32.74% of patients), and venlafaxine (used by 26.79% of patients). These
substances were followed by hydroxyzine and haloperidol, prescribed to 23.81% and 19.64%
of patients, respectively. In Kiel, however, venlafaxine was the most popular substance used
by 30.43% of patients, followed by mirtazapine and promethazine prescribed to 28.88% and
22.36% of patients, respectively. Citalopram was the fourth most frequently used drug, at
5 / 14
MÐmedian, L/U QÐlower and upper quartile, SEMÐstandard error of the mean, NSÐstatistically non-significant
16.15%, followed by olanzapine prescribed to 15.22% of hospitalized patients. Interestingly,
only 1 patient in Poznan received promethazine. On the other hand, no one in Kiel was
treated with hydroxyzine or haloperidol. Both in Poznan (73.81%) and in Kiel (54.04%),
most patients were treated with pharmacotherapy related to concomitant disorders such as
diabetes or hypertension for instance. Considering benzodiazepines in general, this group of
medicines was prescribed to 55.36% of patients in Poznan and to 18.32% of those
hospitalized in Kiel.
In both centers, pharmacotherapy was supported with non-pharmacological interventions.
Nevertheless, it seemed to be more extensive in Kiel mainly due to the wide offer of trainings
which were freely available also in outpatient care. Apart from psychoeducation, music
therapy, and ergotherapy, other popular options in Kiel included light therapy (LT), gymnastics,
Nordic Walking, or bathing in cold water known as ªkneippenº in Germany. Patients in Kiel
had 6 or 7 daily options of various non-pharmacological interventions which were individually
fixed. In Poznan, however, the offer of non-pharmacological therapies used was slightly
limited in comparison to Kiel. There was no ªkneippenº or LT, for instance. Nevertheless,
psychoeducation, occupational therapy, gymnastics, and others were popular, too. The number
of daily training options was smaller than in Kiel, however. Moreover, the problem of
non6 / 14
L/U QÐlower and upper quartile, MÐmedian, SEMÐstandard error of the mean, NSÐstatistically non-significant, SSÐstatistically significant
x Statistically significant difference: D versus PL for p <0.05
7 / 14
MÐmedian, L/U QÐlower and upper quartile, SEMÐstandard error of the mean, NSÐstatistically non-significant, SSÐstatistically significant
x Statistically significant difference: F 33 versus F 32 for p <0.05
pharmacological therapy in Poznan seems to be related to the lack of proper facilities in
outpatient care where patients would be able to continue therapies started during hospitalization.
Depression is considered one of the disorders characterized by the greatest costs and burden
for the society as well as for the public healthcare system [
1, 9, 16
]. In terms of economic
burden, depression is primarily related to indirect costs, but direct costs are responsible for a
significant part of that burden, too [
9, 10, 17, 18
]. In addition to this, a study conducted by
Kleine-Budde et al.  identified costs of hospitalization as the main component of direct
costs of depression. In spite of this fact, there is still insufficient information concerning costs
on inpatient care of depression [
9, 10, 12, 15
], thus the importance of this study. The
evaluation of total cost of hospitalization in 2016, amounting to EUR 491,067.19 (x EUR 2923:02)
in Poznan (n = 168) and EUR 2,847,991.00 (x EUR 8844:69) in Kiel (n = 322), confirms
the significance of costs related to inpatient care and corroborates with other studies where
authors emphasized the degree of economic burden of depression [
9, 10, 15, 19
Although the general trend in depression costs analysis is convergent between individual
studies and confirms the economic burden of that disorder, differences between results from
various countries might be meaningful. For example, Okumura and Higuchi compared annual
direct medical costs of depression in Japan (USD 689 per patient) against outcomes from
Spain (USD 1166 per patient) and the USA (USD 1400 per patient) [
]. Additionally, in the
systematic review of the cost of illness studies, mean direct costs per patient ranged from USD
1000 to USD 2500 annually [
]. Considering these variances and the fact that an average
hospitalization lasted 10 days longer in Poznan (47 days) than in Kiel (37 days), the 3-fold
discrepancy between average costs of hospitalization in the study centers seems hardly surprising.
