Search

Zusammenfassung Ziel der Studie Überprüfung der Wirksamkeit einer stationsäquivalenten psychiatrischen Behandlung (StäB) im Vergleich mit einer vollstationären psychiatrischen Routinebehandlung. Methodik Im Rahmen einer retrospektiven Verlaufsstudie wurden 43 Patient*innen aus der StäB (Interventionsgruppe/IG, n = 43) mit einer gematchten vollstationären Kontrollgruppe (KG, n = 43) hinsichtlich vollstationärer Wiederaufnahmerate und Behandlungstage im 12-Monats-Follow-up verglichen. Ergebnisse Bei den Patient*innen der IG zeigte sich eine um etwa 9 % geringere Wiederaufnahmerate in die vollstationäre Behandlung. Im 12-Monats-Follow-up zeigte sich in dieser Gruppe eine um etwa 30 % längere vollstationäre Behandlungsdauer. Beide Gruppenunterschiede waren statistisch nicht signifikant. Schlussfolgerung Die vorliegende Studie deutet darauf hin, dass StäB hinsichtlich des Wiederaufnahmerisikos einer stationären Behandlung nicht unterlegen ist.

ZUSAMMENFASSUNGDie stationsäquivalente Behandlung (StäB) ist eine besondere Form des international anerkannten und evidenzbasierten Home-Treatment. Als komplexe Intervention erfordert StäB im deutschen Kontext eine Evaluation auf unterschiedlichen Ebenen. Die quasi-experimentelle „AKtiV-Studie“ mit Propensity-Score-gematchter Kontrollgruppe entspricht dieser Forderung. Sie hat eine Laufzeit von 36 Monaten und wird vom Innovationsfonds des Gemeinsamen Bundesausschuss gefördert. In diesem Zeitraum werden neben der Untersuchung klassisch klinischer Endpunkte wie der stationären Wiederaufnahmerate, der Psychopathologie und Recovery-orientierten auch Fragen hinsichtlich der geeigneten Zielpopulationen, Implementierungsbedingungen, Behandlungsprozessen und Wirkfaktoren beantwortet. Dabei werden sowohl die Perspektiven von Patienten, Angehörigen und Mitarbeitenden als auch die Standpunkte und Erfahrungen von Akteuren aus Politik und Selbstverwaltung eruiert. Damit kann erwartet werden, dass die Studienergebnisse für ein breites Publikum interessant sein und zur praxiswirksamen Weiterentwicklung des StäB-Modells beitragen können. Im vorliegenden Artikel wird das Mixed-Methods-Design der AktiV-Studie vorgestellt und diskutiert.

Akutbehandlung im hauslichen Umfeld (AHU) und intensiv-aufsuchende Behandlung (IAB) werden von der Deutschen Gesellschaft fur Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e.V. (DGPPN) aufgrund internationaler randomisierter Studien (RCTs) mit dem hochsten Evidenzgrad empfohlen. Die Ubertragbarkeit internationaler Befunde auf die Versorgungssysteme in Deutschland, Osterreich und der Schweiz konnte jedoch eingeschrankt sein, da sich nationale Gesundheitssysteme stark voneinander unterscheiden. Auswertung der Studienlage zu aufsuchenden psychiatrischen Behandlungsformen in Deutschland, Osterreich und der Schweiz sowie eine Diskussion der Ergebnisse im Kontext internationaler Befunde. Systematische Literaturrecherche in der Datenbank PubMed zu klinischen Studien zu aufsuchenden Behandlungsformen aus Deutschland, Osterreich und der Schweiz. Es konnten 19 Publikationen identifiziert werden, von denen sich 5 Publikationen zu 4 Studien mit insgesamt 2857 Patienten der AHU und 14 Publikationen zu 10 Studien mit insgesamt 3207 Patienten der IAB zuordnen liesen. In den Studien zu AHU zeigten sich positive Werte bez. stationarer Behandlungsdauer und Kosten zugunsten der AHU. In den Studien zu IAB zeigten sich im Vergleich zu den jeweiligen Kontrollbedingungen positive Werte bez. Symptomatik, Krankheitsschwere, Substanzmissbrauch, Funktionsniveau, Remission, Behandlungszufriedenheit, Lebensqualitat, Kosten, Arbeits- und Wohnsituation. Da die vorliegenden Studien hinsichtlich vieler Parameter auf eine Uberlegenheit aufsuchender Behandlung hindeuten, gibt es keine Hinweise, dass international gut abgesicherte Befunde fur Deutschland, Osterreich und die Schweiz nicht gelten konnten. Zudem zeigte sich, dass mit je einer RCT fur AHU und IAB ein Evidenzgrad von mindestens 1b fur aufsuchende Behandlung in den fokussierten Versorgungssystemen vorliegt.

Zusammenfassung Ziel Untersucht werden die Bedingungen und Hürden der Einführung von Stationsäquivalenter Behandlung nach § 115d SGB V (StäB). Methode Qualitative Analyse von Interviews und Fokusgruppen mit Mitarbeitenden (n = 43) an 11 psychiatrischen Kliniken in Berlin/Brandenburg. Ergebnisse Auf Systemebene wird die Implementierung u. a. durch eine inadäquate Leistungsdefinition, fehlende Vorgaben auf Landesebene, Personalmangel und MDK-Prüfungen erschwert. Dies führt bei Kliniken zu zurückhaltender Umsetzung mit teilweise unzureichender personeller Ausstattung der StäB-Teams. Weitere Barrieren betreffen das Fehlen mobiler Lösungen zur Dokumentation und Teamkommunikation. Auf Ebene der Mitarbeitenden wirken sich ein Mangel an Information und Kooperation sowie unklare Aufgaben und Rollen hinderlich aus. Schlussfolgerungen Für eine bedürfnisorientierte, flexible und flächendeckende Einführung von StäB sind Nachbesserungen an den Rahmenbedingungen sowie weitere Forschung zur Wirksamkeit und Implementierung notwendig.

