Search

BACKGROUND: The Collaborative Outcome study on Health and Functioning during Infection Times (COH-FIT; www.coh-fit.com) is an anonymous and global online survey measuring health and functioning during the COVID-19 pandemic. The aim of this study was to test concurrently the validity of COH-FIT items and the internal validity of the co-primary outcome, a composite psychopathology "P-score". METHODS: The COH-FIT survey has been translated into 30 languages (two blind forward-translations, consensus, one independent English back-translation, final harmonization). To measure mental health, 1-4 items ("COH-FIT items") were extracted from validated questionnaires (e.g. Patient Health Questionnaire 9). COH-FIT items measured anxiety, depressive, post-traumatic, obsessive-compulsive, bipolar and psychotic symptoms, as well as stress, sleep and concentration. COH-FIT Items which correlated r ≥ 0.5 with validated companion questionnaires, were initially retained. A P-score factor structure was then identified from these items using exploratory factor analysis (EFA) and confirmatory factor analyses (CFA) on data split into training and validation sets. Consistency of results across languages, gender and age was assessed. RESULTS: From >150,000 adult responses by May 6th, 2022, a subset of 22,456 completed both COH-FIT items and validated questionnaires. Concurrent validity was consistently demonstrated across different languages for COH-FIT items. CFA confirmed EFA results of five first-order factors (anxiety, depression, post-traumatic, psychotic, psychophysiologic symptoms) and revealed a single second-order factor P-score, with high internal reliability (ω = 0.95). Factor structure was consistent across age and sex. CONCLUSIONS: COH-FIT is a valid instrument to globally measure mental health during infection times. The P-score is a valid measure of multidimensional mental health. ispartof: JOURNAL OF AFFECTIVE DISORDERS vol:326 pages:249-261 ispartof: location:Netherlands status: published

AIMS Interventions to decrease readmissions in psychiatric patients are urgently needed. In Switzerland therapeutic leave (TL) composes a cornerstone of inpatient treatment. TL is a planned time-limited absence from the inpatient ward giving patients the opportunity to test their resilience in their usual environment. Evidence of its applicability as an intervention reducing readmissions is lacking. Therefore, our objective was to examine the association between TL and readmission risk. METHODS Using the Kaplan-Meier curve we compared the time to readmission of 3'302 inpatients at the UPK Basel with and without TL. Cox regression was applied, integrating other covariates associated with readmission. RESULTS The Kaplan-Meier curve indicated longer cumulative survival in patients with TL. The log-rank test implied statistical significance (χ2(1) = 18.8, p

Objective: The COVID-19 pandemic posed new challenges for integrated health care worldwide. Our study aimed to describe newly implemented structures and procedures of psychosocial consultation and liaison (CL) services in Europe and beyond, and to highlight emerging needs for co-operation. Methods: Cross-sectional online survey from June to October 2021, using a self-developed 25-item questionnaire in four language versions (English, French, Italian, German). Dissemination was via national professional societies, working groups, and heads of CL services. Results: Of the participating 259 CL services from Europe, Iran, and parts of Canada, 222 reported COVID-19 related psychosocial care (COVID-psyCare) in their hospital. Among these, 86.5% indicated that specific COVID-psyCare co-operation structures had been established. 50.8% provided specific COVID-psyCare for patients, 38.2% for relatives, and 77.0% for staff. Over half of the time resources were invested for patients. About a quarter of the time was used for staff, and these interventions, typically associated with the liaison function of CL services, were reported as most useful. Concerning emerging needs, 58.1% of the CL services providing COVID-psyCare expressed wishes for mutual information exchange and support, and 64.0% suggested specific changes or improvements that they considered essential for the future. Conclusion: Over 80% of participating CL services established specific structures to provide COVID-psyCare for patients, their relatives, or staff. Mostly, resources were committed to patient care and specific interventions were largely implemented for staff support. Future development of COVID-psyCare warrants intensified intra- and inter-institutional exchange and co-operation.

Background: Coercion is routinely used in psychiatry. Its benefits and drawbacks are controversially debated. In addition, the majority of persons with mental health problems are exposed to stigmatization and are assumed to be dangerous. Stigmatization is associated with negative consequences for individuals with mental illness such as disapproval, social rejection, exclusion, and discrimination. Being subjected to coercive measures can increase the stigmatization of the affected persons, and stigmatization might lead to higher approval for coercion.Aims of the Study: This study aims to examine the approval for coercive measures in psychiatry by the general public, and to explore its relation with person- and situation-specific factors as well as with stigmatization.Method: We conducted a representative survey of the general population (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting psychopathological symptoms of a fictitious character and indicate whether they would accept coercive measures for the person in the vignette. Desire for social distance and perceived dangerousness were assessed as measures of stigmatization.Findings: The person in the case vignette exhibiting dangerous behavior, showing symptoms of a psychotic disorder, being perceived as dangerous, and treatment being understood as helpful increased approval of coercion in general, while familiarity of the respondents with mental illness decreased approval.Conclusions: The public attitude regarding the approval of coercion in psychiatry is highly differentiated and largely follows the current legal framework and medical treatment guidelines. Higher approval occurred in situations of self-harm or harm to others and when coercive measures were thought to have a beneficial effect for the affected persons. A considerable part of the approval for coercion is predicted by stigmatization. With the increasing severity of coercive measures, the influence of person- and situation-specific factors and of familiarity with mental illness decreased and generalizing and stigmatizing attitudes became stronger predictors for the approval of more severe measures.

Background: Psychotic disorders are associated with high rates of comorbid substance use disorders. Use of cannabis rich in tetrahydrocannabinol (THC) is linked to an increased risk of psychosis, worsening of psychotic symptoms, and an adverse course of psychotic disorders. Previous studies suggest oral cannabidiol (CBD) as possible novel antipsychotic agent; however, no studies evaluated the effects of smoked CBD.Objective: The main aim of the study was to clarify the antipsychotic potential of CBD used as adjunctive therapy simulating a naturalistic setting. Our trial is the first study evaluating the effects of smoked CBD-cigarettes as adjunctive therapy for psychotic symptoms.Methods: A randomized, placebo-controlled open-label trial of cigarettes containing CBD-rich cannabis (THC < 1%) as adjunctive therapy to standard psychiatric treatment was conducted (ClinicalTrials.gov identifier NCT04700930). Primary outcomes were mean scores of Positive and Negative Syndrome Scale (PANSS), Brøset Violence Checklist, the Beck's Depression Inventory (BDI), the Subjective Well-Being Under Neuroleptics Scale short form (SWN-K), and antipsychotic medication equivalent doses. Outcomes were assessed after 4 weeks of acute treatment and long-term follow-up after discontinuation of CBD-cigarettes after 25 weeks. Participants were 31 acutely psychotic patients with tobacco use disorder and a mean age of 35.1 ± 10.58 years (71% male). Comorbid cannabis use was diagnosed in 51.6%.Results: A discontinuous multilevel model revealed no significant group differences for primary outcomes. After 4 weeks of acute treatment, mean PANSS and BDI decreased in both groups, while an increase of antipsychotic medication equivalent was observed in the placebo group.Conclusions: The presented findings might suggest an antipsychotic medication sparing effect of CBD-cigarettes as adjunctive treatment of acute psychosis. However, the low number of participants did not allow for further statistical analysis. Hence, a larger study sample and a more rigorous study design (blinding of the interventional product, fixed dosing regimen) may reveal different results.Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT04700930