Moreover, it could be even greater if hospitalizations had been equalized in terms of LOHS.
Discrepancies in LOHS for patients with depression are quite common and range from 61
days in Canada, through 51 days in Germany, to 11 days in the USA [
Nonetheless, as in our study, costs differences might be the effect of dissimilarities in
funding of healthcare systems, too. Furthermore, these considerable variances in costs analysis also
8 / 14
depend on settings and methodology used in the studies and might be affected by differences
in economic factors and pharmaceutical costs among countries likewise [
10, 19, 20, 23
Considering, for instance, economic facets it is important to point out that the German economy is
the fifth largest economy in the world in Purchasing Power Parity (PPP) terms and Europe's
largest, whereas Poland has the sixth-largest economy in the European Union . According
to data from 2016 Gross Domestic Product (GDP) per capita and PPP accounted for USD
28.200 and 1.788 (National currency units/US dollar) in Poland respectively. In Germany,
however, it was USD 49.300 and 0.780 (National currency units/US dollar) accordingly [
]. These data confirm the impact of the economy on hospitalization costs differences
observed between Poznan and Kiel, hence the importance of many factors which are
components of economic and public health burden of disease.
Many studies indicate that more women than men are diagnosed with depression [
and these findings corroborate with the results of our study. In general, men are known to
reveal a reluctance to present concerns about their mental health e.g. due to socioculturally
prescribed male roles related to gender-relevant behavior [
], and they do not seek mental
health care as often as women do [
]. Moreover, typical symptoms of depression might be
masked among men by other signs related to men's tendency to be overly sexually active,
usually in the form of promiscuity or a series of brief affairs [
]. Nevertheless, as revealed in our
study, men in both Poznan and Kiel were hospitalized shorter than women and this finding is
in line with results obtained in Japan [
]. On the one hand, it could be deemed surprising,
especially considering the fact that hidden symptoms of depression among men may
contribute to a more severe course of depression. On the other hand, however, it could be related to
potential gender differences in the response to pharmacotherapy used and co-existing eating
disorders as well as anxiety which are more likely to affect women [
]. Nonetheless, this
emphasizes the need to carefully investigate potential facets related to gender differences
affecting the economic burden of depression.
Considering pharmacological treatment of depression, selective serotonin reuptake
inhibitors (SSRI e.g. citalopram) and serotonin-norepinephrine reuptake inhibitors (SNRI e.g.
venlafaxine) as well as noradrenergic and specific serotonergic antidepressants (NaSSA e.g.
mirtazapine), are recommended, for instance, by the American Psychiatric Association as the
first-line treatment of depression [
4, 14, 30
]. Nevertheless, because of the effect on the multiple
receptor systems, concurrent use of antidepressants and antipsychotics (both typical and
atypical) is considered more effective than monotherapy with antidepressants . Therefore, the
use of antipsychotics has been one of the most important strategies aimed at a more effective
treatment of depression  and within the last decade aripiprazole, quetiapine, and
olanzapine were approved by the US Food and Drug Administration (FDA) as an augmentation to
antidepressant therapy in depression . Results of the analysis of medicines used in Poznan
and Kiel corroborate with these findings and confirm that the pharmacotherapy applied was
comprehensive and up-to-date in both centers. There were some differences between Poznan
and Kiel, however. In the Polish hospital, antipsychotics (quetiapine and olanzapine) were the
most frequently used, followed by venlafaxine (SNRI). In Kiel, however, it was venlafaxine,
followed by mirtazapine (NaSSA), and promethazine (H1-receptor antagonist; responsible for
e.g. sedative effect). Although antipsychotics were also frequently used in Kiel, popularity of
venlafaxine and mirtazapine might result not only from the patients' health needs but also
from local conditions because these substances were identified by Warnke et al.  as more
preferred in Germany than in other European countries. It is worth noting that both hospitals
used benzodiazepines frequently as well. This is in line with the study conducted in Brazil by
Cigognini et al. where benzodiazepines were the most frequently prescribed medicines,
followed by fluoxetine [
]. The above-mentioned study, however was carried out in 2002 and
9 / 14
fluoxetine, for instance, is not so popular right now, in contrast to benzodiazepines which are
still used frequently. Furthermore, majority of the patients in Poznan and in Kiel were treated
for comorbid conditions. Hypertension, coronary heart disease, diabetes, or hyperlipidemia
were commonly observed in other studies likewise [
]. These frequently chronic disorders
may significantly affect the economic burden of inpatient care of depression, mainly due to the
possible impact on LOHS.