Schwere psychische Erkrankungen sind oft mit erheblichen Beeintrachtigungen psychosozialer Funktionen und hohen Risiken sozialer Exklusion verbunden. Deshalb sind psychosoziale Interventionen neben somatischen und psychotherapeutischen Behandlungsansatzen ein integraler Bestandteil der Behandlung. Psychosoziale Therapien zielen auf eine verbesserte Teilhabe und ein weitestgehend selbstbestimmtes Leben. Die vorliegende Arbeit gibt einen Uberblick uber den Aufbau und die Empfehlungen der diagnoseubergreifenden DGPPN-S3-Leitlinie „Psychosoziale Therapien bei schweren psychischen Erkrankungen“. In der DGPPN-S3-Leitlinie werden psychosoziale Therapien erstmals systematisiert beschrieben und auf Grundlage einer systematischen Aufbereitung wissenschaftlicher Evidenz und eines formalisierten Konsensprozesses Empfehlungen formuliert. Es werden insgesamt 33 Empfehlungen und 12 Statements formuliert. Fur viele der psychosozialen Interventionen liegt eine breite Evidenzbasis vor. Mit der hochsten Empfehlungsstarke (A) werden im Bereich der Einzelinterventionen Psychoedukation, das Training sozialer Fertigkeiten sowie gesundheitsfordernde Interventionen empfohlen. Im Bereich der Systeminterventionen werden teambasierte, multiprofessionelle gemeindepsychiatrische Ansatze, „supported employment“ (unterstutzte Beschaftigung) und ein selbstbestimmtes Wohnen mit mobiler Unterstutzung als A‑Empfehlung gegeben. Fur andere Interventionen ist die aktuelle Evidenzbasis weniger robust. Der Umsetzungserfolg einer Leitlinie ist nicht nur von deren Qualitat, sondern auch von deren Verbreitung abhangig. Neben der Behandlungsleitlinie wurden auch eine Kurz-, eine Patienten- sowie eine Wartezimmerversion entwickelt.

Purpose This study (a) assessed quality of life (QoL) in a patient sample with severe mental illness in an integrated psychiatric care (IC) programme in selected regions in Germany, (b) compared QoL among diagnostic groups and (c) identified socio-demographic, psychiatric anamnestic and clinical characteristics associated with QoL. Methods This cross-sectional study included severely mentally ill outpatients with substantial impairments in social functioning. Separate dimensions of QoL were assessed with the World Health Organisation’s generic 26-item quality of life (WHOQOL-BREF) instrument. Descriptive analyses and analyses of variance (ANOVAs) were conducted for the overall sample as well as for diagnostic group. Results A total of 953 patients fully completed the WHOQOL-BREF questionnaire. QoL in this sample was lower than in the general population (mean 34.1; 95% confidence interval (CI) 32.8 to 35.5), with the lowest QoL in unipolar depression patients (mean 30.5; 95% CI 28.9 to 32.2) and the highest in dementia patients (mean 53.0; 95% CI 47.5 to 58.5). Main psychiatric diagnosis, living situation (alone, partner/relatives, assisted), number of disease episodes, source of income, age and clinical global impression (CGI) scores were identified as potential predictors of QoL, but explained only a small part of the variation. Conclusion Aspects of health care that increase QoL despite the presence of a mental disorder are essential for severely mentally ill patients, as complete freedom from the disorder cannot be expected. QoL as a patient-centred outcome should be used as only one component among the recovery measures evaluating treatment outcomes in mental health care.

Background: The model for integrated care (IC) of those seriously mentally ill patients insured with the DAK-Gesundheit health insurance and various Betriebskrankenkassen (members of the VAG Mitte) from the regions Berlin, Brandenburg, Lower Saxony and Bremen allows a complex treatment in the outpatient setting which consists of psychiatrists, general practitioners and clinicians, psychiatric nursing, sociotherapy (only in Berlin), internal medicine quality circles, orientation on treatment guidelines and conceptual consensus with the relevant care clinics. The aim of the evaluation is to illustrate the health economic effects of IC. Methods: In the period from 2006 to 2010 insured members of the DAK-Gesundheit and other involved health insurance companies with a serious mental illness, a significant impairment of social functioning and the need to be treated to avoid or substitute an in-hospital stay were included in the integrated care. The cost perspective was that of the statutory health insurance companies. For the health economic evaluation, the utilisation of continuous IC over 18 months was compared to the last 18 months prior to the inclusion in IC. The clinical findings were gathered quarterly during the IC using CGI (Clinical Global Impressions) and GAF (Global Assessment of Functioning Scale). Results: A total of 1 364 patients receiving IC in 66 doctor's practices were documented (of those, 286 had diagnoses of ICD-10 F2, 724 ICD-10 F32-F39). The median age was 48.8 years, 69% were female. 24% had their own source of income, 40% were on the pension, and the rest of the patients were receiving transfer benefits in some form. In 54% of the cases IC was used to avoid an in-hospital stay, in 46% of the cases to substitute an in-hospital stay. The degree of the CGI was 5.5 on average at the time of inclusion and the GAF score was 36.5 on average. The 226 patients with continuous documentation over 18 months were included in the health economic analysis. The number of days spent in hospital was lower during the IC period as compared to the 18 months prior to IV (11.8 vs. 28.6 days, p, Hintergrund: Das Modell der Integrierten Versorgung (IV) schwer psychisch Kranker f��r Versicherte der DAK-Gesundheit und verschiedener Betriebskrankenkassen (Mitglieder der BKK VAG Mitte) der Regionen Berlin, Brandenburg, Niedersachsen und Bremen erm��glicht eine ambulante Komplexbehandlung bestehend aus psychiatrischen Fach��rzten, Haus- und Klinik��rzten, psychiatrischer Fachpflege, Soziotherapie (nur Berlin), inner��rztliche Qualit��tszirkelarbeit, Orientierung an Behandlungspfaden und konzeptioneller Abstimmung mit den zust��ndigen Versorgungskliniken. Ziel der Evaluation war die Darstellung der gesundheits��konomischen Auswirkungen der IV. Methodik: Im Zeitraum zwischen 2006 und 2010 wurden Versicherte der DAK-Gesundheit und der beteiligten Betriebskrankenkassen mit einer schweren psychischen Erkrankung, einer deutlichen Beeintr��chtigung des sozialen Funktionsniveaus und der Erfordernis einer krankenhausvermeidenden oder krankenhausersetzenden Behandlung in die IV eingeschlossen. Die Kostenperspektive war diejenige der Gesetzlichen Krankenversicherung. F��r die gesundheits��konomische Auswertung wurde die Inanspruchnahme ��ber 18 Monate kontinuierliche IV-Behandlung mit den letzten 18 Monaten vor Einschluss in die IV verglichen. Der klinische Befund wurde w��hrend der IV quartalsweise mit globaler Schweregrad- (CGI) und Funktionsbeurteilung (GAF) erhoben. Ergebnisse: Insgesamt wurden 1.364 Patienten mit IV-Behandlung in 66 Arztpraxen dokumentiert (davon 286 ICD-10 F2, 724 ICD-10 F32-F39). Das Durchschnittsalter betrug 48,8 Jahre, 69 % waren weiblich. 24 % verf��gten ��ber ein eigenes Einkommen, 40 % bezogen Rente, die ��brigen Patienten Transferleistungen verschiedener Art. In 54 % der F��lle wurde IV klinikvermeidend, in 46 % klinikersetzend eingesetzt. Der CGI-Schweregrad betrug bei Einschluss durchschnittlich 5,4, der GAF-Score 36,5. In die gesundheits��konomische Analyse wurden die 226 Patienten mit kontinuierlicher Dokumentation ��ber 18 Monate eingeschlossen. Die Anzahl der Krankenhaustage war in 18 Monaten w��hrend IV niedriger als in 18 Monaten vor IV (11,8 vs. 28,6 Tage, p < 0,001), die Ausgaben f��r station��re Behandlung signifikant geringer (5.929 �� 13.837 Euro vs. 2.458 �� 6.940 Euro, p < 0,001), die Gesamtausgaben ver��nderten sich jedoch nicht signifikant (7.777 �� 14.263 Euro vs. 7.321 �� 7.910 Euro, p = 0,65). Die erhebliche Einsparung bei den station��ren Ausgaben wurde durch die Mehrausgaben bei Medikamenten und die Ausgaben der ambulanten Komplexleistungen kompensiert. Analoge Ergebnisse erbrachte die Analyse der 2 Subgruppen der Patienten mit Schizophrenie/ schizoaffektiver St��rung (n = 66, 40,9 vs. 17,9 Tage, p = 0,03; station��re Ausgaben 9.009 �� 15.677 Euro vs. 3.650 �� 8.486 Euro, p = 0,02; Gesamtausgaben 11.789 �� 15.975 Euro vs. 9.623 �� 9.262 Euro, p = 0,33) und mit unipolarer Depression (n = 90, 29,8 vs. 9,8 Tage, p = 0,006; station��re Ausgaben 5.664 �� 14.921 Euro vs. 1.967 �� 5.276 Euro, p = 0,02; Gesamtausgaben 7.146 �� 15.164 Euro vs. 6.234 �� 6.292 Euro, p = 0,57). Schlussfolgerung: Das IV-Modell konnte durch ein komplexes ambulantes Leistungsangebot die station��re Inanspruchnahme deutlich senken und eine Gewichtsverlagerung in eine niedrigschwellige umfassende Versorgungsstruktur realisieren, ohne dass dies aus GKV-Perspektive mit einer Kostensteigerung verbunden war. F��r eine detaillierte Darstellung klinischer Effekte sind weitere Studien erforderlich.