BackgroundPsychiatric inpatient treatment is increasingly performed in settings with locked doors. However, locked wards have well-known disadvantages and are ethically problematic. In addition, recent data challenges the hypothesis that locked wards provide improved safety over open-door settings regarding suicide, absconding and aggression. Furthermore, there is evidence that the introduction of an open-door policy may lead to short-term reductions in involuntary measures. The aim of this study was to assess if the introduction of an open-door policy is associated with a long-term reduction of the frequency of seclusion and forced medication.MethodIn this 6-year, hospital-wide, longitudinal, observational study, we examined the frequency of seclusion and forced medication in 17,359 inpatient cases admitted to the Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken (UPK) Basel, University of Basel, Switzerland. In an approach to enable a less restrictive policy, six previously closed psychiatric wards were permanently opened beginning from August 2011. During this process, a systematic change towards a more patient-centered and recovery-oriented care was applied. Statistical analysis consisted of generalized estimating equations (GEE) models.ResultsIn multivariate analyses controlling for potential confounders, the implementation of an open-door policy was associated with a continuous reduction of seclusion (from 8.2 to 3.5%; ηp2 = 0.82; odds ratio: 0.88) and forced medication (from 2.4 to 1.2%; ηp2 = 0.70; odds ratio: 0.90).ConclusionThis underlines the potential of the introduction of an open-door policy to attain a long-term reduction in involuntary measures.

Background During the COVID-19 pandemic in 2020, psychiatric hospitals all over the world had to adapt their services to the prevailing governmental regulations. As a consequence, home office use and telepsychiatry boomed. Objective The purpose of this study was to evaluate the potential of home office use, its adoption, and the association of home office use with employees’ mental health in a large psychiatric university hospital in Switzerland. Methods We obtained and analyzed home office implementation and use data from the psychiatric university hospital’s information technology services. We also conducted a cross-sectional web-based survey to assess the employees’ attitudes toward the clinic’s crisis management during the COVID-19 pandemic in early 2020. Part of this web-based survey consisted of questions about home office use between March and June 2020, attitudes toward home office implementation, and mental health. Three mental health measures assessed depressive symptoms (Patient Health Questionnaire [PHQ]–2), anxiety (General Anxiety Disorder [GAD]–2), and stress factors (stress module of the PHQ-D); a cut-off score ≥3 was used for the PHQ-2 and GAD-2. Results Of the 200 participating employees, 69 reported that they had worked from home at least partially (34.5%). Home office use differed significantly across professional groups (χ162=72.72, P≤.001, n=200). Employees experienced neither depressive symptoms (mean 0.76, SD 1.14) nor anxiety (mean 0.70, SD 1.03). The employees reported minor psychosocial stressors (mean 2.83, SD 2.92). The number of reported stress factors varied significantly across groups with different levels of home office use (χ42=9.72, P=.04). Conclusions In general, home office implementation appears to be feasible for large psychiatric hospitals, however, it is not equally feasible for all professional groups. Professional groups that require personal contact with patients and technical or manual tasks must work onsite. Further evaluation of home office use in psychiatric hospitals up to the development of clinics that function merely online will follow in future research. The situation created by the COVID-19 pandemic served as a stepping stone to promote home office use and should be used to improve employees’ work–life balance, to save employers costs and foster other benefits.

Aggressive behavior and violence in psychiatric patients have often been quoted to justify more restrictive settings in psychiatric facilities. However, the effects of open vs. locked door policies on aggressive incidents remain unclear. This study had a naturalistic observational design and analyzed the occurrence of aggressive behavior as well as the use of seclusion or restraint in 21 German hospitals. The analysis included data from 1998 to 2012 and contained a total of n = 314,330 cases, either treated in one of 17 hospitals with (n = 68,135) or in one of 4 hospitals without an open door policy (n = 246,195). We also analyzed the data according to participants' stay on open, partially open, or locked wards. To compare hospital and ward types, we used generalized linear mixed-effects models on a propensity score matched subset (n = 126,268) and on the total dataset. The effect of open vs. locked door policy was non-significant in all analyses of aggressive behavior during treatment. Restraint or seclusion during treatment was less likely in hospitals with an open door policy. On open wards, any aggressive behavior and restraint or seclusion were less likely, whereas bodily harm was more likely than on closed wards. Hospitals with open door policies did not differ from hospitals with locked wards regarding different forms of aggression. Other restrictive interventions used to control aggression were significantly reduced in open settings. Open wards seem to have a positive effect on reducing aggression. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient's autonomy and promoting reductions of institutional coercion.

HPA axis functioning plays an important role in the etiology of schizophrenia spectrum disorders (SSD). However, only few studies have examined HPA axis responsivity to psychosocial stress in SSD, and results are heterogeneous. Furthermore, childhood trauma is known to influence psychopathology and treatment outcome in SSD, but studies on the influence of childhood trauma on stress related HPA axis activity are missing. The purpose of this study was to investigate cortisol response to a psychosocial stress challenge in SSD patients, and to examine its association with severity of childhood trauma. The present study included 25 subacutely ill patients with a current episode of a chronic SSD and 25 healthy controls. Participants underwent the modified Trier Social Stress Test, and salivary cortisol levels were assessed. The childhood trauma questionnaire was used to assess severity of adverse life events. Overall, cortisol response was blunted in the patient group compared to the control group (p

Background: Health services research is of increasing importance in current psychiatry. Therefore, large datasets and aggregation of data generated by electronic routine documentation due to legal, financial, or administrative purposes play an important role. However, paper-based routine documentation is still of interest. It remains relevant in less developed health care systems, in emergency settings, and in long-term retrospective and historical studies. Whereas studies examining the reliability of electronic routine documentation support the application of routine data for research purposes, our knowledge regarding reliability of paper-based routine documentation is still very sparse.Methods: Basic documentation (BADO) was completed on paper forms and digitalized manually for all inpatients of the Department of Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf, Germany, treated within the time period from 1998 to 2006. Four hundred twelve cases of first-episode psychosis patients were chosen for comparison with clinical data from paper-based patient files. The percentage of missing information, the percentage of correct classifications, sensitivity, and positive predictive value were calculated for all applicable variables.Results: In eight cases (1.9%), a BADO form was available, but was not filled in. In 37 cases (7.0%), the patient files were lost and could not be obtained from the centralized archive. Routine data were available for all other cases in 20 (58.8%) of the examined 34 variables, and the percentage of missing data for the remaining variables ranged between 0.3% and 22.9%, with only the variables education and suicidality during treatment having more than 5% missing data. In general, the overall rate of correct classifications was high, with a median percentage of 86.4% to 99.7% for the examined variables. Sensitivity was above 75% for eight and

Open doors in psychiatry have been a subject of controversy in recent years. While some studies postulate the clinical necessity of closed doors, others challenge the theoretical advantages of this setting, mention numerous drawbacks of closed wards, and focus on the advantages of open-door settings. With regard to patients diagnosed with substance use disorders (SUD), other standards may apply. Very little research has been done on this topic. Some studies adopted a consumer perspective (i.e. asking involved parties about their experience of the door status). To the authors' knowledge, no study has so far addressed the ideal setting for the treatment of SUD. With our data from the opening of a specialized SUD ward, we take one step to closing this knowledge gap. Applying a qualitative design, we asked patients and health care professionals (HCP) to report changes following the opening of the ward. The results are mainly in line with the literature on the general psychiatric population. The newly introduced open-door setting was mostly perceived as positive, but some disadvantages were mentioned (e.g. less protection of patients, less control over who enters/leaves the ward, the theoretically increased risk of patients absconding). Moreover, HCP (but not patients) mentioned potentially increased substance use on the ward as an additional disadvantage that could arise. Opening a previously closed ward was generally perceived as a positive and progressive decision. These findings support the trend towards an overall open-door policy in psychiatry.

