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Objective: To examine immediate and long-term effectiveness of an adjunctive Internet intervention for depression in a large sample of patients undergoing routine psychotherapy., Method: The current study evaluated a subgroup of patients from the Evident trial, a randomized investigation of a 12-week minimally guided Internet intervention (Deprexis) for the treatment of mild to moderate depression. 340 adults (mean age = 43.3 years; 71.7 % female) of the original sample received routine outpatient psychotherapy during the trial period, resulting in a standard psychotherapy group (n = 174) and an augmented therapy group (n = 166). Outcomes were assessed at baseline, post-treatment and 6-month follow-up., Results: Intention-to-treat analyses indicated that combined treatment led to a greater reduction in symptoms of depression (effect size d = 0.32; p = .002), improved therapeutic progress (d = 0.36; p = .003), and higher mental health-related quality of life (d = 0.34; p = .004). There was no intervention effect on physical health-related quality of life. The same pattern was found at 6-month follow-up, and adjunctive treatment also resulted in increased rates of clinical improvement. Treatment success was independent from therapeutic orientation of combined face-to-face therapy., Conclusion: Results indicate that the adjunctive use of the investigated intervention can produce additional and lasting effects in routine outpatient psychotherapy for mild to moderate levels of depression. The study adds to the ongoing evidence on augmented effects of blended treatment. Future studies should investigate different types of blends in diverse populations by means of change-sensitive assessment strategies., Competing Interests: Declaration of Competing Interest Björn Meyer is employed as research director at GAIA AG, the company that developed, owns and operates the Internet intervention investigated in this trial. All the other authors report no relationships with commercial interests., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: This study analyses the psychometric properties of the Working Alliance Inventory adapted for guided Internet interventions (WAI-I)., Methods: We drew on the data set from a multicenter trial that examined a guided Internet intervention (deprexis) for patients with mild to moderate depression. Two hundred twenty-three patients completed the WAI-I and the Patient Satisfaction Questionnaire (ZUF-8) at posttreatment, and the Attitudes toward Psychological Online-Interventions Questionnaire (APOI) at baseline. We ran confirmatory factor analyses (CFA) testing two- and three-factor solutions and calculated Cronbach's α, item-total correlations, and correlations of the WAI-I with APOI and ZUF-8., Results: The results suggested a two-factor solution, with a very good model fit and evidence of factor independency, adequate internal consistency, and external validity for the complete scale and the sub-scales., Conclusions: The WAI-I showed as a reliable and valid instrument to capture alliance in guided Internet interventions, which might facilitate process-outcome research and treatment development efforts., (© 2019 Wiley Periodicals, Inc.)

Background: Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes., Objective: The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties., Methods: A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment., Results: We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ 02 =-1.74, standard error [SE]=0.40, 95% CI -2.52 to -0.96, t 206 =-4.37, P<.001) and patient well-being (γ 02 =3.10, SE=1.14, 95% CI 0.87-5.33, t 198 =2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68)., Conclusions: The results of this study point out the importance of attuning internet interventions to patients' expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient's individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats., (©Juan Martín Gómez Penedo, Anna Margarete Babl, Martin grosse Holtforth, Fritz Hohagen, Tobias Krieger, Wolfgang Lutz, Björn Meyer, Steffen Moritz, Jan Philipp Klein, Thomas Berger. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 24.03.2020.)

To date, only few studies have attempted to investigate non-ignorable dropout during Internet-based interventions by applying an NMAR model, which includes missing data indicators in its equations. Here, the Muthen-Roy model was used to investigate change and dropout patterns in a sample of patients with mild-to-moderate depression symptoms ( N = 483) who were randomized to a 12-week Internet-based intervention (deprexis, identifier: NCT01636752). Participants completed the PHQ-9 biweekly during the treatment. We identified four change-dropout patterns: Participants showing high impairment, improvement and low dropout probability (C3, N = 134) had the highest rate of reliable change at 6- and 12-month follow-up. A further pattern was characterized by high impairment, deterioration and high dropout probability (C2, N = 32), another by low impairment, improvement and high dropout probability (C1, N = 198). The last pattern was characterized by high impairment, no change and low dropout probability (C4, N = 119). In addition to deterioration, also rapid improvement may lead to dropout as a result of a perceived "good enough" dosage of treatment. This knowledge may strengthen sensitivity for the mechanisms of dropout and help to consider its meaning in efforts to optimize treatment selection.

Objective: Data from the EVIDENT trial were reanalyzed to examine whether specific anxiety-related comorbidities moderate the effect of an Internet intervention on depression outcome., Method: The EVIDENT study is a randomized controlled trial that included N = 1,013 participants with mild to moderate depressive symptoms (i.e., scores between 5 and 14 on the Patient Health Questionnaire-9 [PHQ-9]) who were randomized to a control group with access to care-as-usual (n = 504) or to an intervention group, which accessed the Internet intervention Deprexis adjunctively to care-as-usual (n = 509). Anxiety-related comorbidities (generalized anxiety disorder, social phobia, panic disorder, agoraphobia, panic disorder with agoraphobia, specific phobia, posttraumatic stress disorder, obsessive-compulsive disorder) were assessed with the Web Screening Questionnaire at baseline. Multilevel models were performed., Results: Twelve potential moderators (8 specific anxiety-related comorbidities, depression severity, and 3 previously identified moderators in the EVIDENT trial) were examined within 1 multilevel model, and only social phobia moderated the intervention effect on depression outcome (in favor of Deprexis). This moderating effect of social phobia did not depend on the other moderators' being included in the model. These results emerged for continuous PHQ-9 scores as well as for clinically important PHQ-9 changes as outcome (p < .05). However, moderating effects did not reach small effect sizes, accounted for less than 1% of the variance in change in depressive symptoms, and showed limited reproducibility in randomly selected split halves., Conclusions: Deprexis appears to be most effective for participants with mild to moderate depressive symptoms and comorbid social phobia, but further replications of this finding are necessary. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background: Depression often remains undiagnosed or treated inadequately. Web-based interventions for depression may improve accessibility of treatment and reduce disease-related costs. This study aimed to examine the potential of the web-based cognitive behavioral intervention "deprexis" in reducing disease-related costs., Methods: Participants with mild to moderate depressive symptoms were recruited and randomized to either a 12-week web-based intervention (deprexis) in addition to care as usual (intervention group) or care as usual (control group). Outcome measures were health-related resource use, use of medication and incapacity to work as well as relating direct health care costs. Outcomes were assessed on patients' self-report at baseline, three months and six months., Results: A total of 1013 participants were randomized. In both groups total direct health care costs decreased during the study period, but changes from baseline did not significantly differ between study groups. Numeric differences between study groups existed in outpatient treatment costs. They could be attributed to differences in changes of costs for psychotherapeutic treatment from baseline. Whereas costs for psychotherapeutic treatment decreased in the intervention group, costs increased in the control group (- 16.8% (€80) vs. + 14.7% (€60)) (t df = 685  = 2.57; p = 0.008)., Conclusion: The study indicates the health economic potential of innovative e-mental-health programs. There is evidence to suggest that the use of deprexis over a period of 12 weeks leads to a decrease in outpatient treatment cost, especially in those related to different types of psychotherapeutic treatment.