Zusammenfassung Ziel der Studie Verglichen wurde die klinische Wirksamkeit von „Home Treatment“ (HT) zusammen mit intensiver ambulanter Behandlung (IAB) im Modellprojekt „FlexiTeam“ (FT) mit einer stationär-psychiatrischen Routinebehandlung. Methodik Im Rahmen einer kontrollierten gematchten Vorher-Nachher-Studie wurden Routinedaten von jeweils 83 Patienten im FT und in der stationär-psychiatrischen Routinebehandlung hinsichtlich (teil-)stationärer Wiederaufnahmerate und Verweildauer im 6- und 12-Monats-Follow-up verglichen. Ergebnisse Es zeigt sich keine signifikante Reduktion der (teil-)stationären Verweildauer im Index-Aufenthalt. Durch die Behandlung im FT konnte eine signifikante Reduktion sowohl der (teil-)stationären Wiederaufnahmerate als auch der Verweildauer im 6- und 12-Monats-Follow-up erreicht werden. Schlussfolgerung Eine flexible Kombination aus IAB und HT stellt eine wirksame Ergänzung zur stationär-psychiatrischen Routinebehandlung dar und kann bei geeigneten Patienten das Risiko stationärer Wiederaufnahmen senken.

Background Coercive measures are among the most controversial interventions in psychiatry. There is a large discrepancy between the sheer number of high-quality guidelines and the small number of scientifically accompanied initiatives to promote and evaluate their implementation into clinical routine. In Germany, an expert group developed guidelines to provide evidence- and consensus-based recommendations on how to deal with violence and coercion in psychiatry. Methods The study presented examines whether coercive measures on psychiatric wards can be reduced by means of an operationalized implementation of the guidelines “Prevention of coercion: prevention and therapy of aggressive behavior in adults”. Out of a set of 12 interventions offered, wards are free to choose three interventions they want to implement. The primary outcome is the number of coercive measures per bed and month/year. Secondary outcomes are cumulative duration of coercive measures per bed and month/year. The most important control variable is the number of aggressive incidents. We plan to recruit 52 wards in Germany. Wards treating both voluntary and compulsorily admitted patients will be included. A 1:1 stratified randomized controlled trial will be conducted stratified by the amount of coercive measures and implemented aspects of the guidelines. In addition to the control group analysis, a waiting list design allows a pre-post analysis for all participating wards of the waiting list group. A parallel qualitative study will examine factors related to successful implementation and to successful reduction of coercion as well as relevant barriers. Discussion We are planning a nationwide study on the implementation of evidence- and consensus-based guidelines in psychiatric hospitals. This study intends to promote the transfer of expert knowledge as well as results from clinical trials into clinical routine with the potential to change supply structures in mental health sector. Clinical Trial Registration www.isrctn.com, identifier ISRCTN71467851., publishedVersion

Zusammenfassung Einleitung Schwere psychische Erkrankungen sind mit besonderen Belastungen und Risiken für die Betroffenen und deren Angehörige verbunden. Psychosoziale Therapien sind eine zentrale Säule der Behandlung. Material & Methoden Im Update der S3-Leitlinie „Psychosoziale Therapien bei schweren psychischen Erkrankungen“ werden auf der Basis aktueller wissenschaftlicher Evidenz und strukturierter Konsensfindung in einem repräsentativen Leitliniengremium umfassende Empfehlungen zur psychosozialen Behandlung gegeben. Ergebnisse Das Update der Leitlinie umfasst 33 Empfehlungen und 12 Statements in den Bereichen der System- und Einzelinterventionen (z. B. zu Arbeit, Wohnen und Psychoedukation) sowie zu Ansätzen der Selbsthilfe (z. B. zu Selbstmanagement und Peer-Arbeit) sowie zu Aspekten, die die Ausrichtung des täglichen Handelns aller Beteiligten umfassen (z. B. zu Recovery). Ein sogenanntes Matrixkapitel wird den Besonderheiten des deutschen Versorgungssystems gerecht. Diskussion Es liegt international umfassende wissenschaftliche Evidenz zu verschiedenen psychosozialen Interventionen vor, die Chancen auf eine verbesserte soziale und berufliche Teilhabe für Betroffene eröffnet. Die Implementierung von Leitlinien ist ein wichtiges Entwicklungsfeld, um das Wissen und die Empfehlungen praxiswirksam werden zu lassen.