Objective: The ACCESS treatment model offers assertive community treatment (ACT) embedded in an integrated care program to patients with severe psychotic disorders. Compared to standard care, it proved to be more effective in terms of service disengagement and other outcomes in patients with psychotic disorders over 12, 24, and 48 months. Many patients with severe mental disorders experience involuntary admissions which can be potentially traumatic. In this study, we assessed the effect of ACT on reducing involuntary admissions over an observation period of 4 years.Method: One hundred seventy-one patients treated in ACCESS were included in this study. The primary outcome was rate of involuntary admissions during 48 months. Secondary outcomes were differences between those with and without involuntary admissions in the 2 years prior to ACCESS regarding change of psychopathology, severity of illness, psychosocial functioning, quality of life, satisfaction with care, medication non-adherence, and service-disengagement.Results: Of 171 patients, 58 patients (33.9%) were involuntarily admitted to hospital in the past 2 years before entry. During the 4 years of treatment, 16 patients (9.4%) were involuntarily admitted to hospital which was a significantly lower rate compared to the 2 years before inclusion in ACCESS (p < .001). Comparing the two groups, larger improvements in severity of illness (p = .004) and functional status (p = .043) were detected in the group with no history of involuntary admissions. At 4-year follow-up, of the remaining patients, 69.2% (n = 81) were full adherent (p < .001), compared to 18.9% (n = 31) at baseline with no differences between the two groups over the study period (p = .25). Over 4 years, only 13 patients (13.2%) were service-disengaged due to non-practical reasons.Conclusions: In this long-term study, we were able to demonstrate a reduction in involuntary admissions in four treatment years compared to the 2 years prior to admission to the ACCESS model in patients with severe and mostly multiphase schizophrenia spectrum disorders and affective disorders with psychotic features. This may help prevent patients from suffering from a potentially traumatic experience during treatment in the psychiatric system.Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT01888627.

Background: When persons with a mental illness present a danger to themselves or others, involuntary hospital admission can be used to initiate an immediate inpatient treatment. Often, the patients have the right to appeal against compulsory admission. These processes are implemented in most mental health-care systems, but regulations and legal framework differ widely. In the Swiss canton of Basel-Stadt, a new regulation was implemented in January 2013. While the current literature holds some evidence for factors associated with involuntary admission, knowledge on who uses the right to appeal against admission is sparse. Aims: The study aims to examine if specific sociodemographic and clinical characteristics are associated with involuntary admission and with an appeal against the compulsory admission order. Method: Routine clinical data of all inpatient cases admitted during the period from January 2013 to December 2015 at the Psychiatric University Hospital Basel were extracted. Generalized estimating equation (GEE) analyses were used to examine the association of sociodemographic and clinical characteristics with “involuntary admission” and “appeal against compulsory admission order.” Results: Of the 8,917 cases included in the present study, 942 (10.6%) were admitted involuntarily. Of these, 250 (26.5%) lodged an appeal against the compulsory admission order. Compared with cases admitted on a voluntary legal status, cases admitted involuntarily were older and were admitted more often during the nighttime or weekend. Moreover, involuntarily admitted cases had more often a principal diagnosis of a schizophrenia spectrum disorder. Patients from cases where an appeal was lodged were more often female, had more often Swiss nationality, and were more often diagnosed with schizophrenia spectrum disorder. Conclusion: Despite legal changes, the frequency of involuntary admissions in the observed catchment area seems to be relatively stable across the last 20 years. The percentage of appeals has decreased from 2000 to 2015, and only comparably few patients make use of the possibility to appeal. Better knowledge of the regulations, higher social functioning, and lower insight into illness might be associated with a higher probability of lodging an appeal. Future research should examine if specific patient groups are in need of additional assistance to exert their rights to appeal.

AimTinnitus and hyperacusis are phenomena with a considerable prevalence in the general population, leading to high levels of suffering. It is a symptom that can present itself comorbidly with a variety of psychiatric and medical illnesses. We established a treatment of tinnitus and hyperacusis, which is based on a multimodal approach including a specific cognitive behavioral therapy (CBT) method in an inpatient setting. This approach includes education on tinnitus and hyperacusis, applying coping strategies and techniques of relaxation, directed attention, and music therapy. We aim to evaluate the efficacy of this treatment approach.Materials and MethodsWe included retrospective data of 268 patients who underwent tinnitus treatment throughout the 10-year existence of the treatment program. We assessed routine clinical data pretreatment and posttreatment with parameters concerning tinnitus–distress, hyperacusis, and psychological well-being. To determine these variables, we used validated instruments including the Tinnitus Questionnaire (TQ), Questionnaire on Hypersensitivity to Sound (QHS), Brief Symptom Inventory (BSI), and the Beck Depression Inventory (BDI-II).ResultsPatients showed highly significant reduction in all of the examined clinical outcomes. Reduction of TQ, the primary outcome measure, was 15.39 (SD 21.88) from a mean baseline value of 35.72 (p < 0.001). The QHS showed a reduction of 6.72 (SD 8.23) from a mean baseline value of 18.98 (p < 0.001). Moreover, psychological strain was also reduced with high significance, as illustrated in reduction of BSI and BDI-II; reduction in BSI from 49.63 by 24.41 (SD 26.88; p < 0.001) and BDI-II from 16.89 by 7.47 (SD 8.76; p < 0.001).DiscussionThe multimodal treatment program for tinnitus and hyperacusis including a specific CBT method proves to be a highly effective means of significantly reducing not only tinnitus and hyperacusis but also accompanying distress. Furthermore, it also enables considerable reduction of concomitant psychiatric symptoms such as depression.ConclusionsOur results underline the importance of intensive and multimodal approaches to the treatment of tinnitus and hyperacusis.

Purpose Stressful childhood experiences (SCE) are associated with many different health outcomes, such as psychiatric symptoms, physical illnesses, alcohol and drug abuse, and victimization experiences. Lesbian, gay, bisexual, and transgender (LGBT) people are at risk to be victims of SCE and show higher prevalence of SCE when compared with heterosexual controls. Methods This review analyzed systematically 73 articles that addressed different types of SCE in sexual minority populations and included items of household dysfunction. The samples included adults who identified either their sexual orientation as non-heterosexual or their gender identity as transgender. Results The studies reported childhood sexual abuse (CSA), childhood physical abuse (CPA), childhood emotional abuse (CEA), childhood physical neglect, and childhood emotional neglect. Items of household dysfunction were substance abuse of caregiver, parental separation, family history of mental illness, incarceration of caregiver, and witnessing violence. Prevalence of CSA showed a median of 33.5 % for studies using non-probability sampling and 20.7 % for those with probability sampling, the rates for CPA were 23.5 % (non-probability sampling) and 28.7 % (probability sampling). For CEA, the rates were 48.5 %, non-probability sampling, and 47.5 %, probability sampling. Outcomes related to SCE in LGBT populations included psychiatric symptoms, substance abuse, revictimization, dysfunctional behavioral adjustments, and others. Conclusions LGBT populations showed high prevalence of SCE. Outcomes related to SCE ranged from psychiatric symptoms and disorders to physical ailments. Most studies were based in the USA. Future research should aim to target culturally different LGBT population in the rest of the world.

