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Background There is limited knowledge of whether cognitive-behavioral therapy (CBT) or second-generation antipsychotics (SGAs) should be recommended as the first-line treatment in individuals at clinical high risk for psychosis (CHRp). Hypothesis To examine whether individual treatment arms are superior to placebo and whether CBT is non-inferior to SGAs in preventing psychosis over 12 months of treatment. Study Design PREVENT was a blinded, 3-armed, randomized controlled trial comparing CBT to clinical management plus aripiprazole (CM + ARI) or plus placebo (CM + PLC) at 11 CHRp services. The primary outcome was transition to psychosis at 12 months. Analyses were by intention-to-treat. Study Results Two hundred eighty CHRp individuals were randomized: 129 in CBT, 96 in CM + ARI, and 55 in CM + PLC. In week 52, 21 patients in CBT, 19 in CM + ARI, and 7 in CM + PLC had transitioned to psychosis, with no significant differences between treatment arms (P = .342). Psychopathology and psychosocial functioning levels improved in all treatment arms, with no significant differences. Conclusions The analysis of the primary outcome transition to psychosis at 12 months and secondary outcomes symptoms and functioning did not demonstrate significant advantages of the active treatments over placebo. The conclusion is that within this trial, neither low-dose aripiprazole nor CBT offered additional benefits over clinical management and placebo.

Filicides lead to questions about motives and missed opportunities for prevention. The development of preventive strategies is difficult due to heterogeneous perpetrator-victim dynamics. Eighteen c...

Combining antipsychotics is common in schizophrenia treatment, despite evidence-based guidelines generally not recommending such practice. Otherwise, evidence remains inconclusive, especially regarding specific combinations. The trial aimed to test whether a combination of amisulpride plus olanzapine is more effective than either intervention as a monotherapy.A multicentre, 16-week, randomised, double-blind, controlled trial was done at 16 psychiatric in-patient centres throughout Germany. Inclusion criteria were adults aged 18-65 years with non-first episode schizophrenia or schizoaffective disorder and with a Positive and Negative Syndrome Scale (PANSS) total score of at least 70 and at least two items of the positive symptoms subscale rated at least 4. Patients were randomly assigned to receive 16 weeks of treatment with either amisulpride plus olanzapine, amisulpride plus placebo, or olanzapine plus placebo (1:1:1), and block randomisation was stratified by study site. To keep patients and investigators masked throughout the duration of the trial, amisulpride, olanzapine, and placebo were administered as identical capsules. Flexibly dosed monotherapy of oral amisulpride (amisulpride plus placebo, 200-800 mg per day) or olanzapine (olanzapine plus placebo, 5-20 mg per day) was compared with a combination of amisulpride plus olanzapine. The primary outcome was symptom reduction measured by the PANSS total score after 8 weeks, in the modified intention-to-treat population (all patients randomly assigned to an intervention and receiving at least one study drug dose). As determined a priori, group differences were examined by t tests (Bonferroni-Holm-adjustment) followed by pre-planned Bayesian analyses as well as imputation methods based on mixed models to account for missing values and post-hoc ANCOVA adjusting for PANSS baseline scores. The study was registered on ClinicalTrials.gov, NCT01609153; the German Clinical Trials Register, DRKS00003603; and the European Union Drug Regulating Authorities Clinical Trials Database, EudraCT-No. 2011-002463-20.Between June 15, 2012, and Dec 15, 2018, 13 692 patients were assessed for eligibility. 13 364 patients were excluded (including for not meeting inclusion criteria, declining to participate, or inappropriate reasons for changing pharmacological treatment), and 328 were then randomly assigned to an intervention group. 112 patients were randomly assigned to receive amisulpride plus olanzapine, 109 were randomly assigned to receive amisulpride plus placebo, and 107 were randomly assigned to receive olanzapine plus placebo. 321 patients were analysed for the primary outcome in the modified intention-to-treat population after exclusion of screening failures and patients who did not receive the intervention (110 for amisulpride plus olanzapine, 109 for amisulpride plus placebo, and 102 for olanzapine plus placebo). Among the 321 patients who were randomly assigned to intervention groups and analysed for the primary outcome, 229 (71%) were male, 92 (29%) were female; the mean age was 40·2 years (SD 11·7); and 296 (92%) were White and 25 (8%) were classified as other ethnicity. PANSS total score improved significantly more at 8 weeks in the amisulpride plus olanzapine group (-29·6 [SD 14·5]) than in the olanzapine plus placebo group (-24·1 [13·4], p=0·049, Cohen's d=0·396). A significant difference was not observed in reduction of PANSS total score between the amisulpride and olanzapine group compared with the amisulpride and placebo group (-25·2 [SD 15·9], p=0·095, Cohen's d=0·29). After 8 weeks and 16 weeks, sexual dysfunction, weight, and waist circumference increase were significantly higher for patients receiving amisulpride plus olanzapine than for those receiving amisulpride plus placebo, with no differences in serious adverse events. Two patients died during study participation; one randomly assigned to the amisulpride plus olanzapine group, and one assigned to the olanzapine plus placebo group (both assessed with no relation to treatment).The advantages of amisulpride plus olanzapine have to be weighed against a higher propensity for side-effects. The use of this specific combination therapy could be an alternative to monotherapy in certain clinical situations, but side-effects should be considered.German Federal Ministry of Education and Research.