Over the last decades, many high-income countries have successfully implemented assertive outreach mental health services for acute care. Despite evidence that these services entail several benefits for service users, Germany has lagged behind and has been slow in implementing outreach services. In 2018, a new law enabled national mental health care providers to implement team-based crisis intervention services on a regular basis, allowing for different forms of Inpatient Equivalent Home Treatment (IEHT). IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user’s home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity. The presented naturalistic, quasi-experimental cohort study will evaluate IEHT in ten hospitals running IEHT services in different German regions. Within a multi-method research approach, it will evaluate stakeholders’ experiences of care, service use, efficacy, costs, treatment processes and implementation processes of IEHT from different perspectives. Quantitative surveys will be used to recruit 360 service users. Subsequently, 180 service users receiving IEHT will be compared with 180 matched statistical ‘twins’ receiving standard inpatient treatment. Assessments will take place at baseline as well as after 6 and 12 months. The primary outcome is the hospital re-admission rate within 12 months. Secondary outcomes include the combined readmission rate, total number of inpatient hospital days, treatment discontinuation rate, quality of life, psycho-social functioning, job integration, recovery, satisfaction with care, shared decision-making, and treatment costs. Additionally, the study will assess the burden of care and satisfaction with care among relatives or informal caregivers. A collaborative research team made up of researchers with and without lived experience of mental distress will conduct qualitative investigations with service users, caregivers and IEHT staff teams to explore critical ingredients and interactions between implementation processes, treatment processes, and outcomes from a stakeholder perspective. By integrating outcome, process and implementation research as well as different stakeholder perspectives and experiences in one study, this trial captures the various facets of IEHT as a special form of home treatment. Therefore, it allows for an adequate, comprehensive evaluation on different levels of this complex intervention. Trial registrations: 1) German Clinical Trials Register (DRKS), DRKS000224769. Registered December 3rd 2020, https://www.drks.de/drks_web/setLocale_EN.do ; 2) ClinicalTrials.gov, Identifier: NCT0474550 . Registered February 9th 2021.

Hintergrund Im Rahmen psychosozialer Interventionen fur psychisch kranke Menschen nehmen Wohnangebote eine Schlusselposition ein. Welche Evidenz gibt es hinsichtlich deren Effektivitat? Methode Systematische Literaturrecherche nach randomisierten kontrollierten Studien (RCTs). Ergebnisse Wenige RCTs, vornehmlich mit Wohnungslosen, wurden identifiziert. Wohninterventionen in Form unabhangigen Wohnens mit Unterstutzung (Supported Housing) bei Wohnungslosen fuhren zu groserer Wohnstabilitat. Aussagen zur Effektivitat verschiedener Wohninterventionen im Vergleich lassen sich kaum treffen. Schlussfolgerungen Mit dem Begriff des Supported Housing wurde ein Paradigmenwechsel eingelautet. Es besteht erheblicher Forschungsbedarf, insbesondere fur schwer psychisch Kranke, die nicht explizit von Wohnungslosigkeit bedroht sind.

Introduction: Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The Safewards Model is an evidence-informed conflict-reduction strategy to prevent and reduce such incidents. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care. Materials and Methods: We evaluated outcomes of the implementation of the Safewards Model in two locked psychiatric wards in Germany. Frequency and duration of coercive interventions applied during a period of 10 weeks before and 10 weeks after the implementation period were assessed through routine data. Fidelity to the Safewards Model was assessed by the Organization Fidelity Checklist. Results: Fidelity to the Safewards Model was high in both wards. The overall use of coercive measures differed significantly between wards [case-wise: χ2 (1, n = 250) = 35.34, p ≤ 0.001; patient-wise: χ2 (1, n = 103) = 21.45, p ≤ 0.001] and decreased post-implementation. In one ward, the number of patients exposed to coercive interventions in relation to the overall number of admissions decreased significantly [χ2 (1, 182) = 9.30, p = 0.003]. Furthermore, the mean duration of coercive interventions overall declined significantly [U(55,21) = −2.142, p = 0.032] with an effect size of Cohen’s d = −0.282 (95% CI: −0.787, 0.222) in that ward. Both aspects declined as well in the other ward, but not significantly. Discussion: Results indicate that the implementation of the Safewards interventions according to the model in acute psychiatric care can reduce coercive measures. They also show the role of enabling factors as well as of obstacles for the implementation process.

Ziele der Studie Die vorliegende Studie uberprufte anhand einer Kohorte (n = 85) die Anwendbarkeit eines Indikatorensets fur die Integrierte Versorgung von Menschen mit Schizophrenie. Methoden Erste Kennzahlen zu Basis- und Qualitatsindikatoren wurden anhand von Routine- und Primardaten ermittelt. Ergebnisse Fur 4 Indikatoren liegen Zielwerte vor, die zum Teil deutlich verfehlt wurden. Die Indikatoren fur antipsychotische Polypharmazie, psychotherapeutische Behandlung und Kontinuitat psychiatrischer Behandlung nach Entlassung aus der Klinik zeigen eine geringe Leitlinienkonformitat. Schlussfolgerung Die Studie zeigt, dass die Erhebung von Qualitatsindikatoren moglich ist, weist aber auch auf die Grenzen hinsichtlich der Machbarkeit, Anderungssensitivitat und Validierung hin.

The burden of severe and persistent mental illness is high. Beside somatic treatment and psychotherapeutic interventions, treatment options for patients with severe mental illness also include psychosocial interventions. This paper summarizes the results of a number of systematic literature searches on psychosocial interventions for people with severe mental illness. Based on this evidence appraisal, recommendations for the treatment of people with severe mental illness were formulated and published in the evidence-based guideline series of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) as an evidence-based consensus guideline ("S3 guideline"). Recommendations were strongly based on study results, but used consensus processes to consider external validity and transferability of the recommended practices to the German mental healthcare system. A distinction is made between system-level interventions (multidisciplinary team-based psychiatric community care, case management, vocational rehabilitation and participation in work life and residential care interventions) and single psychosocial interventions (psychoeducation, social skills training, arts therapies, occupational therapy and exercise therapy). There is good evidence for the efficacy of the majority of psychosocial interventions in the target group. The best available evidence exists for multidisciplinary team-based psychiatric community care, family psychoeducation, social skills training and supported employment. The present guideline offers an important opportunity to further improve health services for people with severe mental illness in Germany. Moreover, the guideline highlights areas for further research.

Kunstlerische Therapien bilden neben anderen psychosozialen Interventionen ein wichtiges Element im Rahmen multimodaler Behandlungskonzepte fur Menschen mit psychischen Storungen. Der Beitrag fasst die systematisch recherchierte Evidenz zusammen und stellt die Empfehlungen dar, die im Rahmen der S3-Leitlinie „Psychosoziale Therapien bei Menschen mit schweren psychischen Storungen“ der Deutschen Gesellschaft fur Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) erarbeitet wurden. Die Studien zeigen, dass die zusatzliche Anwendung kunstlerischer Therapien insbesondere die Negativsymptomatik bei Menschen mit schizophrenen Erkrankungen reduziert. Die aussagekraftigste Befundlage existiert dabei fur die Musiktherapie. In der Behandlung schwerer depressiver Erkrankungen gibt es Hinweise, dass eine zusatzliche musiktherapeutische Intervention die depressive Symptomatik reduziert. Kunstlerische Therapien werden im Rahmen der Leitlinie mit einem Empfehlungsgrad B empfohlen.