In spite of the fact that we were unable to calculate the percentage share of
pharmacotherapy in total cost of hospitalization because of the structure of hospital records and funding of
mental health care in Kiel, hospital staff mentioned a growing share of generic drugs.
Interestingly, based on the information obtained from the hospital staff, costs of pharmacotherapy
decreased significantly and constituted approximately 2% of total costs of inpatient care,
which is consistent with the results obtained in Poznan.
Apart from pharmacotherapy, non-pharmacological interventions are recommended as a
concomitant treatment of depression as well [
]. Several non-pharmacological therapies like
cognitive behavioral therapy, psychotherapy, or exercise therapy are considered effective also
in terms of relapse rates [
] and might, thus, contribute to a decrease of depression costs,
especially in the long run. Comparing these interventions between Poznan and Kiel,
non-pharmacological therapies at the Polish hospital seemed to be less structured. In Kiel, for instance,
owing to the many daily training options, non-pharmacological treatment could be more
customized. Aside from quite popular trainings, such as psychoeducation, patients hospitalized in
Kiel attended ªkneippenº or LT. Nonetheless, Farah et al.  claimed that several
non-pharmacological interventions are characterized by similar effectiveness, hence
non-pharmacological therapies of patients in Poznan could be considered as sufficient and equally effective as
those in Kiel. On the other hand, especially LT seems to be quite easy and cheap to incorporate
and, according to the study conducted by Winkler-Pjerk et al. [
], this method is not only
frequently used in Germany, Austria and Switzerland, but is known as an effective intervention
These therapies should be also available, however, in outpatient care to provide a
comprehensive and the most effective treatment. Nevertheless, access to non-pharmacological
interventions for patients discharged from hospital seems to be limited in Poznan compared to
Kiel, mainly due to the lack of suitable facilities. In Germany, there are also many employment
possibilities after a mental health crisis, making the unemployment rate among the mentally ill
significantly lower than in other countries [
]. In addition to this, employment is
therapeutic and reduces the risk of hospital readmissions among patients suffering from mental
14, 36, 37
]. Moreover, employment of those people could help reduce the social and
] as well as indirect (productivity loss) and direct costs (hospitalization rates)
]. From this study's perspective, savings in terms of direct medical costs are crucial. It is
particularly important in Poznan where mental healthcare turned out to be significantly
underfunded by the national healthcare payer. This statement is in line with the study carried out by
Zaprutko et al. [
] where authors revealed the same problem in Poland and the Ukraine. In
spite of the fact that the present study demonstrated that treatment applied at the Polish
hospital was comprehensive and state-of-the-art, findings related to underfunding confirm the
urgent need of improvement of mental healthcare funding in Poland. It also shows that the
development of facilities providing daily care with additional non-pharmacological therapies
could pay off in terms of public health and economic burden of depression, especially because
mental well-being is crucial for achievement of the strategic objectives of the European Union
health policy [
Our study has some limitations, though. It would be very interesting to study more hospitals
from Poland and Germany and roll the study out to other countries afterwards. Considering
10 / 14
insufficient number of studies related to economic burden of inpatient care of depression,
however, this study might be recognized as an important contribution in the field. In spite of
the fact that funding of mental healthcare in Germany and structure of hospital records
prevented us from presenting the exact percentage share of pharmacotherapy and diagnostic tests
in total cost of hospitalization, it would be interesting for the readers to learn such information.