Only about half of those suffering from a depressive disorder seek treatment. Self-management interventions are one way to reduce this treatment gap. These interventions are mostly based on evidence-based techniques of cognitive behavioural therapy, which are taught by a computer program instead of a therapist. Numerous studies have shown the effectiveness of these interventions. However, these studies also raise a number of questions. These concern the efficacy both in the external rating and in the long-term course and the efficacy in severe depressive symptoms or in combination with antidepressant medication. Finally, the question arises as to the use of these interventions in patients in clinical practice and in people who are not particularly Internet-savvy. We addressed these questions in a large randomized study (EVIDENT study). This study investigated the efficacy of Intervention deprexis®. The results of this study are summarised in this overview and placed in the context of other interventions available in Germany., Competing Interests: MH erhielt und erhält Finanzierung für Klinische Studien vom BMBF, DFG, BMG; Vortragshonorare von der Firma Servier, welche die Selbstmanagement Intervention deprexis vertreibt; Buchhonorare von den Verlagen Hogrefe, Beltz, Springer, Kohlhammer, Thieme u. a. JPK erhielt und erhält Finanzierung für klinische Studien (Bundesministerium für Gesundheit, Servier), Honorare für Vorträge zu Internetinterventionen (Servier) und für Workshops und Bücher (Beltz, Elsevier, Hogrefe, Springer) über Psychotherapie chronischer Depression und psychiatrische Notfälle. WL erhielt und erhält Finanzierung für Klinische Studien von der DFG, BMG, Wellcome Trust, UK, u. a. Buchhonorare von den Verlagen Hogrefe, Huber, Taylor & Francis, Wiley, u. a. JS erhielt Honorare für Vorträge zu Online-Interventionen (Servier).Für die Durchführung der EVIDENT-Studie, deren Ergebnisse in diesem Beitrag zusammenfassend dargestellt werden, wurden die Lizenzen für die im Rahmen der Studie untersuchte Selbstmanagement Intervention deprexis kostenlos von der Firma GAIA zur Verfügung gestellt. Die Firma GAIA hat deprexis entwickelt und betreibt diese Intervention. Die EVIDENT-Studie wurde finanziert durch das Bundesministerium für Gesundheit (Förderkennzeichen II A 5-2512 FSB 052). Der Leiter der Forschungsabteilung der Firma GAIA, Dr. Björn Meyer, bildete zusammen mit TB, JPK und SM die Steuerungsgruppe der EVIDENT-Studie., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Psychological online interventions (POIs) for depression have demonstrated promising effects. However, there are fewer randomized controlled studies on POIs among older adults with depression. The goal of the present study was to compare the use and efficacy of Deprexis, an online intervention for depression, among Millennials (18-35 years) and Baby Boomers (50-65 years)., Methods: We completed a secondary data analysis on a subset (N = 577) of participants in the EVIDENT trial, a parallel-groups, pragmatic, randomized, controlled single-blind study, which compared a 12-week POI (Deprexis) to care as usual (CAU). Outcomes were assessed at baseline, 3 months (post-assessment) and 6 months (follow-up). The main outcome of interest was change on self-rated depression severity (PHQ-9)., Results: Compared to Millennials, Boomers used the intervention significantly more often (d = 0.45) and for a longer duration (d = 0.46), and endorsed more positive attitudes towards POIs (d = 0.14). There was no significant Age Group by Intervention Group interaction for change in PHQ-9. The post-assessment between-group effect size (intervention vs. CAU control) for Millennials and Boomers were d = 0.26 and d = 0.39, respectively, and were stable at follow-up (d = 0.37 and d = 0.39)., Limitations: Age-based dichotomization may not accurately represent participants' experiences with and use of technology., Conclusions: The POI examined in this trial was superior to CAU and was comparably effective among groups of adults defined as Millennials and Baby Boomers. Adults of the Baby Boomer generation who participate in POIs may have more positive attitudes towards POIs compared to their younger counterparts., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Research on neurobiological effects of psychotherapy in depression facilitates the improvement of treatment strategies. The cortico-limbic dysregulation model serves as a framework for numerous studies on neurobiological changes in depression. In this model, depression is described as hypoactivation of dorsal cortical brain regions in conjunction with hyperactivation of ventral paralimbic regions. This assumption has been supported by various studies of structural and functional brain abnormalities in depression. However, also regions not included in the original cortico-limbic dysregulation model, such as the dorsomedial prefrontal cortex, seem to play an important role in depression. Functional connectivity studies of depression have revealed an enhanced connectivity within the so-called default mode network which is involved in self-referential thinking. Studies also point to a normalization of limbic and cortical brain activity, especially in the anterior cingulate cortex, during psychotherapy. Some neurobiological markers like the activity of the anterior cingulate cortex, striatum and insula as well as hippocampal volume have been proposed to predict treatment response on a group-level. The activity of the anterior insula appears to be a candidate bio-marker for differential indication for psychotherapy or pharmacotherapy. The cortico-limbic dysregulation model and following research have inspired new forms of treatment for depression like deep brain stimulation of the subgenual anterior cingulate cortex, repetitive transcranial magnetic stimulation of the dorsolateral prefrontal cortex, neurofeedback and attention training., Competing Interests: Die Autoren geben an, dass keine Interessenkonflikte vorliegen., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Most individuals with depression do not receive adequate treatment. Internet interventions may help to bridge this gap. Research on attitudes toward Internet interventions might facilitate the dissemination of such interventions by identifying factors that help or hinder uptake and implementation, and by clarifying who is likely to benefit. This study examined whether attitudes toward Internet interventions moderate the effects of a depression-focused Internet intervention, and how attitudes change over the course of treatment among those who do or do not benefit., Methods: We recruited 1,004 adults with mild-to-moderate depression symptoms and investigated how attitudes toward Internet interventions are associated with the efficacy of the program deprexis, and how attitudes in the intervention group change from pre to post over a 3 months intervention period, compared to a control group (care as usual). This study consists of a subgroup analysis of the randomized controlled EVIDENT trial., Results: Positive initial attitudes toward Internet interventions were associated with greater efficacy (η 2 p  = .014) independent of usage time, whereas a negative attitude (perceived lack of personal contact) was associated with reduced efficacy (η 2 p  = .012). Users' attitudes changed during the trial, and both the magnitude and direction of attitude change were associated with the efficacy of the program over time (η 2 p  = .030)., Conclusions: Internet interventions may be the most beneficial for individuals with positive attitudes toward them. Informing potential users about evidence-based Internet interventions might instill positive attitudes and thereby optimize the benefits such interventions can provide. Assessing attitudes prior to treatment might help identify suitable users., (© 2018 Wiley Periodicals, Inc.)