OBJECTIVE To report about existing evidence of effectiveness of home treatment for severely mentally ill adults and implementation in Germany. METHODS Systematic electronic and manual literature search. RESULTS Compared to standard care, home treatment was equally or more efficacious with respect to general state of health and mental health. Home treatment was superior with regard to other outcomes. So far, implementation in Germany is limited. CONCLUSIONS Home treatment can be seen as an effective addition to existing approaches of psychiatric care. It may be cost-effective also in Germany. Reasons for limited implementation in routine care are discussed.

Schueler Y-B, Koesters M, Wieseler B, Grouven U, Kromp M, Kerekes MF, Kreis J, Kaiser T, Becker T, Weinmann S. A systematic review of duloxetine and venlafaxine in major depression, including unpublished data. Objective: To determine the short-term antidepressant efficacy and tolerability of duloxetine and venlafaxine vs. each other, placebo, selective serotonin reuptake inhibitors (SSRIs), and tri- and tetracyclic antidepressants (TCAs) in adults with major depression. Method: Meta-analysis of randomised controlled trials identified through bibliographical databases and other sources, including unpublished manufacturer reports. Results: Fifty-four studies including venlafaxine arms (n = 12 816), 14 including duloxetine arms (n = 4528), and two direct comparisons (n = 836) were analysed. Twenty-three studies were previously unpublished. In the meta-analysis, both duloxetine and venlafaxine showed superior efficacy (higher remission and response rates) and inferior tolerability (higher discontinuation rates due to adverse events) to placebo. Venlafaxine had superior efficacy in response rates but inferior tolerability to SSRIs (OR = 1.20, 95% CI 1.07–1.35 and 1.38, 95% CI 1.15–1.66, respectively), and no differences in efficacy and tolerability to TCAs. Duloxetine did not show any advantages over other antidepressants and was less well tolerated than SSRIs and venlafaxine (OR = 1.53, 95% CI 1.10–2.13 and OR 1.79, 95% CI 1.16–2.78, respectively). Conclusion: Rather than being a first-line option, venlafaxine appears to be a valid alternative in patients who do not tolerate or respond to SSRIs or TCAs. Duloxetine does not seem to be indicated as a first-line treatment.

Introduction: Although a range of adverse effects of antipsychotic medication are well documented, less attention has been paid to the issue of reduced life expectancy. Method: The medical literature was searched to identify studies assessing severe somatic side‐effects of long‐term antipsychotic treatment with a possible impact on mortality, and studies evaluating antipsychotic‐associated brain structure changes. Results: Short‐term cardiac and long‐term metabolic side effects increasing cardiovascular risk exert a negative influence on mortality in people diagnosed with schizophrenia. Three out of five studies examining antipsychotic dosage and higher mortality showed a significant association for one or more antipsychotics. Two out of four found negative effects of antipsychotic polypharmacy on life‐expectancy. One large historical cohort study found an association between longer duration of cumulative use and lower mortality, whereas other prospective studies found no effect. There is evidence for fro...

Objective To provide an overview of diagnostics, outcome and treatment of "non-schizophrenic psychotic disorders" (ICD-10: delusional disorders, acute and transient psychotic disorders and schizoaffective disorders). Methods Literature was identified by searches in "Medline" and "Cochrane Database of Systematic Reviews". Results The frequency of "non-schizophrenic psychotic disorders" within the whole diagnostic group "schizophrenia, schizotypal and delusional disorders" (ICD-10) ranges between 22% and 49%. Patients with these disorders show a more favourable long-term outcome than those with schizophrenia. With regard to therapy, as yet only a small empirical database exists. The comparability of those studies is limited by the use of different diagnostic criteria. There are only few evidence-based treatment guidelines for these disorders. Conclusions There is a substantial need for controlled studies on the treatment of "non-psychotic schizophrenic disorders". Alternatively, clinical guidelines could be based on a dichotomy of affective and schizophrenic disorders or on a dimensional approach.

A number of reviews have claimed that the selective serotonin and noradrenalin re-uptake inhibitor venlafaxine is more effective than selective serotonin re-uptake inhibitors (SSRIs) in achieving remission and symptom reduction in major depression. The aim of this study was to systematically review studies on the efficacy of venlafaxine vs SSRI and to evaluate the influence of methodological issues on the effect sizes. Following a systematic literature search, we pooled data on depression scores, response, remission and dropout rates. We also performed sub-group analyses. Seventeen studies were included. We found no significant superiority in remission rates (risk ratio [RR] = 1.07, 95% confidence intervals [95%CI] = 0.99 to 1.15, numbers needed to treat [NNT] = 34) and a small superiority in response rates (RR = 1.06, 95%CI = 1.01 to 1.12, NNT = 27) over SSRIs. There was a small advantage to venlafaxine in change scores (effect size = −0.09, 95%CI = −0.16 to −0.02, p = 0.013), which did not reach significance when post-treatment scores were used (effect size = −0.06, 95%CI = −0.13 to 0.00). Discontinuation rates due to adverse events were 45% higher in the venlafaxine group. The main reasons for the differences between this analysis and previous reviews were the exclusion of studies with methodological limitations, avoiding to pool selectively reported study results and exclusion of studies available as abstracts only. Our analysis does not support a clinically significant superiority of venlafaxine over SSRIs. Differences between our study and previous reviews were not accounted for by technical aspects of data synthesis, but rather by study selection and choice of outcome parameters.

Objective To evaluate guideline adherence in in-patient medication care of psychotic disorders. Method A total of 508 persons with psychotic disorders were included in a naturalistic multisite hospital study. Subjects were assessed weekly on mental state, social functioning, socioeconomic factors and medication prescriptions. Results In total, 17% of individuals were prescribed antipsychotic dosages above the recommended value. Among those with persistent psychotic symptoms, 73% received insufficient antipsychotic drug management. About 58% of patients with depressive symptoms were not treated according to guidelines, and 53% of patients did not receive adequate management of side-effects from antipsychotic medications. Subjects with more than six previous psychiatric hospitalizations (OR 1.80, CI: 1.05-3.08) and those with a prominent thought disorder (OR 2.28, CI: 1.23-4.23) had a higher likelihood of not being treated according to guidelines. Conclusion Individuals with chronic and thought-disordered psychosis may be at a higher risk of receiving medication care not supported by guidelines.

