mental disorders cause a substantial proportion of the burden of disease in the general 
 population .
neuropsychiatric disorders rank second in the list of disability adjusted life 
 years ( daly ) in europe , preceded only by cardio - vascular diseases .
they are also responsible 
 for the largest part of causes for years lived with disability ( yld ) , and account for 19.5% 
 of dalys and 40% for yld , 
 .
an overview over 27 studies on the prevalence of mental disorders in europe yielded an 
 estimate of 27% of the adult population between 18 and 65 years , who fulfilled criteria of 
 at least one mental disorder . 

prevalence rates between studies ranged considerably , with highest prevalence rates for a ) 
 affective disorders with a median ( md ) rate of 6.9% , b ) specific phobias , md  =  6.4% , c ) 
 somatoform disorders , md  =  6.3% , d ) substance use disorders , md  =  2.4% , and e ) social 
 phobias , md  =  2.3% .
in germany point - prevalence ( four weeks ) is estimated with 20% , the 12-months - prevalence 
 with 31% , and life - time prevalence with 43% .
the most frequent disorders are affective , 
 somatoform , substance - use and panic disorders .
prevalence is estimated with 26% and increases with geographical agglomeration 
 up to 35% in metropolitan areas .
standardised diagnostic procedures distinguished themselves because of their high 
 reliability in epidemiological studies as well as in clinical settings . on the other hand , 
 clinical diagnoses without structuring are less reliable and valid .
as basis for estimates on morbidity and ensuing 
 planning of demand , clinical diagnoses have to be regarded with greater care .
persons with mental disorders call on medical treatments more often and are more frequently 
 on sick leave .
however only 
 one third of all persons concerned , has sought out psychotherapeutic treatments , or have 
 received psychotherapy . 

these high demands on health care provision are met with a differentiated system of 
 services . in international comparison
, the wide range of differentiated services of 
 inpatient psychotherapeutic care in germany takes a leading position .
it encompasses a ) specialists in 
 neurology / psychiatry who are contracted through a staturory health insurance ( shi ) , b ) shi 
 psychotherapists , c ) shi psychotherapists for children and adolescents , d ) psychosomatic 
 primary care through shi general practitioners , e ) outpatient care clinics , f ) psycho - social 
 counselling centres , and g ) day care centres .
waiting time 
 for an intake interview lasts about two months , waiting time for psychotherapy to begin 
 lasts about four and a half months . in the geographical region of the former gdr ( east - germany ) 
 waiting times last about ten weeks and over three months respectively . comparing the mental health care provision by regional aspects , schulz and colleagues 
 summarise :  a comparison of density of supply in different regions within germany shows , 
 with the exception of inpatient care for children and adolescents , a striking 
 east - west - difference to the disadvantage of east - germany .
the under - supply seems to be especially striking in the 
 outpatient provision for children and adolescents . even in the otherwise well provisioned 
 federal state of baden - wrttemberg ,
only between 4% and 35% of all children and adolescents 
 concerned found a treatment place .
the aim of this study is , with regard to a posited bottleneck in supply , to paint a more 
 precise picture of the provision of care for persons with mental disorders within a rural 
 area in east - germany .
we do not only take data from the psychotherapeutic provision of care 
 into account , but data from the whole statutory health insurance .
we assume that by 
 analysing reimbursement claims from shi physicians , we gain insights into areas where 
 persons with mental disorders are cared for outside psychotherapeutic provision of care . 

this view creates an image of the real - life provision of in an economically underdeveloped 
 region .
this parallels 
 a population density of 72 inhabitants per square kilometre ( in germany the population 
 density is 231 inhabitants per square kilometre ) .
about one third lives in cities with 
 between 45,000 and 198,000 inhabitants , another third in communities with less than 2,000 
 inhabitants . only one
mental disorders take middle and forward ranks in the burden of disease . with respect to 
 their relative frequencies the following rank order results in mecklenburg - west 
 pomerania : a ) 29.2% of all new entries into 
 the statutory pension funds ( rank 1 ) , b ) 18.1% of all rehabilitative treatments ( rank 3 ) , c ) 
 8.1% of all sick certificates ( rank 4 ) , d ) 1.7% of mortality ( rank 7 ) , and e ) 6.1% of all 
 hospitalisations ( rank 8) .
the density of supply with psychotherapists varies between 5,000 
 and 120,000 inhabitants per psychotherapist ; in the very sparsely inhabited areas the supply 
 density ranges between 15,000 and 150,000 . to address our research questions , we analysed the billing data of mecklenburg - west 
 pomerania s association of shi physicians from the years 2006 / 2007 .
the exception here is ambulatory health care centres ( mvz ) , where more than one 
 specialised practice work as one treatment unit .
they bill under one single billing account , 
 so that the specialty of every single provider can not be identified .
also the group of 
 neurologists and psychiatrists bill their reimbursement claims under one single account so 
 it s not possible to differentiate between neurological and psychiatric practices . and 