Background: Adherence to Internet interventions is often reported to be rather low and this might adversely impact the effectiveness of these interventions. We investigated if patient characteristics are associated with adherence, and if adherence is associated with treatment outcome in a large RCT of an Internet intervention for depression, the EVIDENT trial., Methods: Patients were randomized to either care as usual (CAU) or CAU plus the Internet intervention Deprexis. A total of 509 participants with mild to moderate depressive symptoms were included in the intervention group and of interest for the present study. We assessed depression symptoms pre and post intervention (12 weeks). Patient characteristics, a self-rating screening for mental disorders, attitudes towards online interventions, and quality of life were assessed before randomization., Results: Adherence in this study was good with on average seven hours of usage time and eight number of sessions spent with the intervention. Some of the patient characteristics (age, sex, depressive symptoms, and confidence in the effectiveness of the program) predicted higher number of sessions in different models (explaining in total between 15 and 25% of variance). Older age (β = .16) and higher depressive symptoms (β = .15) were associated with higher usage duration. Higher adherence to the program predicted a greater symptom reduction in depressive symptoms over 12 weeks (number of sessions: β = .13, usage duration: β = .14), however, this prediction could mostly be explained by receiving guidance (β = .27 and .26)., Limitations: Receiving guidance and symptom severity at baseline were confounded since only participants with a moderate symptom severity at baseline received e-mail support. Therefore no firm conclusions can be drawn from the association we observed between baseline symptom severity and usage intensity., Conclusions: We conclude that older age was associated with adherence and adherence was positively associated with outcome. The effects we have found were small however suggesting that adherence might also be influenced by further variables., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Internet interventions are effective in treating depressive symptoms but few studies conducted a long-term follow-up. The aim of this study was to test the effectiveness of an internet intervention in increasing the remission rate over a twelve months period., Methods: A total of 1013 participants with mild to moderate depressive symptoms were randomized to either care as usual alone or a 12-week internet intervention (Deprexis) plus usual care. Self-rated depression severity (PHQ-9) was assessed regularly over twelve months., Results: Remission rates over time were significantly higher in the intervention group (Cox regression: hazard ratio [HR] 1.31; p = 0.009). The intervention was more effective in the subgroup not taking antidepressant medication (Cox regression: HR 1.88; p < 0.001). PHQ-change from baseline was greater in the intervention group (linear mixed model [LMM]: p < 0.001) with the between-group effect gradually decreasing from d = 0.36 at three months to d = 0.13 at twelve months (LMM: group by time interaction: p < 0.001)., Conclusion: This internet intervention can contribute to achieving remission in people with mild to moderate depressive symptoms, especially if they are not on antidepressant medication (Trial Registration: NCT01636752)., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: This study aims to examine whether the effects of internet interventions for depression generalise to participants recruited in clinical settings., Design: This study uses subgroup analysis of the results of a randomised, controlled, single-blind trial., Setting: The study takes place in five diagnostic centres in Germany., Participants: A total of 1013 people with mild to moderate depressive symptoms were recruited from clinical sources as well as internet forums, statutory insurance companies and other sources., Interventions: This study uses either care-as-usual alone (control) or a 12-week internet intervention (Deprexis) plus usual care (intervention)., Main Outcome Measures: The primary outcome measure was self-rated depression severity (Patient Health Questionnaire-9) at 3 months and 6 months. Further measures ranged from demographic and clinical parameters to a measure of attitudes towards internet interventions (Attitudes towards Psychological Online Interventions Questionnaire)., Results: The recruitment source was only associated with very few of the examined demographic and clinical characteristics. Compared with participants recruited from clinical sources, participants recruited through insurance companies were more likely to be employed. Clinically recruited participants were as severely affected as those from other recruitment sources but more sceptical of internet interventions. The effectiveness of the intervention was not differentially associated with recruitment source (treatment by recruitment source interaction=0.28, p=0.84)., Conclusion: Our results support the hypothesis that the intervention we studied is effective across different recruitment sources including clinical settings., Trial Registration Number: ClinicalTrials.gov NCT01636752., Competing Interests: Competing interests: JPK received funding for clinical trials (German Federal Ministry of Health, Servier - distributor of the internet intervention “Deprexis"), payments for presentations on internet interventions (Servier) and payments for workshops and books (Beltz, Elsevier and Hogrefe) on psychotherapy for chronic depression and on psychiatric emergencies. BM is employed as research director at GAIA AG, the company that developed, owns and operates the internet intervention “Deprexis”. MH is a consultant of Servier. He was an invited speaker at several workshops and continuous education workshops over the last two years. All the other authors report no relationships with commercial interests., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Web-based interventions for individuals with depressive disorders have been a recent focus of research and may be an effective adjunct to face-to-face psychotherapy or pharmacological treatment., Objective: The aim of our study was to examine the early change patterns in Web-based interventions to identify differential effects., Methods: We applied piecewise growth mixture modeling (PGMM) to identify different latent classes of early change in individuals with mild-to-moderate depression (n=409) who underwent a CBT-based web intervention for depression., Results: Overall, three latent classes were identified (N=409): Two early response classes (n=158, n=185) and one early deterioration class (n=66). Latent classes differed in terms of outcome (P<.001) and adherence (P=.03) in regard to the number of modules (number of modules with a duration of at least 10 minutes) and the number of assessments (P<.001), but not in regard to the overall amount of time using the system. Class membership significantly improved outcome prediction by 24.8% over patient intake characteristics (P<.001) and significantly added to the prediction of adherence (P=.04)., Conclusions: These findings suggest that in Web-based interventions outcome and adherence can be predicted by patterns of early change, which can inform treatment decisions and potentially help optimize the allocation of scarce clinical resources., (©Wolfgang Lutz, Alice Arndt, Julian Rubel, Thomas Berger, Johanna Schröder, Christina Späth, Björn Meyer, Wolfgang Greiner, Viola Gräfe, Martin Hautzinger, Kristina Fuhr, Matthias Rose, Sandra Nolte, Bernd Löwe, Fritz Hohagen, Jan Philipp Klein, Steffen Moritz. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 09.06.2017.)