Court-mandated treatments imply a dual role for therapy providers not only of caring for, but also of having control over, involuntary clients. The impact of legal coercion on the therapeutic relationship and feelings of stigma is widely regarded as negative and detrimental for treatment outcomes. This point of view stands in contrast to advocates of the perspective that involuntary treatment can ameliorate social functioning and thus promote a better quality of life. Regarding other outcome measures, there is evidence that offender treatment is effective and leads to reduced recidivism in criminal behavior. This narrative review provides an overview of research assessing the effects of mandatory treatment on therapeutic process and outcome factors. We conclude that legal mandatory treatment does not have to necessarily result in perceived coercion and reduced satisfaction with treatment and that a caring and authoritative treatment style aids a favorable therapeutic alliance, motivation, and therapy outcomes.

For psychiatric patients, compulsory admission and coercive measures can constitute distressing and sometimes traumatizing experiences. As a consequence, clinicians aim at minimizing such procedures. At the same time, they need to ensure high levels of safety for patients, staff and the public. In order to prevent compulsory measures and to favor the use of less restrictive alternatives, innovative interventions improving the management of dangerous situations are needed. Animal-assisted therapy (AAT) is being applied in a variety of diagnoses and treatment settings, and could have the potential to reduce aggression and psychopathology. Therefore, AAT might be of use in the prevention and early treatment of aggression, and might constitute a promising component of treatment alternatives to forced interventions. To our knowledge, no study evaluating the effect of AAT on compulsory measures in persons with psychiatric diseases has been published up to date. This narrative expert review including a systematic literature search examines the published literature about the use of AAT in psychiatry. Studies report reduced anxiety and aggressiveness as well as positive effects on general wellbeing, self-efficacy, quality of life and mindfulness. Although literature on the applicability of AAT as a component of preventive or de-escalating treatment settings is sparse, beneficial effects of AAT have been reported. Therefore, we encourage examining AAT as a promising new treatment approach to prevent compulsory measures.

Social distancing and the shortage of healthcare professionals during the COVID-19 pandemic, the impact of population aging on the healthcare system, as well as the rapid pace of digital innovation are catalyzing the development and implementation of new technologies and digital services in psychiatry. Is this transformation a blessing or a curse for psychiatry? To answer this question, we conducted a literature review covering a broad range of new technologies and eHealth services, including telepsychiatry; computer-, internet-, and app-based cognitive behavioral therapy; virtual reality; digital applied games; a digital medicine system; omics; neuroimaging; machine learning; precision psychiatry; clinical decision support; electronic health records; physician charting; digital language translators; and online mental health resources for patients. We found that eHealth services provide effective, scalable, and cost-efficient options for the treatment of people with limited or no access to mental health care. This review highlights innovative technologies spearheading the way to more effective and safer treatments. We identified artificially intelligent tools that relieve physicians from routine tasks, allowing them to focus on collaborative doctor–patient relationships. The transformation of traditional clinics into digital ones is outlined, and the challenges associated with the successful deployment of digitalization in psychiatry are highlighted.

People who suffer from severe mental illness often present with histories of abuse during childhood. Alcohol use disorders is a common co-morbidity of survivors of childhood abuse and neglect. This study analyzes the effects of stressful childhood experiences, a proxy for trauma, on the frequency of alcohol consumption and the utilization of health care services in a population of people with severe mental illness. There were 111 men (mean age: 35 years) and 72 women (mean age: 40.0 years) with severe mental illness that were recruited from psychiatric outpatient clinics in New York City. The analysis focused on lifetime prevalence of stressful childhood experiences, alcohol consumption, and utilization of health care services over time. The longitudinal data were analyzed over 12 months with a level-2 model (multilevel modeling). Out of the participants, 41.5% reported a history of more than four types of abusive experiences. There were 33.3% that had a DSM-IV diagnosis of alcohol abuse and 27.3% qualified for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of alcohol dependence throughout their lives. Stressful childhood experiences predicted an increased frequency of alcohol consumption over time. People with histories of childhood abuse had more often been to outpatient clinics and 12-step programs, but at the same time showed lower frequency rates of psychiatrist visits and visits to outpatient clinics. Childhood abuse is prevalent in people with severe mental illness and is related to an increased alcohol consumption. Despite an increased need of health care services, affected persons might encounter more barriers to access them.

Inpatient suicide and absconding of inpatients at risk of self-endangering behaviour are important challenges for all medical disciplines, particularly psychiatry. Patients at risk are often admitted to locked wards in psychiatric hospitals to prevent absconding, suicide attempts, and death by suicide. However, there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes. We did this study to compare hospitals without locked wards and hospitals with locked wards and to establish whether hospital type has an effect on these outcomes.In this 15 year, naturalistic observational study, we examined 349 574 admissions to 21 German psychiatric inpatient hospitals from Jan 1, 1998, to Dec 31, 2012. We used propensity score matching to select 145 738 cases for an analysis, which allowed for causal inference on the effect of ward type (ie, locked, partly locked, open, and day clinic wards) and hospital type (ie, hospitals with and without locked wards) on suicide, suicide attempts, and absconding (with and without return), despite the absence of an experimental design. We used generalised linear mixed-effects models to analyse the data.In the 145 738 propensity score-matched cases, suicide (OR 1·326, 95% CI 0·803-2·113; p=0·24), suicide attempts (1·057, 0·787-1·412; p=0·71), and absconding with return (1·288, 0·874-1·929; p=0·21) and without return (1·090, 0·722-1·659; p=0·69) were not increased in hospitals with an open door policy. Compared with treatment on locked wards, treatment on open wards was associated with a decreased probability of suicide attempts (OR 0·658, 95% CI 0·504-0·864; p=0·003), absconding with return (0·629, 0·524-0·764; p0·0001), and absconding without return (0·707, 0·546-0·925; p=0·01), but not completed suicide (0·823, 0·376-1·766; p=0·63).Locked doors might not be able to prevent suicide and absconding.None.

Objective Agitation, aggression, and violence are increased in psychotic disorders. Additionally, an earlier age at onset may be associated with aggressive behavior. However, the relationship of age at onset, an agitated-aggressive syndrome as measured with the Positive And Negative Syndrome Scale for Schizophrenia - Excited Component (PANSS-EC), and its potential correlates in first-episode psychosis (FEP) has not been studied. Method This study assessed the association between age at onset, an agitated-aggressive syndrome, and its potential correlates in a prospective sample of 52 FEP patients with early-onset and adult-onset followed up for 12 months. Results Twenty-six patients conformed to the criteria of early-onset psychosis. Early age at onset was associated with antisocial personality disorder (p = 0.004; φc = 0.39), a history of legal involvement (p = 0.005; φc = 0.39), and higher rates of lifetime substance use disorder (SUD; p = 0.002; φc = 0.42). Early-onset patients had significantly higher PANSS-EC scores over the course of observation (F(1,44.4) = 5.39; p = 0.025; d = 0.656), but no significant group differences emerged for the remaining PANSS subscores. PANSS-EC scores were correlated positively with antisocial personality disorder and forensic history at 6 weeks, 3 months, 6 months, and 12 months, and with lifetime substance use disorder at 3 months and 6 months. Conclusions Patients with early onset psychosis may have increased levels of agitation/aggressiveness, and, more likely, antisocial personality disorder, forensic history, and lifetime substance use disorder. These variables were linked to suicidality, aggressiveness, and involuntary treatment.