within the group of psychotherapists it s not possible to differentiate between medical and 
 psychological psychotherapists . in analysing
a treatment 
 corresponds to a medical treatment or service that has been billed within one billing 
 quarter ( three months ) .
a case corresponds to a person ( patient ) , for whom one or more 
 treatments may be billed within one quarter . following this logic
this entails that with respect to cases the relative frequencies of diagnoses may vary . for 
 example
a patient with a depression , a phobic disorder and nicotine dependence would be 
 counted with three diagnoses , when the distribution of diagnoses on the level of cases is 
 considered . since no ordering according to importance of disorder ( primary diagnosis , 
 secondary diagnosis etc . ) has been recorded within the data , we were unable to rank - order 
 diagnoses accordingly for each case .
therefore we investigated 
 from the data from the last quarter of 2007  as a proxy for the whole period  how many 
 diagnoses and how many cases have been billed by how many treatment providers .
for the last 
 quarter in 2007 that corresponds to 564,279 treatments for 303,839 cases .
the data have been provided by the association of shi physicians mecklenburg - west 
 pomerania .
ethical , legal or data - safety regards are warranted : anonymous data were 
 provided , data can not be traced back to individuals and additional diagnostic or therapeutic 
 means have not been taken .
the basis for the relative frequencies for treatment cases it should be noted that more 
 that one diagnosis may be valid for one case . accordingly single cases may weigh with 
 more than single weight in the determination of relative frequencies .
altogether data stem from 4,246,734 treatments from the years 2006 and 
 2007 , that have been billed to the association of shi physicians in mecklenburg - west 
 pomerania for an icd-10 chapter v diagnosis . of these treatments ,
inaccurate means a diagnostic code 
 has been billed that does not exist in icd-10 chapter v ( e.g. f45.51 , or f10.17 ) ; incomplete 
 means the billed diagnostic code does nt allow for unambiguous allocation to one category 
 ( e.g. f45 , or f10 ) . for our further analysis , we limit ourselves to the remaining 3,905,262 
 treatments .
category encompasses medical treatment centres ( mvz ) , ophtalmotologists , 
 surgeons , anaesthesiologists , pulmologists , emergency clinics , laboratory practices , 
 radiologists , neurosurgeons , central emergency services , oral and facial surgery , 
 nuclear physicians and other central services .
the distributions of the relative frequencies of diagnoses according to icd-10 subchapters 
 on the basis of treatments as well as on the basis of cases are given in table 1 .
remarkable is that more than one third of all treatments 
 billed for reimbursement are allocated to neurotic , stress - related and somatoform disorders 
 ( f4x.xx ) , a little bit less than one quarter of all claims are allocated to mood ( affective ) 
 disorders ( f3x.xx ) and a little more than one tenth of all claims are allocated to substance 
 use disorders ( f1x.xx ) .
here it is worth remarking that almost half of all claims were filed by general 
 practitioners .
psychotherapists ( medical and psychological psychotherapists combined ) claimed with only 
 3.1% a minor proportion of claims .
for the 303,839 cases from the last quarter of 2007 , claims were billed in 
 193,717 cases ( 63.8% ) for a single diagnosis , in 63,941 cases ( 21.0% ) for two diagnosis , in 
 26,006 cases for ( 8.6% ) three diagnoses , and in 20,175 cases ( 6.6% ) for more than three 
 different icd-10 chapter v diagnoses .
these were billed in 244,070 cases ( 80.3% ) from one 
 group of specialists , in 49,528 cases ( 16.3% ) from two different groups , in 8,757 cases 
 ( 2.9% ) from three different groups , and in 1,484 cases ( 0.5% ) from more than three different 
 groups of specialists .
the significance of alcohol and tobacco related disorders , depression , anxiety and 
 somatoform disorders , that has been reported in large epidemiological studies , also pictures 
 in everyday health care provision .
a broad spectrum of practitioners provides health care 
 for the patients , with the stress on general practices and family doctors who bill about 
 half of the claims .
the group of neurologists / psychiatrists cares for about one seventh of 
 all cases .
opposed to that , psychotherapeutic practices ( medical as well as psychological ) 
 bill claims for only about three percent of all cases .
collaborative treatment of patients 
 with mental disorders seems to be the exception rather than the rule ; treatments for four 
 fifth of cases are claimed by one single practitioner .
these results complement the image from other german studies on health care provision of 
 patients with mental disorders .
striking is the large proportion of treatments that are 
 claimed by general practitioners . since 80% of all treatment claims
are billed by one single 
 practitioner , we may well assume that to a large degree , patients with mental disorders are 
 cared for by general practitioners alone .
taking into account the urban - rural - divide that 
 schulz and colleagues 
 observed in 2008 with regard to psychotherapeutic provision of care , and against the 
 background of long waiting times as reported by zepf and colleagues and peikert and 
 colleagues it may be 
 assumed that the treatments of mental disordered patients provided by general practitioners 
 owe to at least to a certain degree a bottleneck in the provision of care by 
 neurologists / psychiatrists and psychotherapists ; and that this shows more pronounced in a 
 rural and remote area as mecklenburg - west pomerania . that the outpatient provision of care 
 in rural and remote areas lacks behind that in metropolitan areas
is also shown in the study 
 by peikert and colleagues ; about one fifth of the inhabitants in east - germany live in urban 
 areas .
accordingly the provision of care in urban areas is evaluated more favourably by 
 psychotherapists and waiting times are much shorter in bigger cities than in the other 
 regions . in sum , this study provides insight into the epidemiology of mental disorders in germany 
 under the actual status quo with the regard to health care provision . and these reflect on 
 the one hand the large proportion of substance use disorders , depression , anxiety , and 
 somatoform disorders on the burden of disease due to mental disorders . on the other hand , 