Objectives: To compare treatment effect estimates obtained from a regression discontinuity (RD) design with results from an actual randomized controlled trial (RCT)., Study Design and Setting: Data from an RCT (EVIDENT), which studied the effect of an Internet intervention on depressive symptoms measured with the Patient Health Questionnaire (PHQ-9), were used to perform an RD analysis, in which treatment allocation was determined by a cutoff value at baseline (PHQ-9 = 10). A linear regression model was fitted to the data, selecting participants above the cutoff who had received the intervention (n = 317) and control participants below the cutoff (n = 187). Outcome was PHQ-9 sum score 12 weeks after baseline. Robustness of the effect estimate was studied; the estimate was compared with the RCT treatment effect., Results: The final regression model showed a regression coefficient of -2.29 [95% confidence interval (CI): -3.72 to -.85] compared with a treatment effect found in the RCT of -1.57 (95% CI: -2.07 to -1.07)., Conclusion: Although the estimates obtained from two designs are not equal, their confidence intervals overlap, suggesting that an RD design can be a valid alternative for RCTs. This finding is particularly important for situations where an RCT may not be feasible or ethical as is often the case in clinical research settings., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Borderline Personality Disorder (BPD) is a severe, challenging to treat mental disorder. Schema therapy (ST) as an individual therapy has been proven to be an effective psychological treatment for BPD. A group format of ST (GST) has been developed and evaluated in a randomized controlled trial in the United States and piloted in The Netherlands. These results suggest that GST speeds up and amplifies treatment effects of ST and might reduce delivery costs. However, feasibility in the German health care system and with BPD patients with high BPD severity and comorbidity, and frequent hospitalization, has not been tested to date. We investigated GST in 10 severely impaired, highly comorbid female patients with BPD, that needed frequent hospital admission. Patients received an outpatient ST-treatment program with weekly group and individual sessions for 1 year. Outcome measures including BPD severity, general psychopathology, psychosocial functioning, quality of life, happiness, schemas, and modes, and days of hospitalization were assessed at the start of treatment and 6, 12, and 36 months later with semi-structured interviews and self-report measures. We observed significant decreases in severity of BPD symptoms, general symptom severity, dysfunctional BPD-specific modes and schemas, and days of hospitalization. Functional modes, quality of live and happiness improved. The results of this feasibility study are promising and encourage further implementation of ST outpatient treatment programs even for patients with severe BPD and high hospitalization risk. However, small sample size and the missing of a control group do not allow the generalizability of these findings.

Background: Guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with obsessive-compulsive disorder (OCD) is an important part of the care available for these patients. It may not be adequately reflected in the current personnel resources available according to the German psychiatry personnel regulation (Psych-PV)., Objectives: The goal of this work was to assess the personnel resources necessary for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD and compare the necessary resources with the resources available according to Psych-PV., Methods: Based on the German national guidelines for OCD and a meta-analysis on treatment intensity, we formulated a normative weekly treatment plan. Based on this plan we calculated the necessary personnel resources and compared these with the resources available according to Psych-PV category A1 (standard care)., Results: The weekly treatment time for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is 23.5 h per week. This corresponds to a weekly personnel requirement of 20.9 h. This requirement is only partly reflected in the Psych-PV (17.3 h, 82.8 %). The coverage of personnel resources by Psych-PV is even lower for psychotherapy provided by psychiatrist and psychologists (38.3 %, i. e. 183 min in the normative plan versus 70 min in Psych-PV)., Conclusions: The current paper shows that the personal resources required for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is not adequately reflected in the German psychiatry personnel regulation (Psych-PV). The actual shortage may be underestimated in our paper.