Aims:Our study aimed to explore the effects of different types of adverse childhood experiences (e.g. domestic violence, early loss, parental dysfunction, sexual and physical abuse) as well as experiences of sexual and physical abuse in adulthood on dissociative symptoms in adult patients with schizophrenia-spectrum disorders. Methods:145 patients were examined for psychotic symptoms with the Positive and Negative Syndrome Scale (PANSS), for dissociative symptoms with the German version of the Dissociative Experiences Scale (DES) and for adverse experiences in childhood and adulthood with the Structured Trauma Interview (STI). Results: Childhood physical abuse was reported by 32%, childhood sexual abuse by 17% of the patients. Other forms of childhood adversity were also quite common; 18% had witnessed domestic violence, 26% reported early loss, and nearly half of patients reported at least one condition potentially related to parental dysfunction. The DES total score was significantly associated with childhood sexual abuse, witnessing of domestic violence and paternal dysfunction, as well as with physical violence in adulthood. In the final regression model, reports of paternal dysfunction and sexual abuse in childhood were independently associated with adult dissociation. Variance in dissociative symptoms was mainly explained by paternal dysfunction (18%). Conclusion:Substantial rates of childhood adversity were found and specific associations were evident with adult dissociation amongst psychosis patients who reported sexual abuse or paternal dysfunction in childhood. Therefore, it is important that patients with schizophrenia-spectrum disorders are routinely asked about a broad range of possible adverse childhood experiences in order to provide appropriate interventions.

Objectives: Current risk assessment tools can predict problematic behavior and the need for coercive measures, but only with a moderate level of accuracy. The aim of this study was to assess antecedents and triggers of seclusion.Methods: Narrative notes of health care professionals on psychiatric inpatients were analyzed daily starting 3 days prior to seclusion in the case group (n = 26) and compared to a matched control group without seclusion (n = 26) by use of quantitative and qualitative research methods, based on qualitative content analysis.Results: Quantitative measures showed more aggression in the case group with highly significant differences between the groups (p < 0.001) at all measurement times. Seclusion was significantly associated with the total word count of the narrative notes. Subjective emotional expressions by staff were more apparent before seclusion (p = 0.003). Most frequently, subjective expressions regarding “arduous/provocative” (p < 0.001) and “anxious” (p = 0.010) sentiments could be identified in the case group. Description of patients' behavior in the case group included more negatively assessed terms (p = 0.001). Moreover, sleep loss, refusing medication, high contact frequency, demanding behavior and denied requests were present in a significantly higher frequency before seclusion. Expressions like “threatening” (p = 0.001) were found only before seclusion and appeared to have the function of personal risk assessment. The expression “manageable” (p = 0.035) appeared often in difficult situations that could still be handled.Conclusion: Several factors preceding seclusion could be identified. Narrative notes of staff already showed differences 3 days before the escalation. Particularly the word count, the analysis of terms describing patients' behavior, subjective expressions of staff, and terms used as a function of personal risk assessment could help to provide better predictions of aggressive incidents and to prevent coercive measures.

Background and methods: Aggression in psychosis is clinically important. We systematically compiled the evidence on functional correlates of aggression in psychosis searching PubMed, EMBASE, ScienceDirect, and PsycINFO until September 2017. We included studies reporting functional brain imaging correlates of aggression comparing: (1) affective or non-affective psychosis groups with a history of violence or with aggression operationalized using questionnaires, (2) affective or non-affective psychosis groups with a history of violence or with aggression operationalized using questionnaires to controls, (3) affective or non-affective psychosis groups with a history of violence or with aggression operationalized using questionnaires to controls with diagnoses other than affective or non-affective psychoses. We applied no language restriction and required patients to have a DSM or ICD diagnosis of affective or non-affective psychosis. Results: Our sample consisted of 12 studies with 334 patients and 113 controls. During n-back tasks, violent (VS) as opposed to non-violent persons with schizophrenia (NVS) hypoactivated their inferior parietal lobe. When anticipating shock, VS vs. NVS hyperactivated their medial prefrontal gyrus, cuneus, middle temporal gyrus, and middle occipital gyrus. When viewing negative emotional pictures, VS vs. NVS hyperactivated the middle frontal gyrus, inferior frontal gyrus, anterior cingulate, lingual gyrus, precentral gyrus, globus pallidus, mid-cingulate, and precuneus. Limitations: Due to the small number of available studies, sample overlap, and insufficient reporting of relevant moderators we could not conduct a meta-analysis. Conclusions: We found non-systematic functional correlates of aggression in schizophrenia. Only few studies using varied paradigms and often overlapping samples have been conducted. There have been no attempts to replicate any of the observed findings in the published literature. Focusing on future directions, we recommend that authors adhere to clear definitions of aggression, measurements of psychopathology, comorbidities, and medication. In particular, replication studies would allow for a better synthesis of the findings. PROSPERO Registration Number: CRD42016048579.

Anti-aggression and de-escalation (ADE) trainings of healthcare professionals working on psychiatric inpatient wards have been shown to increase staff knowledge and confidence, which could be connected with higher subjective safety. Additionally, a potential reduction of aggressive incidents could improve ward atmosphere. Thus, the current study aimed to investigate the effects of ADE training on ward atmosphere and subjective safety. In 2015, an ADE training was established at the Psychiatric University Clinics (UPK), University of Basel. Nursing staff from 22 wards received theoretical and practical training over the course of five days. Ward atmosphere and subjective safety were assessed using the Essen Climate Evaluation Schema (EssenCES). A total of 46 people had been assessed in 2012 before training implementation (baseline), and 45 persons in 2016 after implementation. In the 2016 group, 23 people had previously participated in an ADE training, and 22 were first-time participants. Patients’ coherence (p = 0.004), subjective safety (p = 0.004), and ward atmosphere (p = 0.001) were rated significantly higher by first-time ADE training participants compared to baseline, and patients’ coherence (p = 0.029) and ward atmosphere (p = 0.011) were rated significantly higher by first-time ADE training participants than by nurses with prior ADE training. There were no significant differences regarding any EssenCES ratings by nurses with prior ADE training compared to baseline. ADE training was exclusively connected with higher ratings on most EssenCES scales for first-time participants. This indicates that the positive effects of ADE training may depend on previous training experience.

Background: Implementing an open door policy is a complex intervention comprising changes in therapeutic stance, team processes, and a change from locked to open doors. Recent studies show that it can lead to a reduction of seclusion and forced medication, but the role of the physical change of door status is still unclear. Aims: To examine the transition from closed to predominantly open doors on a psychiatric intensive care unit (PICU) and its associations with the frequency of seclusion and forced medication. Method: A PICU at the Department of Adult Psychiatry, University of Basel, Switzerland, implemented evidence-based strategies for operating an open door policy within the context of acute psychiatry and participated in a hospital-wide implementation of an open door policy before changing door status. 131 inpatient cases hospitalized on this PICU were examined regarding the frequency of seclusion and forced medication using explorative analyses over a time span of 32 weeks (16 weeks after implementation of the new treatment concept but before door opening, 16 weeks after door opening). Results: Following door status change, the PICU was completely open on 51% of the days, and partly open on 23% of the days. The mean number of open hours per day was 12.8 ± 3.9 hours. The frequency of forced medication did not change, the frequency of seclusion decreased significantly (χ2 (1, N = 131) = 4.73, p = .036). Conclusion: This pilot study underlines the potential of a change of door status to attain a reduction in safety measures in the first four months. Declaration of interest: The authors declare no conflict of interest.