Behandlungsergebnisse und Leitlinienkonformitat in ausgewahlten Indikationsbereichen bei der stationaren Schizophreniebehandlung wurden anhand von 597 Patienten aus 7 psychiatrischen Kliniken systematisch dargestellt und verglichen. Es zeigten sich deutliche Unterschiede in der Patientenstruktur und den angewandten Behandlungsverfahren zwischen den Kliniken. Patientenmerkmale, insbesondere die Psychopathologie bei Aufnahme und die Chronizitat der Erkrankung stellten sich als die starksten patientenbezogenen Pradiktoren fur den klinischen Status bei Entlassung heraus. Eine Beurteilung der Behandlungsqualitat in den Kliniken mittels definierter Indikatoren ist nur eingeschrankt und nach einer Case-Mix-Adjustierung unter Berucksichtigung prognostisch relevanter Parameter moglich. In diesem Modell war ein ungunstigeres durchschnittliches Behandlungsergebnis im Klinikvergleich mit geringerer Leitlinienkonformitat bei einer Reihe von Indikationsbereichen verbunden. Diese Ergebnisse unterstutzen die Verwendung der Leitlinienkonformitat in der Schizophreniebhandlung als zu vergleichendes Klinikmerkmal zur datengestutzten internen Qualitatsoptimierung und lassen die Entwicklung von Strategien zur Steigerung der Leitlinienorientierung sinnvoll erscheinen.

The aim of this study was to estimate costs accrued by the health care of children with asthma in comparison to children with atopic eczema and seasonal rhinitis and to investigate cost determinants. From the multicenter cohort study (MAS-90), we selected children with an asthma, atopic eczema and/or seasonal rhinitis diagnosis during the first 8 years of life, and overall 8-year health care utilization was estimated retrospectively by reviewing medical records. Asthma treatment (n = 76) incurs an average cost of 627 US dollars per year, 44% due to hospital stays. Atopic eczema treatment (n = 91) cost on average 219 US dollars and seasonal rhinitis (n = 69) 57 US dollars per year. In asthma and atopic eczema, costs increase significantly with disease severity. Allergy diagnostics use accounts for only 1% of total costs. Costs for asthma and atopic eczema treatment are highest in those years when topical steroids are used for the first time, but decrease with every further year of steroid use. A remarkable 25% of asthmatic children with severe symptoms were not treated according to national guidelines, so that most steroid treatment was initiated during the first hospital stay. In the case of asthma, total direct costs increased until the 3rd year of the disease, and then decreased with further years of diagnosis, while steroid use continued to increase. These results indicate a 'learning effect' in the treatment of asthma and atopic eczema for each patient as well as considerable cost-saving potential by preventing severe asthma. Moreover, the importance of considering cost-driving factors and using cohort or longitudinal designs in cost-of-illness approaches is emphasized.

Introduction/objectivesThere is currently a variety of initiatives to improve the quality of care for schizophrenia, but there is no established core set of quality indicators in schizophrenia. In 2009, Weinmann and Becker published a set of indicators for quality monitoring of schizophrenia care. This study aims to evaluate the feasibility of these indicators.MethodsAdult schizophrenic patients insured by the Federal Association of Local Health Insurance Funds (AOK) were recruited in two large psychiatric hospitals. Participants were evaluated using PANSS, CGI, Camberwell Assessment of Need-European Version (CAN-EU) and the Verona Service Satisfaction Scale (VSSS) at discharge and after six month. Furthermore, 18-month AOK administrative data was available for all patients included. Feasibility of structural and quality indicators described by Weinmann and Becker (2009) will be tested by applying the full set of indicators.Results82 patients with a mean age of 40 and an average GAF score of 44.3 were included. We were able to calculate all indicators. Outpatient data was available with a delay of over six month. Patients had on average 1.6 additional psychiatric diagnoses (S1) and a mean length of stay of 44 days (S6). 67% of the patients were satisfied with the treatment received (Q17). 25% of the patients were re-admitted to an inpatient psychiatric care within 30 days after discharge.ConclusionsThe usage of Quality Indicators seems to be feasible in routine care. However, delay in the availability of outpatient data has to be considered if these indicators are implemented.

This systematic review evaluated Chinese trials examining the efficacy of venlafaxine in the treatment of depression. Chinese databases CNKI and VIP and western databases were searched for blinded randomized controlled trial publications comparing venlafaxine to other antidepressants or placebo (in English or Chinese). Trials had to establish diagnosis of depression according to the Chinese Classification of Mental Disorders, Diagnostic and Statistical Manual of Mental Disorders, or International Classification of Diseases. Studies were excluded if more than 20% of participants had a primary diagnosis of dysthymia or if more than 15% had a primary diagnosis of bipolar disorder. Effect sizes were calculated as Hedges' g for rating scale scores and Mantel-Haenszel risk ratios (MH RR) for response and remission data. Effect sizes were combined in a fixed-effects model. A total of 25 studies were included. Nine trials compared venlafaxine to selective serotonin reuptake inhibitor; placebo-controlled trials were lacking. Quality was at best modest, and all trials were underpowered. There were more responders (MH RR, 1.08; 95% confidence interval [CI], 1.02-1.15) and remitters (MH RR, 1.12; 95% CI, 1.02-1.24) in venlafaxine groups compared with those in tricyclic antidepressant group. Hamilton Depression Rating Scale end point scores in the venlafaxine groups were lower (Hedges' g = 0.16; 95% CI, 0.04-0.27), and venlafaxine was better tolerated than tricyclic antidepressant (Hedges' g = 0.56; 95% CI, 0.37-0.74). There were no significant differences between venlafaxine and selective serotonin reuptake inhibitor on any of these parameters. Analyses of publication bias were inconclusive. Chinese researchers have published a number of randomized controlled trials comparing venlafaxine to active comparators, but study quality was found to be low. To make optimal use of their research potential Chinese, researchers will have to improve trial reporting and the peer-review process.

Aim– We aimed at developing a prioritized set of quality indicators for schizophrenia care to be used for continuous quality monitoring. They should be evidence-based and rely on routine data.Methods– A systematic literature search was performed to identify papers on validated quality indicators published between 1990 to April 2008 in MEDLINE, the Cochrane databases, EMBASE and PsycINFO. Databases of relevant national and international organizations were searched. Indicators were described with respect to meaningfulness, feasibility and actionability. A workshop with relevant stakeholders evaluated the measures through a structured consensus process.Results– We identified 78 indicators through literature search and selected 22 quality indicators. Furthermore, 12 structural and case-mix indicators were choosen. Only five quality indicators were rated “essential indicators” (priority 1), 14 were rated “additional first choice” (priority 2), and three were rated as “additional second choice” (priority 3). Only four indicators assessed outcome quality. In the majority of indicators the evidence base supporting the indicator recommendation was weak. None of the selected indicators was validated in experimental studies.Conclusions– Evidence and validation base played only a subordinate role for indicator prioritisation by stakeholders indicating that there are discrepancies between clinical questions and requirements in schizophrenia care and scientific research.Declaration of Interest: Stefan Weinmann and Thomas Becker received an unrestricted grant from the Federal Association of Local Health Funds (AOK-BV) for the whole project. Christiane Roick is an employee of the AOK-BV. All authors declare that there are no other financing arrangements or payments that might be considered a conflict of interests related to the present paper.