Background: Mild to moderate depressive symptoms are common but often remain unrecognized and treated inadequately. We hypothesized that an Internet intervention in addition to usual care is superior to care as usual alone (CAU) in the treatment of mild to moderate depressive symptoms in adults., Methods: This trial was controlled, randomized and assessor-blinded. Participants with mild to moderate depressive symptoms (Patient Health Questionnaire, PHQ-9, score 5-14) were recruited from clinical and non-clinical settings and randomized to either CAU or a 12-week Internet intervention (Deprexis) adjunctive to usual care. Outcomes were assessed at baseline, 3 months (post-assessment) and 6 months (follow-up). The primary outcome measure was self-rated depression severity (PHQ-9). The main analysis was based on the intention-to-treat principle and used linear mixed models., Results: A total of 1,013 participants were randomized. Changes in PHQ-9 from baseline differed signixFB01;cantly between groups (t825 = 6.12, p < 0.001 for the main effect of group). The post-assessment between-group effect size in favour of the intervention was d = 0.39 (95% CI: 0.13-0.64). It was stable at follow-up, with d = 0.32 (95% CI: 0.06-0.69). The rate of participants experiencing at least minimally clinically important PHQ-9 change at the post-assessment was higher in the intervention group (35.6 vs. 20.2%) with a number needed to treat of 7 (95% CI: 5-10)., Conclusions: The Internet intervention examined in this trial was superior to CAU alone in reducing mild to moderate depressive symptoms. The magnitude of the effect is clinically important and has public health implications., (© 2016 S. Karger AG, Basel.)

Background: Obsessive-compulsive disorder (OCD) is a psychiatric disorder which is characterized by recurrent intrusive thoughts (obsessions) and ritualized, repetitive behaviors or mental acts (compulsions). The gold standard for the treatment of OCD is cognitive behavioral therapy (CBT) with exposure and response prevention. This is the first study exploring the predictive value of resting-state functional connectivity for the outcome of CBT., Methods: We assessed whole-brain resting-state functional connectivity in a group of 17 un-medicated OCD inpatients prior to CBT compared to 19 healthy controls using functional magnetic resonance imaging. The graph theoretical metric degree centrality served as indicator for altered voxel-wise whole-brain functional connectivity. The relative change in the Yale-Brown Obsessive Compulsive Scale (YBOCS) score was used to evaluate treatment outcome., Results: The degree centrality of the right basolateral nuclei group of the amygdala was positively correlated with the response to subsequent CBT. OCD patients showed a lower degree centrality of the superficial amygdala (bilateral)., Conclusions: Our results suggest that two different sub-regions of the amygdala and their respective neural networks are affected in OCD: the superficial amygdala and networks related to evaluation of reinforcers and risk anticipation and the basolateral amygdala which is implicated in fear processing. The diminished CBT response in patients showing a lower degree centrality of the basolateral amygdala reflects a deficient fear circuit in these patients which may impact fear extinction as a core mechanism of exposure-based CBT., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: The financing of psychiatric psychotherapeutic care in Germany is determined by the German psychiatric staffing regulations which are unchanged since 1991. Psychotherapy was established after 1991 as an effective and indispensable treatment of mental and behavioral disorders., Aims and Objectives: The aim of this study was to empirically investigate the use of psychiatrists' and psychologists' working time for psychotherapy in guideline-adherent hospital care. A further aim was to compare these results to the resources defined by the German psychiatric staffing regulations and in the new prospective payment system for psychiatry and psychosomatics in Germany., Material and Methods: University hospitals for psychiatry and psychotherapy were asked to retrospectively provide data of patients for which guideline-adherent care was possible. Participating institutions provided both data describing the staff time utilization of psychotherapeutic services provided by psychiatrists and psychologists and patient classifications according to the German psychiatric staffing regulations and the new prospective payment system for psychiatry and psychosomatics., Results: Resources defined by the German psychiatric staffing regulations covered a mean of only 71 min of psychotherapy per patient and week while the actual mean intensity of psychotherapeutic care provided by the participating hospitals was 194 min per patient and week. The associated use of staff time was 102 min per patient and week. Both figures increased during an inpatient episode. The resources defined by the German psychiatric staffing regulations covered only 70 % of medical and psychological personnel. The current configuration of the new prospective payment system for psychiatry and psychosomatics covered only 59 % of staff time., Conclusion: The results of this study provide another unambiguous recommendation to adjust the out-dated German psychiatric staffing regulations to the current evidence and S3 guidelines for psychiatric psychotherapeutic hospital care. In particular, more resources are required for the provision of psychotherapeutic care.

Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive thoughts and ritualized, repetitive behaviors, or mental acts. Convergent experimental evidence from neuroimaging and neuropsychological studies supports an orbitofronto-striato-thalamo-cortical dysfunction in OCD. Moreover, an over excitability of the amygdala and over monitoring of thoughts and actions involving the anterior cingulate, frontal and parietal cortex has been proposed as aspects of pathophysiology in OCD. We chose a data driven, graph theoretical approach to investigate brain network organization in 17 unmedicated OCD patients and 19 controls using resting-state fMRI. OCD patients showed a decreased connectivity of the limbic network to several other brain networks: the basal ganglia network, the default mode network, and the executive/attention network. The connectivity within the limbic network was also found to be decreased in OCD patients compared to healthy controls. Furthermore, we found a stronger connectivity of brain regions within the executive/attention network in OCD patients. This effect was positively correlated with disease severity. The decreased connectivity of limbic regions (amygdala, hippocampus) may be related to several neurocognitive deficits observed in OCD patients involving implicit learning, emotion processing and expectation, and processing of reward and punishment. Limbic disconnection from fronto-parietal regions relevant for (re)-appraisal may explain why intrusive thoughts become and/or remain threatening to patients but not to healthy subjects. Hyperconnectivity within the executive/attention network might be related to OCD symptoms such as excessive monitoring of thoughts and behavior as a dysfunctional strategy to cope with threat and uncertainty., (Copyright © 2014 Wiley Periodicals, Inc.)