Perceptions of dangerousness are an influential component of mental health stigma and can be driven by the display of psychiatric symptoms and the use of psychiatric service institutions. Yet, no previous study compared symptoms and service use associated perceptions of dangerousness. Therefore, we conducted a representative survey (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to answer the perceived dangerousness scale with respect to a vignette that either depicted psychiatric symptoms of a fictitious character or a psychiatric service institution the fictitious character had been admitted to. Between the vignettes, type of symptoms, type of psychiatric service, dangerousness, and gender were systematically varied. Perceived dangerousness was significantly lower as related to psychiatric service use than related to psychiatric symptoms. Overall, symptoms of alcohol dependency, behavior endangering others, and male gender of the fictitious character tend to increase perceived dangerousness. Furthermore, being hospitalized in a psychiatric unit at a general hospital or the rater being familiar with psychiatric services tends to decrease perceived dangerousness. Effective anti-stigma initiatives should integrate education about dangerousness as well as methods to increase familiarity with psychiatry. Additionally, an integration of modern psychiatry in somato-medical care institutions might decrease stigmatization.

Purpose Change of treatment policy from closed to open ward settings has been shown to reduce coercive measures. The aim of the current study was to examine the effects of the change from closed to open wards on the frequency of seclusion and forced medication in a hospital-wide setting. Subjects and methods 2-year, longitudinal observational study with 2838 inpatient cases. Results On a hospital-wide level, the percentage of patients with at least one seclusion was decreased significantly ( χ 2 ( 1) = 5.8; p = .016), while there was no significant change in forced medication ( χ 2 (1) = .08; p = .775). The frequency of seclusions and forced medication decreased significantly on newly opened wards, and there were no significant changes regarding seclusion on permanently closed or open wards, while the number of forced medications increased significantly on closed wards. The decrease in seclusions on newly opened wards remained statistically significant after controlling for diagnoses and severity of illness. Discussion Our results indicate that a reduction of overall seclusion can be successfully attained, and that, in particular, the frequency of seclusion and forced medication on newly opened wards was decreased significantly. These changes were not accompanied by a significant increase in seclusion on other wards. Conclusion Open ward treatment was successfully implemented and was associated with a significant decrease of coercive measures in our study. It might therefore provide a good care model, strengthening the patient's right to autonomy and leading to a reduction of coercive measures.

Objective To assess the association of subjective quality of life as measured by the Subjective Well-being under Neuroleptic Treatment questionnaire (SWN-K) with neuropsychological functioning; to address interactions with the SWN-K domain mental functioning as a measure of subjective cognitive dysfunction; and to examine the interaction of subjective well-being and psychopathology ratings. Methods Forty-five patients diagnosed with schizophrenia spectrum disorder (SSD) were assessed regarding subjective well-being (SWN-K), neuropsychological impairment, and psychopathology (Brief Psychiatric Rating Scale; BPRS). Results After controlling for multiple comparisons, SWN-K total score showed significant positive correlations with concentration/attention ( r =.498), working memory ( r =.537), verbal memory ( r =.522), and global cognition ( r =.459). No correlations of SWN mental functioning and neuropsychological impairment remained significant after Bonferroni correction. Correlations between SWN-K subscales and neuropsychological functioning were generally positive, indicating higher subjective well-being in patients with better neurocognition. In multivariate analyses, global cognition was a significant predictor ( p =.011), accounting for 19.7% of SWN total score variance. Adding BPRS total score as predictor ( p =.054) explained an additional 6.9% of SWN-K variance. Linear regression analyses with SWN-K mental functioning as dependent variable did not yield statistically significant models. Conclusion Subjective well-being and objective neuropsychological functioning show only moderate associations and can be seen as largely independent parameters. In particular, subjective mental functioning cannot serve as a proxy for objective neuropsychological testing.

The objective is to investigate the relationship between psychopathology measured by the positive and negative syndrome scale (PANSS) and concurrent global assessment of functioning (GAF) and subjective well-being under neuroleptics (SWN) in patients with schizophrenia spectrum disorder (SSD) regarding severity of illness and disease phase. We analyzed a sample of 202 SSD patients consisting of first episode psychosis (FEP) and multiple episode psychosis (MEP) patients followed up to 12 months using linear mixed models. All PANSS syndromes except excitement were associated with GAF scores (positive syndrome: p

Objective: Substance use treatment is often performed inside locked wards. We investigate the effects of adopting a policy of open-door treatment for a substance use treatment and dual diagnosis ward. Methods: This is a prospective open-label study investigating 3-month study periods before opening (P1), immediately after (P2), and 1 year after the first period (P3). Data on committed patients, coercion (seclusion, forced medication, absconding events with subsequent police search), violence, and substance use was collected daily. We applied generalised estimating equation models. Results: The mean daily number of patients with ongoing commitment changed from 2.64 (P1) to 2.12 (P2) to 0.96 (P3), corresponding to a reduction of relative risk (RR) for having an ongoing commitment by 20% in P2 (RR 0.80; 95% CI 0.66-0.98) and 67% in P3 (RR 0.33; 95% CI 0.25-0.42). The mean daily number of coercive events was 0.29, 0.13, and 0.05, corresponding to a risk for undergoing coercive measures reduced by 56% (RR 0.44; 95% CI 0.22-0.90) and 85% (RR 0.15; 95% CI 0.05-0.45). Substance use, violence or ward atmosphere did not differ significantly. Conclusions: Our results support findings from general psychiatric wards of reduced coercion after adopting a primarily open-door policy. However, coercive events were rare during all periods. The widespread practice of restricting the freedom of inpatients with substance use disorders by locking ward doors is highly questionable.

Rationale An ongoing debate concerns acceptability, benefits, and shortcomings of coercive treatment such as assisted outpatient treatment (AOT). The hypothesis that involuntary commitment to outpatient treatment may lead to a better clinical outcome for a subgroup of persons with severe mental illness (SMI) is controversial. Nonetheless, positive effects of AOT may be mediated by an increased availability of healthcare resources or increased service use. Objective The purpose of the present study is to evaluate the course of delusions, hallucinations, and negative symptoms among patients with SMI receiving AOT compared to patients receiving non-compulsory treatment (NCT). Moreover, we assessed if the effects of AOT on psychotic symptoms were mediated by increased healthcare service use. Methods This study used a quasi-experimental design to examine the effect of AOT and the use of healthcare services on psychotic symptoms. In total, 76 (41.3%) participants with SMI received AOT, and 108 (58.7%) received NCT. The participants were interviewed at baseline every 3 months up to 1 year. Propensity score matching was used to control for group differences. Results In the basic model, AOT was associated with lower severity of psychotic symptoms over all follow-up points. In the model including healthcare service use, the frequency of case manager visits predicted a reduction in severity of all psychotic symptoms. The frequency of visits to the outpatient clinics, frequency of emergency room, and psychiatrist visits were independently associated with lower levels of delusional symptoms. Psychiatrist visits were related to a decrease in negative symptoms. Conclusion Results indicate that the treatment benefits of AOT are enhanced with the increased use of mental healthcare services, suggesting that the positive effect of AOT on psychotic symptoms is related to the availability of mental healthcare service use. Coercive outpatient treatment might be more effective through greater use of intensive services.

Background There is evidence for two different types and/or sources of mental illness stigma, namely the display of psychiatric symptoms and the use of psychiatric service institutions. However, no current study has compared the two. Furthermore, gaps exist in our knowledge of both types of stigma. Little is known about the perceived stigma of specific psychiatric service treatment environments, for instance forensic settings. In addition, systematic research on stigma attached to symptoms of personality disorders in the general population is scarce, and for borderline personality disorder, nonexistent. Methods We conducted a representative survey of the general population (N = 2207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting either the psychiatric symptoms of a fictitious character or a psychiatric service institution to which the character had been admitted, and indicate desired social distance (an indicator for stigma). Type of symptoms, type of psychiatric service, dangerousness, and gender were systematically varied between vignettes. Findings Desired social distance was significantly lower in relation to psychiatric service use than to psychiatric symptoms. Overall, symptoms of alcohol dependency, behavior endangering others, and the fictitious character’s being male tend to increase stigmatization. Interestingly, the character’s being hospitalized in a psychiatric unit at a general hospital and also respondent familiarity with psychiatric services tend to decrease stigmatization. Interpretation Familiarity of the general population with psychiatric patients should be increased. Furthermore, treatment in psychiatric units located within general hospitals should be promoted, as such treatment is associated with decreased stigma.