Background The benefit of Ginkgo biloba has been discussed controversially. The aim of this review was to assess the effects of Ginkgo biloba in Alzheimer's disease as well as vascular and mixed dementia covering a variety of outcome domains. Methods We searched MEDLINE, EMBASE, the Cochrane databases, CINAHL and PsycINFO for controlled trials of ginkgo for Alzheimer's, vascular or mixed dementia. Studies had to be of a minimum of 12 weeks duration with at least ten participants per group. Clinical characteristics and outcomes were extracted. Meta-analysis results were expressed as risk ratios or standardized mean differences (SMD) in scores. Results Nine trials using the standardized extract EGb761® met our inclusion criteria. Trials were of 12 to 52 weeks duration and included 2372 patients in total. In the meta-analysis, the SMDs in change scores for cognition were in favor of ginkgo compared to placebo (-0.58, 95% confidence interval [CI] -1.14; -0.01, p = 0.04), but did not show a statistically significant difference from placebo for activities in daily living (ADLs) (SMD = -0.32, 95% CI -0.66; 0.03, p = 0.08). Heterogeneity among studies was high. For the Alzheimer subgroup, the SMDs for ADLs and cognition outcomes were larger than for the whole group of dementias with statistical superiority for ginkgo also for ADL outcomes (SMD = -0.44, 95% CI -0.77; -0.12, p = 0.008). Drop-out rates and side effects did not differ between ginkgo and placebo. No consistent results were available for quality of life and neuropsychiatric symptoms, possibly due to the heterogeneity of the study populations. Conclusions Ginkgo biloba appears more effective than placebo. Effect sizes were moderate, while clinical relevance is, similar to other dementia drugs, difficult to determine.

Case reports indicate that antipsychotics can cause priapism, a persistent penile erection possibly leading to erectile dysfunction. The mechanism of antipsychotic-induced priapism is thought to be related to blockade of alpha1 adrenergic receptors, but clinical data supporting this hypothesis are lacking. The aim of this study was to investigate if the presence of safety signals for antipsychotics and priapism is associated with their alpha1 affinity. Spontaneous reports of adverse drug reactions contained in the US Adverse Event Reporting System database were used to calculate reporting odds ratios (RORs) of priapism for antipsychotics. In total, 426 cases of priapism with 144 of them attributed to antipsychotics were identified. For antipsychotics with high alpha1 affinity, the adjusted ROR was markedly elevated (ROR = 9.9; 95% CI, 7.9-12.4), whereas a weaker signal was observed for antipsychotics with low/medium alpha1 affinity (ROR = 3.6; 95% CI, 2.4-5.2). Signals were present for chlorpromazine, quetiapine, risperidone, ziprasidone, and aripiprazole. After restricting the analysis to cases with medical intervention or disability, the safety signal remained evident only for antipsychotics with high but not for those with low/medium affinity. The observed pattern of signals indicates a relationship between alpha1 affinities of antipsychotics and the occurrence of priapism.

Background Antipsychotic medication is the cornerstone of schizophrenia treatment. The impact of long-term exposure to antipsychotics on life-expectancy has recently received some attention, partly because awareness is increasing of the differential mortality of people with schizophrenia and the general population. Methods A systematic review of studies assessing the association between antipsychotic exposure and mortality in persons with schizophrenia was undertaken. Results In total, 12 studies met the inclusion criteria. Three out of five studies examining antipsychotic dosage and higher mortality showed a significant association for one or more antipsychotics. Two out of four found negative effects of antipsychotic polypharmacy on life-expectancy. Some studies found a lower cardiovascular mortality risk with higher treatment intensity or when comparing current versus past or non-use of antipsychotics. Others established a stable correlation between antipsychotic exposure and an increase in cardiovascular mortality. Evidence for differential effects on mortality in favor of second generation (SGA) compared to first generation antipsychotics was inconsistent. No study of SGA drugs had a sufficient follow-up time. A major confounding factor may be a higher risk factor load for somatic disorders in the most severely mentally ill. Conclusion There is some evidence that long-term exposure to antipsychotics increases mortality in schizophrenia. More rigorously designed, prospective studies are urgently needed.

Background In mental health care, a range of guidelines with sound methodology is available; however, implementation studies in routine care are scarce. Method In a controlled before-and-after study design, the pharmacologic part of the German evidence-based schizophrenia guideline was implemented using a quality-circle-based intensive implementation program. 151 adult inpatients with a diagnosis of schizophrenia or schizo-affective disorder (according to ICD-10 criteria) were assessed in 4 psychiatric wards before (N = 77) and after (N = 74) guideline implementation. Treatment process and patient outcome were assessed at admission and discharge using the Positive and Negative Syndrome Scale (PANSS) and predefined process measures. A propensity score model adjusted for baseline psychopathology and sociodemographic variables was used. Data were collected from April to September of 2005 and from January to May of 2006 for the preintervention and postintervention periods, respectively. Results After guideline implementation, the rate of antipsychotic monotherapy at discharge increased from 39.5% to 67.6% (p = .021) and the incidence of significant neurologic side effects decreased from 26.3% to 7.0% (p = .038). Antipsychotic dosage and prescriptions of other psychotropic drugs did not change. Although patients in the postintervention group were more severely disturbed at baseline, the reduction in PANSS total score was significantly greater among this group than among the preintervention group (p = .048). Conclusion After guideline implementation, we observed significantly more antipsychotic monotherapy and a decrease in adverse drug effects. Changing physician behavior and improving process and outcome measures requires intense efforts.

Abstract Guidelines for the treatment of attention-deficit hyperactivity disorder (ADHD) in adults advocate methylphenidate as first-line treatment. The aim of this study was to review the effectiveness of methylphenidate treatment of adult ADHD and to examine the influence of methods on meta-analytic results. Electronic databases were searched to identify clinical trials comparing methylphenidate with placebo in the treatment of adult ADHD. Studies were summarised with meta-analytic methods. Subgroup analyses were conducted with respect to parallel group versus cross-over trials and self versus observer ratings. The relationship between dosage and effect size was explored by weighted regression analysis. The results were tested for publication bias, and several sensitivity analyses were performed. Findings and methods were compared with a previous meta-analysis. Eighteen studies met the inclusion criteria of which 16 were included in the meta-analysis. The overall effect size (d = 0.42) was significantly different from zero, but was only half the size expected on the basis of a previous meta-analysis. No significant differences could be observed in the subgroup analyses. The regression analysis showed no significant influence of mean daily dose on effect size. These results contradict findings of a previous meta-analysis and challenge guideline recommendations. Methodological issues in meta-analyses are discussed.