Objective: Patients with both major depression and personality disorders have a high risk of suicidal behavior. Lithium is meant to have anti-suicidal properties in patients with affective disorders. The anti-suicidal effect of lithium in patients with affective disorders and comorbid personality disorders has not been investigated yet., Methods: A post-hoc analysis of a subsample of patients with depression and comorbid personality disorder (PD) and a recent suicide attempt (n = 19) from the prospective, placebo-controlled lithium intervention study (N = 167), was conducted., Results: Three patients in the lithium group (n = 8) and two patients in the placebo group (n = 11) presented a suicide attempt throughout the course of the study. No differences related to suicidal behavior could be detected between the placebo group and the group with lithium intervention., Conclusions: On the basis of the small sample size, among patients with comorbid PD, lithium does not seem to have an effect on suicidal behavior in contrast to patients with affective disorders without comorbid PD.

Background: Depressive disorders are among the leading causes of worldwide disability with mild to moderate forms of depression being particularly common. Low-intensity treatments such as online psychological treatments may be an effective way to treat mild to moderate depressive symptoms and prevent the emergence or relapse of major depression., Methods/design: This study is a currently recruiting multicentre parallel-groups pragmatic randomized-controlled single-blind trial. A total of 1000 participants with mild to moderate symptoms of depression from various settings including in- and outpatient services will be randomized to an online psychological treatment or care as usual (CAU). We hypothesize that the intervention will be superior to CAU in reducing depressive symptoms assessed with the Personal Health Questionnaire (PHQ-9, primary outcome measure) following the intervention (12 wks) and at follow-up (24 and 48 wks). Further outcome parameters include quality of life, use of health care resources and attitude towards online psychological treatments., Discussion: The study will yield meaningful answers to the question of whether online psychological treatment can contribute to the effective and efficient prevention and treatment of mild to moderate depression on a population level with a low barrier to entry., Trial Registration Number: NCT01636752.

Background: The aim of the present study was to develop a questionnaire to assess the perception and evaluation of admission to a psychiatric hospital from a patient's perspective (QAE-P)., Material and Methods: Based on existing literature and a preparatory pilot study, a questionnaire consisting of 126 items was developed, and 708 inpatients based in 6 psychiatry and psychotherapy clinics were asked to answer the items. The resulting data were split into two data sets. In the first subset, exploratory factor analysis was used to help determine the number of scales and provide the basis for item reduction. The resulting questionnaire was validated by means of confirmatory factor analyses (CFA) in the second data subset., Results: The resulting questionnaire comprises 33 items in 7 scales, which assess: (1) helpful, positive relations with staff members; (2) offering of medical explanations to patients and their involvement in treatment planning; (3) evaluation of rooms and clinical environment; (4) dissatisfaction with doctors and staff members; (5) evaluation of handling of ward rules by staff; (6) perception of ward atmosphere; and (7) negative perception of other inpatients. The plausibility of this factorial structure was supported by the results of the CFA., Conclusions: The QAE-P is a short and feasible questionnaire that meets the criteria of classic test theory and assesses different dimensions of the patient's experience of admission to a psychiatric hospital.

Background: The purpose of this study was to investigate associations of patient's scores in the newly constructed questionnaire on patients' psychiatric admission experiences (QAE-P) and individual, institutional, and situational factors., Patients and Methods: Data of 708 patients and 6 participating hospitals were analyzed. Patient characteristics between clinics were compared and univariate as well as multivariate analyses were applied to examine associations of QAE-P total score and individual as well as institutional variables (t tests, univariate and multivariate analyses of variance, correlation analyses, and effect sizes of significant associations)., Results: There was little variance of patient characteristics between hospitals. Multiple univariate associations with small to medium effect sizes were found between total QAE-P scores and demographic and clinical variables of the patients, institutional variables, and (non-independent) situational views of the patients. After multivariate analyses were applied, these associations remained significant for gender, age, diagnosis, the personal decision to be admitted, and for previous planning of admission with the outpatient doctor. The hospital variables shown to be associated with total QAE-P scores were open versus closed ward, disorder-specific organization of the ward, and the number of other patients being treated under the German Mental Health Act., Conclusion: Principally the QAE-P seems to be a suitable instrument of quality management. A number of factors were identified that show associations with the subjective evaluation of admission as reported by the patients. Some of these variables are within the control of the clinical management.

Since the advent of non-invasive methods such as proton magnetic resonance spectroscopy ((1)H-MRS), obsessive-compulsive disorder (OCD) has been increasingly associated with an altered composition of neurometabolites and neurotransmitters in several brain areas. Particularly, Inositol has not only been implicated in OCD pathophysiology, but also shown effective in pilot studies in therapy-refractory OCD patients. However, the relevance of regional brain neurochemistry for therapy outcome has not yet been investigated. Whereas numerous neuroimaging findings support a dysfunction of the orbitofrontal cortex (OFC) in OCD, MR-spectroscopic investigations of this region are missing. (1)H-MRS and psychometric measurements were obtained from twenty unmedicated patients with OCD, subsequently enrolled in a 3-month structured inpatient cognitive-behavioural therapy programme, and from eleven matched control subjects. Multiple regression of symptom score changes (Y-BOCS) on (myo-)inositol concentrations in three areas (right orbitofrontal cortex (OFC), right striatum and anterior cingulate cortex) was performed. The concentration of (myo-)inositol in the OFC only predicted the outcome of subsequent CBT regarding Y-BOCS score reduction (Spearman's r(s) = .81, P < 0.003, corrected). The (myo-)inositol concentration did not differ between OCD patients and healthy controls and did not change during therapy. We provide preliminary evidence for a neurochemical marker that may prove informative about a patient's future benefit from behaviour therapy. Inositol, a metabolite involved in cellular signal transduction and a spectroscopic marker of glial activity, predicted the response to CBT selectively in the OFC, adding to the evidence for OFC involvement in OCD and highlighting neurobiological underpinnings of psychotherapy.