the study supports the picture of a suboptimal provision of mental health care outside the 
 metropolitan areas . in order to improve the provision of care especially in rural and remote 
 areas ,
it could be considered to take aspects of population density into account , when 
 practice settlements for psychotherapists and neurologists / psychiatrists are planned .
it 
 appears also worthwhile to think about a further accentuation in basic and continuing 
 medical education in diagnostics and treatment of mental disorders of general practitioners . 

but also alternative concepts to secure service provision , such as the implementation of 
 mobile treatment facilities or actively calling on patients in their homes , may cause some 
 relief . additionally to these ramifications , in the face of the high prevalence of mental 
 disorders , interventions to prevent mental disorders should also be kept in mind .
the results of this investigation have to be put into perspective by a number of 
 limitations .
for instance it can not be safely assumed that all diagnoses have been secured 
 by standardised and structured diagnostic interviews .
it may well be that the frequency of 
 certain diagnoses have been under- or overestimated .
it has to be seen critically that 
 almost ten percent of all billed claims base on incorrect or incomplete diagnostic codes and 
 had to be discarded from our analyses .
furthermore our study does not provide differential 
 insight as to what kind of treatment has been provided for which kind of disorder . for future evaluations it may be advisable to be able to differentiate the treatments 
 provided according to the kind of disorder . taking a future perspective ,
utilising modern 
 methods of spatial statistics in combination with geographical information systems may serve 
 as a basis for empirically and geographically based service provision planning .
this may lead to demand - oriented 
 plans for service provision that is more strongly oriented towards the demands of the 
 population serviced .
 mental disorders cause a substantial amount of the burden of disease . 
 although they are 
 less frequent in rural areas , their provision of care is disproportionately lower . 
 
 reimbursement claims in the federal state of mecklenburg - west pomerania of the years 
 2006/2007 serve as the basis for the descriptive distribution of subgroups on the total 
 number of mental disorders and their outpatient care . of all claims , 35.3% were allotted 
 to neurotic , stress - related and somatoform disorders , 24.2% to affective disorders and 
 12.5% to substance use disorders . 
 claims for reimbursement were made for 44.7% by general 
 practitioners , 15.1% by neurologists and psychiatrists , 12.6% by gynaecologists , and 8.1% 
 by internists . 
 psychotherapists claimed 3.1% . 
 these results cause considerations regarding 
 the establishment of psychotherapeutic and neurological / psychiatric practices as well as 
 the significance of mental disorders in the training of general practitioners . 
Introduction
Material and Methods
Results
Discussion