Objective: To identify evidence from comparative studies on the effects of psychiatric guideline implementation on provider performance and patient outcome. Effects of different implementation strategies were reviewed. Method: Articles published between 1966 and March 2006 were searched through electronic databases and hand search. A systematic review of comparative studies of structured implementation of specific psychiatric guidelines was performed. Rates of guideline adherence, provider performance data, illness detection and diagnostic accuracy rates were extracted in addition to patient relevant outcome data. Results: Eighteen studies (nine randomized-controlled trials, six non-randomized-controlled studies and three quasiexperimental before-and-after studies) were identified. Effects on provider performance or patient outcome were moderate and temporary in most cases. Studies with positive outcomes used complex multifaceted interventions or specific psychological methods to implement guidelines. Conclusion: There is insufficient high-quality evidence to draw firm conclusions on the effects of implementation of specific psychiatric guidelines.

It is well known that schizophrenia has a neuroprogressive component with many patients presenting tissue volume decrease occurring after onset. These changes include both grey and white matter with a special focus on the frontal lobes. To explore the role of antipsychotic medication we performed a systematic review which identified ten longitudinal studies on frontal brain volume reduction in patients with schizophrenia spectrum disorders using magnetic resonance imaging and data on antipsychotic treatment. We correlated antipsychotic treatment dose with volume changes and tried to control disease severity as a confounder. The findings indicate that there is evidence for grey and white matter atrophy of the frontal brain, which cannot be explained by the severity of the disease alone but is also very likely a manifestation of long term effects of antipsychotics. Despite many methodological shortcomings, most studies point to significant effects of antipsychotics. Five of eight studies with patients on first generation antipsychotics show reductions in frontal grey matter or cortical thickness which correlated with antipsychotic dose. This was also true in four of eight studies with second generation antipsychotics. Five studies had study durations of more than two years. More recent studies suggest that changes occur already in the first weeks of treatment. Considering the contribution of antipsychotics to the changes in brain structure, which seem to depend on cumulative dosage and can exert adverse effects on neurocognition, negative and positive symptoms and psycho-social functioning, guidelines for antipsychotic long term treatment should be reconsidered.

Antipsychotic medication can substantially improve acute psychotic symptoms, however, there is an increasing concern about long-term effects of anti-psychotic medication. We review brain imaging studies that assess prefrontal cortical volume in longitudinal designs and report the effects of neuroleptic dose as well as symptom severity. In these prospective studies, a majority of studies reported a significant effect of neuroleptic dose on brain volume reductions when controlling for symptom severity. These findings strengthen the concern that long-term and rather high dose neuroleptic medication contribute to prefrontal cortical atrophy. Low doses and psychosocial and psychotherapeutic interventions that help to reduce the need for medication therefore are highly warranted.

The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia

The influence of combining antipsychotics and different classes of psychotropic drugs on treatment outcome in schizophrenia remains unclear. As part of a comprehensive quality management program, we prospectively evaluated two schizophrenia polypharmacy performance measures in a cohort of 1,075 consecutively recruited individuals with schizophrenia in seven psychiatric hospitals. Multiple concurrent antipsychotic and overall psychotropic polypharmacy rates were noticeably high. In case-mix-adjustment models controlling for a variety of confounding baseline parameters, patients discharged with more than one antipsychotic had significantly poorer outcomes with respect to both mental state and social functioning. Prescription of more than three psychotropic agents did not adversely affect social functioning when patients taking more than three were compared to patients given fewer medications. Case-mix models suggest that antipsychotic polypharmacy, while used more often for individuals with chronic disease and more thought disturbance, is only partly a reaction to disease severity. The antipsychotic polypharmacy process measure may be used to identify treatment problems in order to find alternatives to polypharmacy. The measure can be easily assessed in a variety of settings and does not depend on the availability of case-mix data. The rising trend toward polypharmacy in schizophrenia care, which is not supported by current guideline recommendations, warrants critical appraisal.

Background: Within a pharmacoepidemiologic study, characteristics of patients with schizophrenia switched from first- to second-generation antipsychotics (FGAs and SGAs, respectively) or to antipsychotic polypharmacy were compared with those of patients maintained on treatment with FGAs. The primary aim was to assess factors associated with antipsychotic switching and to compare disease course with regard to mental state and social functioning. Method: Adult inpatients with an ICD-10 diagnosis of schizophrenia or schizoaffective disorder were assessed in 7 psychiatric hospitals. Data were collected between 2001 and 2002. For those patients (N = 847) with an antipsychotic prescription at discharge, t tests and covariance and logistic regression analyses were used to evaluate the relationship between demographic and clinical characteristics and antipsychotic switching. Results: Patients switched from FGAs to SGAs had fewer previous psychiatric admissions, a shorter illness duration, fewer substance disorders, and a higher probability of working in a competitive setting but more pronounced symptoms than those maintained on treatment with FGAs. Mental state and social functioning after case-mix adjustment were more favorable in the group switched to SGA monotherapy but not in those patients administered FGAs and SGAs concurrently at discharge. Logistic regression controlling for demographic and clinical variables revealed that a short disease duration (p

Zusammenfassung In dieser Übersicht werden die Ergebnisse longitudinaler Studien zur frontalen Hirnvolumenminderung bei Menschen mit einer Erkrankung aus dem Spektrum schizophrener Psychosen dargestellt und zur Behandlung mit Antipsychotika in Beziehung gesetzt. Nach einer systematischen Literaturrecherche wurden alle Studien ausgewertet, in denen an einer größeren Population Ergebnisse bildgebender Diagnostik zur Veränderung der Hirnstruktur im Langzeitverlauf mit Daten zur antipsychotischen Behandlung und zur Schwere der Erkrankung korreliert wurden. Die Ergebnisse zeigen, dass es eine Evidenz für eine Volumenminderung grauer und weißer Substanz des Frontalhirns gibt, die sich nicht alleine durch die Erkrankung selbst und ihre Krankheitsschwere erklären lässt, sondern mit hoher Wahrscheinlichkeit auch Ausdruck einer langfristigen Antipsychotikawirkung auf das Gehirn ist. Ob sog. „Second-generation“-Antipsychotika hier einen mittel- bis längerfristigen Vorteil gegenüber „First-generation“-Antipsychotika besitzen, ist derzeit unklar. Angesichts des Beitrags von Antipsychotika zu den hirnstrukturellen Veränderungen, die offenbar kumulativ dosisabhängig sind und negative Auswirkungen für die Neurokognition, die Positiv- und Negativsymptomatik und das soziale Anpassungsniveau mit sich bringen können, sollten die Empfehlungen zur antipsychotischen Langzeitbehandlung neu überdacht werden. Vor dem Hintergrund der neurobiologischen Befunde empfehlen wir und andere, möglichst niedrige antipsychotische Dosierungen zur Symptomkontrolle einzusetzen. Bei psychiatrischen Störungen außerhalb des Schizophreniespektrums sollten Antipsychotika ebenfalls nur mit Vorsicht und nach sorgfältiger Abwägung von Risiken und Nutzen angewandt werden. In diesem Kontext werden zunehmend auch Behandlungsansätze relevant, welche die antipsychotische Medikation minimieren oder sogar einen nur selektiven Einsatz erlauben.