Background: The improvement of medical education is at the center of efforts to reform the studies of medicine. Furthermore, an excellent teaching program for students is a quality feature of medical universities. Besides teaching of disease-specific contents, the acquisition of interpersonal and decision-making skills is important. However, the cognitive style of senior physicians leading to a diagnosis cannot easily be taught. Therefore, the following study aimed at examining whether specific training in iterative hypothesis testing (IHT) may improve the correctness of the diagnostic process., Materials and Methods: Seventy-one medical students in their 9th-11th terms were randomized to medical teaching as usual or to IHT training for 4 weeks. The intervention group received specific training according to the method of IHT. All students were examined by a multiple choice (MC) exam and additionally by simulated patients (SP). The SPs were instructed to represent either a patient with depression and comorbid anxiety and substance use disorder (SP1) or to represent a patient with depression, obsessive-compulsive disorder and acute suicidal tendencies (SP2)., Results: All students identified the diagnosis of major depression in the SPs, but IHT-trained students recognized more diagnostic criteria. Furthermore, IHT-trained students recognized acute suicide tendencies in SP2 more often and identified more comorbid psychiatric disorders. The results of the MC exam were comparable in both groups. An analysis of the satisfaction with the different training programs revealed that the IHT training received a better appraisal., Conclusions: Our results point to the role of IHT in teaching diagnostic skills. However, the results of the MC exam were not influenced by IHT training. Furthermore, our results show that students are in need of training in practical clinical skills.

Major depressive disorder (MDD) is associated with increased volumes of visceral fat and a high prevalence of the metabolic syndrome. In turn, affective disorders are frequently found in patients with borderline personality disorder (BPD). It is therefore unclear whether BPD per se may influence body composition. In order to clarify a potential relationship between BPD and body composition, we measured visceral fat content (VFC) in young depressed women with and without comorbid BPD and related this parameter to various features of the metabolic syndrome. Visceral fat content was measured by magnetic resonance imaging in 22 premenopausal women with MDD only, in 44 women with comorbid MDD and BPD, in 12 female BPD patients without MDD, and in 34 healthy women (CG). Data showed that depressed women without comorbid BPD had a 335% higher VFC and women with comorbid BPD had a 250% higher VFC than the CG women. When controlling for age, data showed significant effects of MDD on VFC (F = 8.4; P = 0.005). However, BPD, with or without MDD, was not related to VFC. Young depressed women with and without comorbid BPD display increased visceral fat content when compared to control subjects and may therefore constitute a risk group for the development of the metabolic syndrome. BPD per se is not an additive risk factor in this context.

Repetitive, intrusive cognitive phenomena are central both to obsessive-compulsive patients - typically as obsessive thoughts - and to depressed patients - typically as ruminative thoughts. The objective of the present study is to compare obsessive and ruminative thoughts in non-depressed obsessive-compulsive and depressed patients. Thirty-four patients diagnosed with obsessive-compulsive disorder and 34 patients diagnosed with major depression disorder were asked to identify both a personally relevant obsessive and a personally relevant ruminative thought and to subsequently evaluate these thoughts on a modified version of the Cognitive Intrusions Questionnaire (CIQ) developed by Freeston, Ladouceur, Thibodeau, and Gagnon (1991). The CIQ assesses general descriptors, emotional reactions, appraisal and coping strategies on a nine-point Likert scale. A mixed-model ANOVA demonstrated that obsessive and ruminative thoughts are distinct cognitive processes, clearly distinguishable in form, appraisal and temporal orientation across disorders. In obsessive-compulsive patients, ruminative thoughts were more common and more emotionally distressing than predicted. In depressed patients, obsessive thoughts occurred infrequently and were not associated with high negative emotions. Clarifying similarities and differences between ruminative and obsessive thoughts and understanding their interaction might ultimately help to expand on the role of cognitive vulnerability factors in obsessive-compulsive and major depression disorder., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Meta-analyses of the randomized controlled trials (RCT) in obsessive-compulsive disorder (OCD) have clearly demonstrated that selective serotonin reuptake inhibitors (SSRIs) are the medication treatment of choice, while cognitive behavioural therapy (CBT) with exposure and response prevention is the psychotherapy of choice in OCD. Several guidelines emphasized that SSRIs are the first choice of medication in OCD. It has been noted that these agents may need to be given at a higher dose, and for a longer duration, than is usually the case in disorders such as depression. In the management of refractory patients, medication history should be carefully reviewed and adherence to the recommendations of the guideline established. Antipsychotics (risperidone, quetiapine, haloperidol) are currently the pharmacotherapy augmentation strategy of choice. In those OCD patients who fail to respond to a range of SSRIs and augmentation strategies combined with CBT, more unusual interventions (including deep brain stimulation) can be considered.

Context: The risk to develop dementia is significantly increased in diabetes mellitus. Memantine, an N-methyl-D-aspartate receptor antagonist, which is clinically applied in dementia, has been shown to exert neuroprotective effects under hypoglycemic conditions in rats., Objective: We hypothesized that memantine may prevent hypoglycemia-induced decrements in the cerebral high-energy phosphate, i.e. ATP, metabolism to exert its neuroprotective action under these conditions., Design and Participants: In a randomized, double-blind crossover design, we applied memantine vs. placebo in 16 healthy male subjects and examined the cerebral high-energy phosphate metabolism by (31)phosphor magnetic resonance spectroscopy, hormonal counterregulation, and neurocognitive performance during hypoglycemic glucose clamp conditions., Results: We found increments in hormonal counterregulation and reduced neurocognitive performance during hypoglycemia (P < 0.05). Cerebral ATP levels increased upon hypoglycemia in the memantine condition as compared with placebo (P = 0.006) and remained higher after renormalizing blood glucose concentrations (P = 0.018), which was confirmed by ATP to inorganic phosphate ratio (P = 0.046). Phosphocreatine levels and phosphocreatine to inorganic phosphate ratio remained stable throughout the experiments and did not differ between conditions (P > 0.1 for both)., Conclusion: Our data demonstrate that memantine preserves the cerebral energy status during experimentally induced hypoglycemia in healthy subjects. An improved neuronal energy status may thus be involved in the neuroprotective effect under these conditions and may qualify memantine as potential future option to combat cognitive impairments and dementia in diabetes.