To compare the 1-year cost-effectiveness of therapeutic assertive community treatment (ACT) with standard care in schizophrenia. ACT was specifically developed for patients with schizophrenia, delivered by psychosis experts highly trained in respective psychotherapies, and embedded into an integrated care system.Two catchment areas in Hamburg, Germany, with similar population size and health care structures were assigned to offer 12-month ACT (n = 64) or standard care (n = 56) to 120 first- and multiple-episode patients with schizophrenia spectrum disorders (DSM-IV), the latter with a history of relapse due to medication nonadherence. Primary outcome was the incremental cost-effectiveness ratio (ICER) based on mental health care costs from a payer perspective and quality-adjusted life-years (QALYs) as a measure of health effects during the 12-month follow-up period (2006-2007).ACT was associated with significantly lower inpatient but higher outpatient costs than standard care, resulting in nonsignificantly lower total costs (P = .27). Incremental QALYs in the ACT group were 0.1 (P.001). Thus, the point estimate for the ICER showed dominance of ACT. The probability of an ICER below €50,000 per QALY gained was 99.5%.The implementation of a psychotherapeutically oriented schizophrenia-specific and -experienced ACT team led to an improved patient outcome with reduced need of inpatient care. Despite the introduction of such a rather "costly" ACT team, treatment in ACT was cost-effective with regard to improved quality of life at comparable yearly costs.ClinicalTrials.gov identifier: NCT01081418.

OBJECTIVE The aim of this study was to estimate the potential bias by personality traits for ratings on the Positive and Negative Syndrome Scale (PANSS). METHODS Personality dimensions (five factor model), personality traits (SCID-II) and PANSS scores were assessed prospectively in 45 patients with schizophrenia spectrum disorders (SSD). RESULTS Borderline (r=0.34; p=0.021), avoidant (r=0.66; p

The ACCESS trial examined the 12-month effectiveness of continuous therapeutic assertive community treatment (ACT) as part of integrated care compared to standard care in a catchment area comparison design in patients with schizophrenia spectrum disorders treated with quetiapine immediate release.Two catchment areas in Hamburg, Germany, with similar population size and health care structures were assigned to offer 12-month ACT as part of integrated care (n = 64) or standard care (n = 56) to 120 patients with first- or multiple-episode schizophrenia spectrum disorders (Structured Clinical Interview for DSM-IV Axis I Disorders criteria); multiple-episode patients were restricted to those with a history of relapse due to medication nonadherence. The primary outcome was time to service disengagement. Secondary outcomes comprised medication nonadherence, improvements of symptoms, functioning, quality of life, satisfaction with care from patients' and relatives' perspectives, and service use data. The study was conducted from April 2005 to December 2008.17 of 120 patients (14.2%) disengaged with service, 4 patients (6.3%) in the ACT and 13 patients (23.2%) in the standard care group. The mean Kaplan-Meier estimated time in service was 50.7 weeks in the ACT group (95% CI, 49.1-52.0) and 44.1 weeks in the standard care group (95% CI, 40.1-48.1). This difference was statistically significant (P = .0035). Mixed models repeated measures indicated larger improvements for ACT compared to standard care regarding symptoms (P. 01), illness severity (P. 001), global functioning (P. 05), quality of life (P. 05), and client satisfaction as perceived by patients and family (both P. 05). Logistic regression analyses revealed that ACT was associated with a higher likelihood of being employed/occupied (P = .001), of living independently (P = .007), and of being adherent with medication (P. 001) and a lower likelihood of persistent substance misuse (P = .027).Compared to standard care, intensive therapeutic ACT as part of integrated care could improve 1-year outcome. Future studies need to address in which settings these improvements can be sustained.clinicaltrials.gov Identifier: NCT01081418.

OBJECTIVE Overview on the current knowledge concerning sexual dysfunctions in patients with schizophrenia and implications for treatment, compliance, quality of life and partnership. METHOD Selective literature research on classification, occurrence, effects and therapy. RESULTS Frequency and subjective distress of sexual problems in patients with schizophrenia are widely underestimated. Pharmacogenic and morbogenic causes of the sexual problems are often difficult to differentiate. The low awareness of health care professionals for sexual problems and their persistence have significant negative impact on patients' satisfaction with the treatment, compliance, quality of life and partnership. CONCLUSIONS It is important to consider patients' sexuality as an integral part of a treatment approach to achieve compliance and mental stabilization as well as an improvement in quality of life.

Purpose of review To give an overview of recent developments in neuroimaging in psychiatry and on the current discussion about the relationship between theoretical concepts and data from neuroimaging studies. Recent findings In psychiatric neuroimaging, broad concepts such as the self, well being, insight, empathy and volition form an integral part of the questions to be answered and cannot be avoided. Although, currently, the intradisciplinary discussion in neuroscience is mainly focused at the methodological and neurobiological level, psychological and philosophical theories are also needed for the interpretation of results. This raises questions regarding the epistemic priority of neuroimaging data and theories. Summary In the current paper, we present the hypothesis that there is an interdependence of neuroimaging data and theoretical concepts. An approach to ‘correlational neuroscience’ with an awareness of this issue may help in avoiding misunderstandings and oversimplifications as well as building an interdisciplinary theoretical framework that is able to integrate findings from life sciences, mind sciences and humanities.

INTRODUCTION: Agitation is a common phenomenon in schizophrenia or acute mania. Because of the inability of patients to give informed consent in such situations, data from consenting studies are limited. METHODS: This observational prospective 5-day study evaluated the effectiveness of olanzapine in a sample of highly agitated patients with aggression. Primary endpoint was mean change of the PANSS-Excited Component (PANSS-EC) score. RESULTS: Mean PANSS-EC score at baseline was 25.5 points, 60.2% were severely agitated and 41.6% severely aggressive. A significant decrease in PANSS-EC total score (−13.3 points) was observed with rapid dose escalation and an average daily dose of 21.2 mg/day of olanzapine. 40 patients (24.1%) required treatment with another antipsychotic and 21 patients (12.7%) were not treated with olanzapine at day 5. At endpoint, 64.2% of patients were in remission of agitation. PANSS-EC reduction was not significantly different in patients with or without concurrent benzodiazepine use. DISCUSSION: Severe agitation with aggression may be well controlled with olanzapine in many cases, possibly by higher initial and overall doses of olanzapine. Controlled studies are needed to confirm these findings.

Incomplete remission and treatment resistance are common even in first-episode psychosis patients.The aim of this review was to provide an overview of the available interventions and treatment pathways for the management of incomplete remission and treatment resistance in first-episode psychosis.The review undertook a computerized and manual literature search for relevant articles published within recent years.Standard therapy has to be optimized in order to prevent treatment non-response. The early detection strategies of incomplete remission and treatment resistance include re-evaluation of the diagnosis and optimization of pharmacological and non-pharmacological interventions including the treatment of co-morbid disorders. If partial or non-response is confirmed, pharmacological and psychosocial treatment adaptations should be applied stepwise as presented in the current review. Interventions have to be offered in a timely manner because early adaptation of treatment is associated with a greater probability of remission.