It could also be worthwhile to perform a prospective analysis of this issue, as it would help us
collect the patients' opinions about their feelings on various non-pharmacological
interventions and the issue of public and personal stigma. Furthermore, the analysis of the marital
status and family structure could provide interesting information about the possible effect on
LOHS and, thus, costs of inpatient care of depression. Besides, it could be interesting to
conduct a detailed analysis of ICD-10 codes (F32 from F32.0 to F32.3 and F33 from F33.0 to
F33.3) of patients admitted to the hospital. Thus, if Kiel admits only severe patients and Poznan
admits only moderate patients, or inversely, it could have the impact on presented results
related to LOHS and costs of inpatient care likewise. Nonetheless, costs of depression are
frequently presented under the general term ªdepressionº or ªmajor depressive disorderº. On the
other hand, some authors [
] decided to use diagnosis codes in their analyses but only F32
and F33 were applicable and, after a very careful consideration, we decided to follow them and
analyze F32 and F33 separately. However, as indicated by the Heads (they are also co-authors
of this study) of Psychiatry Departments in Poznan and in Kiel there were mixed diagnoses,
hence presented results might be considered as valuable and comparable too. Moreover, the
value of the study would be higher if we were able to present information about the number of
staff employed in the study centers (physicians, nurses, non-pharmacological therapists). It
would be also valuable to present more economic factors (e.g. Gini coefficient) and to
implement International Dollar in the analysis, which is a hypothetical currency aimed at explaining
and comparing prices from one country to another. Nevertheless, the authors decided to use
the European currency to ensure clarity of the text also for readers who are not specialists in
the field. Another limitation is related to a possibly interesting new point in terms of the
economic burden of multiple disorders. Evaluation of the cost of translation could be interesting
as well. In Kiel, in the case of some immigrants, there was a real language barrier, requiring a
temporary employment of translators. Although it is difficult to compare costs in different
countries, this study could be considered a valuable source of data on the economic burden
and treatment of depression.
Although this study confirms the significant economic burden of depression in terms of
hospitalizations costs, it also emphasizes the need of urgent improvement of mental health care
funding in Poland, especially due to the underfunding observed. Patients in Poznan were
hospitalized on average 10 days longer than in Kiel which confirms that a reduction of LOHS in
Poznan seems possible. In spite of the fact that pharmacotherapy was responsible for a low
percentage share of total costs of inpatient care, treatment was comprehensive in both centers.
Nevertheless, access to non-pharmacological therapies during outpatient care was limited in
Poznan compared to Kiel.
S1 Table. Medicines used in Kiel. This is the list of medicines used in Kiel. (XLSX)
11 / 14
S2 Table. Costs in Poznan. This is the list of costs' components of costs of inpatient care of
depression in Poznan.
S3 Table. Medicines used in Poznan. This is the list of medicines used in Poznan.
S4 Table. Costs in Kiel. This is the list of costs' components of costs of inpatient care of
depression in Kiel.
Conceptualization: Tomasz Zaprutko, Elżbieta Nowakowska.
Data curation: Tomasz Zaprutko, Wiktor Paøys.
Formal analysis: Tomasz Zaprutko, Krzysztof Kus.
Funding acquisition: Tomasz Zaprutko.
Investigation: Tomasz Zaprutko, Robert GoÈder, Wiktor Paøys.
Methodology: Tomasz Zaprutko.
Project administration: Tomasz Zaprutko.
Resources: Tomasz Zaprutko.
Software: Tomasz Zaprutko.
Validation: Tomasz Zaprutko. Visualization: Tomasz Zaprutko.
Writing ± original draft: Tomasz Zaprutko.
Supervision: Tomasz Zaprutko, Filip Rybakowski, Elżbieta Nowakowska.
Writing ± review & editing: Tomasz Zaprutko, Robert GoÈder, Filip Rybakowski, Elżbieta
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