Only selected aspects of the history of the House of the Poor Insane in the Hanseatic Free City of Lübeck have been studied to date.This article presents the results of an entire source study of this small institution in the 17th and 18th centuries, and briefly also during the next 40 years after the opening of a new building. In addition to the minute-book of the Governors, now kept in the Lübeck Municipal Archives, the results are based primarily on the account-books,which illustrate the institution's social history and activities. Examples are given. During most of the 17th century, the House was generally rather like a prison for the insane, but at the end of this century and in the early 18th there was a reform phase.This was followed by phases of repression and 'containment' at the end of the 18th century and in the early 19th century, before a renewed reform by the medical profession.The findings for Lübeck are compared with the development of inpatient care in institutions elsewhere, and the decisive factors in Lübeck are discussed.

Objective: The study aims to investigate the recognition of patients with Obsessive-Compulsive Disorder (OCD) in psychiatric outpatients., Subjects and Methods: A total of 2282 outpatients seen at 14 different psychiatric clinics in South Germany were asked to participate in the study. Five hundred and eighty-nine (30%) of the original 2282 patients met screening criteria for OCD, and of those, 237 (42%) participated in the final interview including DSM-IV diagnosis, and comorbidity., Results: Sixty-nine of 589 participating patients who screened positively for obsessive symptoms actually had an Obsessive-Compulsive Disorder. Only 19 (28%) of the outpatients diagnosed with OCD according to DSM-IV criteria were also given this diagnosis by their consultant. The psychopathology scores indicated that the OCD patients had clinically relevant OCD with a mean Yale-Brown Obsessive Compulsive Score (Y-BOCS) of 17.5 (± 5.4), and a mean Clinical Global Impression Score (CGI) of 5.2 (± 1.2)., Conclusions: In outpatient clinics over 70% of OCD patients remain unrecognised and thus untreated by consultants. Screening questions provide a rapid way of identifying those who may have OCD and should be incorporated into every mental state examination by consultants., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Objective: Iterative hypothesis testing (IHT) or related strategies of diagnostic decision making have been taught in many curricula for medical students but not in psychiatry. We therefore asked whether the addition of training in IHT may add to the quality of the psychiatry course., Method: Seventy-two medical students were randomized to four weeks problem-based learning or to IHT. Knowledge and skills of the students were tested using a multiple choice exam and simulated patients., Results: Iterative hypothesis testing-trained students recognized more diagnostic items and more often identified comorbid psychiatric disorders and acute suicidal tendencies. Acquisition of general psychiatric knowledge and global satisfaction with the course were similar in both groups., Conclusion: We conclude that teaching IHT to medical students may enhance their clinical ability to recognize complex disease patterns. Further studies are required concerning the enhancement of clinical skills in the psychiatric specialty.

Objective: We examined the prevalence of pain and pain severity in a sample of psychiatric inpatients. Currently, scant information exists about which patient groups are most affected by pain., Methods: Pain was assessed in 416 psychiatric inpatients using the brief pain inventory. Patients were characterized by applying DSM-IV criteria and obtaining self-reports of adverse childhood experiences., Results: Of psychiatric inpatients, 31.0% reported having substantial pain. Women with posttraumatic stress disorder (PTSD) had the highest prevalence of substantial pain among all psychiatric inpatients and a significantly higher rate compared to women without PTSD (49% vs. 28%, P=.02). Pain was significantly associated with adverse childhood experiences in both men and women., Conclusion: Within a group of psychiatric inpatients, pain is associated with PTSD in women and with adverse childhood experiences in both men and women. Attention should therefore be paid towards such high-risk groups and the consequences that the pain might entail for physical and mental health., (Copyright © 2010 Elsevier Inc. All rights reserved.)

The classic criticism levelled at German medical studies was addressed in 2002 with the reform of the German medical accreditation system. For the specialties Psychiatry and Psychotherapy, a national workshop of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) was held in Heidelberg on 23.01.2004 to implement the new legal requirements for teaching. In 2008, a postal survey was conducted among the 36 German medical faculties by the DGPPN to establish the current status of the proposed implementation, with the general structure of undergraduate medical training, student-centered syllabuses and the general significance of teaching forming the main points. With a response rate of 75%, the results can be considered representative. In general, a cautiously positive conclusion can be drawn on the implementation of the medical accreditation system. Having said that, it should be borne in mind that implementation is not yet complete and still requires optimization, for example in terms of making examinations not only theoretical but also more practical in approach.

Cerebral energy metabolism has been suggested to have an important function in body weight regulation. We therefore examined whether there is a relationship between body mass and adenosine triphosphate (ATP) metabolism in the human brain. On the basis of our earlier findings indicating a neuroprotective preferential energy supply of the brain, as compared with peripheral muscle on experimentally induced hypoglycemia, we examined whether this physiological response is preserved also in low-weight and obese participants. We included 45 healthy male subjects with a body mass index (BMI) ranging from 17 to 44 kg/m(2). Each participant underwent a hypoglycemic glucose-clamp intervention, and the ATP metabolism, that is, the content of high-energy phosphates phosphocreatine (PCr) and ATP, was measured repeatedly by (31)phosphor magnetic resonance spectroscopy ((31)P-MRS) in the cerebral cortex and skeletal muscle. Results show an inverse correlation between BMI and high-energy phosphate content in the brain (P<0.01), whereas there was no such relationship found between skeletal muscle and BMI. The hypoglycemic clamp intervention did not affect the ATP metabolism in both tissues. Our data show an inverse correlation between BMI and cerebral high-energy phosphate content in healthy humans, suggesting a close relationship between energetic supply of the brain and body weight regulation.