Objective Clinical management of aggression depends on the availability of easily administrable measurements allowing reliable evaluation. The present study's aim is to validate a Clinical Global Impression-Severity of Aggression scale (CGI-A). Method 558 inpatients with psychiatric disorders and an agitated–aggressive syndrome at baseline were continuously assessed over 5 days using CGI-A and the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC). Equipercentile linking, correlation analyses and linear regression were applied. Results Relationship between CGI-A and PANSS-EC total score was found to be linear. On a 5-level CGI-A scale, values of 1 to 5 points were found to correspond to PANSS-EC scores of 12.2, 16.7, 21.3, 25.8, and 30.4, respectively (average increase: 4.6). All findings remained stable when only data from patients with schizophrenia spectrum disorders were analyzed. Conclusions The CGI-A is proposed as a quickly administrable scale for the assessment of patients' aggressiveness.

Early psychosis represents a distinct period in which specific guidelines for the use of antipsychotic medications apply. Individuals with a first episode of psychosis are typically drug-naive and while they tend to respond to lower doses, they are also more sensitive to side effects. As a result of this, guidelines for the use of antipsychotic medication in early psychosis have been developed and provide guidance on their appropriate use, such as the concept of ‘start low, go slow'. While the introduction of second-generation antipsychotic medications led to a reduction in the side effects traditionally associated with the earlier first-generation antipsychotic medication such as extrapyramidal side effects and tardive dyskinesia, they are associated with different side effects, such as metabolic syndrome and sexual dysfunction. Adherence to antipsychotic medication is low, often below 50%, and the reasons for this are multifactorial and include insight, attitudes towards medication and engagement. There is a lack of clarity as to how long individuals who have remitted from a first episode of psychosis should remain on antipsychotic medication. High relapse rates have been observed following the discontinuation of antipsychotic medication; however, there is emerging evidence that earlier discontinuation could be associated with higher functioning in the longer term. This chapter will first introduce the general underlying mechanism of action associated with antipsychotic medication and will broadly discuss the effectiveness of the different antipsychotic medications. International guidelines specific for the use of antipsychotic medication in early psychosis have been developed and the general principles of these guidelines and recommendations specific to certain guidelines will be outlined. There are a wide range of side effects associated with antipsychotic medications; however, two particular side effects will be discussed, namely metabolic syndrome and sexual dysfunction, as they are highly prevalent with the newer second-generation antipsychotic medications. These side effects, in addition to other factors, contribute to the low adherence rates in early psychosis. The clinical dilemma of how long antipsychotic medication should be continued in individuals who have remitted from a first episode of psychosis will be discussed. Finally, the current controversy of whether antipsychotic medication could be responsible for changes in brain structure will be reviewed.

Despite increasing interest in global mental health training opportunities, only a few psychiatry residency programs offer global mental health training experiences in developing countries and even fewer programs offer it in other first-world countries. The authors developed a global mental health elective giving US psychiatry residents the opportunity to visit Switzerland to study and experience the mental health care system in this European country. This elective focuses on four major learning objectives: (1) the system of training and curriculum of postgraduate psychiatry education in Switzerland, (2) clinical and organizational aspects of Swiss mental health, (3) administrative aspects of Swiss mental health care delivery, and (4) scholarly activity. This program was uniquely tailored for psychiatry residents. The preliminary experiences with US psychiatry residents show that they value this learning experience, the opportunity to access a different mental health care system, as well as the potential to build international connections with peers.

We assessed both current maladaptive personality traits (MPTs) and, retrospectively, premorbid MPTs in patients with schizophrenia spectrum disorders (SSDs). This was to examine whether the patients had the impression that their personality had changed and which traits were affected. We also wanted to determine whether the perceived changes could be explained by SSD psychopathology. MPTs were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses, axis II disorders, screening questionnaire and interview, integrating questions on subjective estimation of premorbid MPTs in moderately ill SSD patients. Forty-five patients were included. Premorbid MPTs were remembered as significantly less pronounced than current MPTs for the whole spectrum of personality traits (p < 0.001). Antisocial traits had worsened significantly less (p < 0.001), and borderline and obsessive-compulsive traits had worsened significantly more (both p < 0.01) than the mean increase. Associations between MPT increase and SSD psychopathology were significant for schizotypal, avoidant, and depressive traits. According to the patients' retrospective assessment, MPTs increased through onset and course of SSDs. Memory bias, depressed mood, and SSD symptoms alone could not sufficiently explain these differences. Subjective MPT increase may play a role for the patients' concept of illness, quality of life, and adherence to therapeutic interventions. It should be addressed in SSD treatment.

article i nfo Background: Aggression and suicidality prior to the initiation of treatment are frequent phenomena in psychosis patients.IncreasedscoresintheBriefPsychiatric Rating Scale ExcitedComponent(BPRS-EC)have beenshownto predict involuntary treatment, aggression, and suicide in first-episode psychosis (FEP) patients. However, it is unclear if an agitated-aggressive syndrome as measured with the BPRS-EC is already present in at-risk mental state (ARMS). Methods: BPRS-EC scores from 43 ARMS patients, 50 FEP patients, and 25 healthy controls (HC) were analyzed. Multivariate analyses were performed to review if group differences were mediated by potential confounders. In addition, the association of BPRS-EC scores with clinical variables was examined. Results: BPRS-EC scores were significantly different across diagnostic groups (H(2) = 22.1; p b .001), and post- hoc analyses showed significantly higher BPRS-EC scores for ARMS (p = .001) and for FEP patients (p b .001) compared to HC. Differences remained significant after controlling for gender, years of education, and intelli- gence. No significant differences emerged between ARMS and FEP patients. BPRS-EC was significantly correlated with lower intelligence (r = −.27; p = .008), reduced level of functioning (r = −.44; p b .001), and with smoking behavior (r =. 22;p =. 019). Conclusions: ARMS and FEP patients in our sample had significantly higher BPRS-EC scores compared to HC. This may constitute a correlate of an agitated-aggressive syndrome and an increased risk for aggression and suicidality.

Structure and function are closely related in the healthy human brain. In patients with chronic heroin exposure brain imaging studies have identified long lasting changes in gray matter (GM) volume. More recently we showed that acute application of heroin in dependent patients results in hypoperfusion of fronto temporal areas compared with the placebo condition. However the relationship between structural and cerebral blood flow (CBF) changes in heroin addiction has not yet been investigated. Moreover it is not known whether there is any interaction between the chronic structural changes and the short and long term effects on perfusion caused by heroin. Using a double blind within subject design heroin or placebo (saline) was administered to 14 heroin dependent patients from a stable heroin assisted treatment program in order to observe acute short term effects. Arterial spin labeling (ASL) was used to calculate perfusion quantification maps in both treatment conditions while Voxel Based Morphometry (VBM) was conducted to calculate regional GM density. VBM and ASL data were used to calculate homologous correlation fields by Biological Parametric Mapping (BPM) and a whole brain Pearson r correlation. We correlated each perfusion condition (heroin and placebo) separately with a VBM sample that was identical for the two treatment conditions. It was assumed that heroin associated perfusion is manifested in short term effects while placebo associated perfusion is more related to long term effects. In order to restrict our analyses to fronto temporal regions we used an explicit mask for our analyses. Correlation analyses revealed a significant positive correlation in frontal areas between GM and both perfusion conditions (heroin and placebo). Heroin associated perfusion was also negatively correlated with GM in the inferior temporal gyrus on both hemispheres. These findings indicate that in heroin dependent patients low GM volume is positively associated with low perfusion within frontal regions.