Background. The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services. Methods. We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases. Results. We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare. Conclusions. Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Background Impairments of social cognition are considered core features of schizophrenia and are established predictors of social functioning. However, affective aspects of social cognition including empathy have far less been studied than its cognitive dimensions. The role of empathy in the development of schizophrenia remains largely elusive. Methods Emotional and cognitive empathy were investigated in large sample of 120 individuals at Clinical High Risk of Psychosis (CHR-P) and compared with 50 patients with schizophrenia and 50 healthy controls. A behavioral empathy assessment, the Multifaceted Empathy Test, was implemented, and associations of empathy with cognition, social functioning, and symptoms were determined. Results Our findings demonstrated significant reductions of emotional empathy in individuals at CHR-P, while cognitive empathy appeared intact. Only individuals with schizophrenia showed significantly reduced scores of cognitive empathy compared to healthy controls and individuals at CHR-P. Individuals at CHR-P were characterized by significantly lower scores of emotional empathy and unspecific arousal for both positive and negative affective valences compared to matched healthy controls and patients with schizophrenia. Results also indicated a correlation of lower scores of emotional empathy and arousal with higher scores of prodromal symptoms. Conclusion Findings suggest that the tendency to 'feel with' an interaction partner is reduced in individuals at CHR-P. Altered emotional reactivity may represent an additional, early vulnerability marker, even if cognitive mentalizing is grossly unimpaired in the prodromal stage. Different mechanisms might contribute to reductions of cognitive and emotional empathy in different stages of non-affective psychotic disorders and should be further explored.

ZusammenfassungZiel der Arbeit war die Evaluation eines betriebsnahen integrierten Versorgungsmodells (IGV) zur Optimierung der Behandlung depressiver Störungen. Es handelte sich um eine Kooperation zwischen einem Betrieb und einer externen Versorgungseinrichtung mit dem Ziel der Früherkennung, einem frühen Behandlungszugang sowie der Unterstützung bei der Rückkehr zur Arbeit. Methode: IGV-Patienten mit Depressionen (N=64) wurden mit einer parallelisierten Kontrollgruppe der Regelversorgung (N=64) retrospektiv verglichen. Die Evaluation erfolgte primär anhand der Messung der Rückkehr zur Arbeit. Ergebnisse: Patienten der IGV kehrten häufiger (Odds Ratio 11.9; p

Background The objective of this study is to test the conflicting theories concerning the association of negative self and other schemata and paranoid ideation. Methods A risk-based approach, including risk stratification, is used to gain insight into the association of the negative self and other schemata that may be shared by individuals or differentiate between individuals at clinical high risk (CHR) for a first-episode psychosis and those with full-blown psychosis. The dataset includes a sample of individuals at CHR (n = 137) and a sample of individuals with persisting positive symptoms (PPS, n = 211). The CHR sample was subdivided according to a prognostic index yielding 4 CHR sub-classes with increasing risk for transition to psychosis. Results Negative beliefs about the self were associated with paranoid ideation in CHR and a lower risk state. In the highest risk state and full-blown psychosis, there is an association with negative beliefs about others. Conclusion These findings are in line with theories suggesting a switch from a predominantly activated negative self-schema to a malevolent others-schema in association with paranoid ideation along the risk-continuum. However, due to methodological limitations these results should be replicated by future studies.

Fur die Messung der Behandlungsqualitat psychisch Kranker in Deutschland wurden bereits verschiedene Qualitatsindikatoren-Sets vorgeschlagen und in vereinzelten psychiatrischen Einrichtungen pilotiert. Die Deutsche Gesellschaft fur Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN) befasst sich in einer „Task Force Qualitatsindikatoren (QI)“ mit der Weiterentwicklung und praktischen Umsetzung von Qualitatsindikatoren fur Schizophrenie. Das Ziel war die Auswahl von Qualitatsindikatoren fur Schizophrenie, die auf andere Diagnosen ubertragbar sowie fur generische Erhebungen geeignet sind und ohne hohen zusatzlichen Dokumentationsaufwand gemessen werden konnen. In einem mehrstufigen Selektionsprozess wahlte die DGPPN Task Force QI in Abstimmung mit dem Trialogischen Forum der DGPPN aus einem Grundbestand von 161 Qualitatsindikatoren aus dem nationalen und internationalen Raum Indikatoren aus, die sich auf wichtige Qualitatsaspekte beziehen. Die DGPPN schlagt die folgenden zehn Indikatoren fur die Messung der Versorgungsqualitat bei Schizophrenie vor, die aus bestehenden Indikatoren-Sets inhaltlich adaptiert wurden: QI1 Langzeittherapie/Monitoring von Nebenwirkungen, QI2 Zwangsmasnahmen, QI3 Anzahl der Suizide, QI4 Psychoedukativ-orientierte Angehorigengesprache, QI5 Zeitnahe ambulante Weiterbehandlung nach stationarer Entlassung, QI6 Deeskalationstraining – stationar, QI7 Diagnostik/Korperliche Untersuchung, QI8 Antipsychotische Polypharmazie, QI9 Rehabilitation/Berufliche Wiedereingliederung, QI10 Diagnostik/Funktionsfahigkeit. Die hier vorgeschlagenen Qualitatsindikatoren mussten grostenteils mit Daten aus zusatzlichen Erhebungen gemessen werden. Nach Einschatzung der DGPPN Task Force QI ist dieser zusatzliche Dokumentationsaufwand leistbar, der Mehraufwand aber zusatzlich zu verguten. In einem Machbarkeitstest sollen die Indikatoren in verschiedenen psychiatrischen Kliniken Deutschlands pilotiert werden.

Schizophrenia is one of the most severe mental diseases and leads to significant personal and social impairments for affected persons. The illness is characterized by frequent relapses, results in increased mortality and is associated with the highest socioeconomic costs of all diseases. Moreover, patients with schizophrenia are often stigmatized in everyday life and also in most treatment settings. In 1998 the first German schizophrenia guidelines were published, followed by the first S3 guidelines for schizophrenia in 2006. The revision process started in 2012 coordinated by the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and the revised guidelines were published in 2019. The target group for the revised S3 guidelines includes all persons involved in the care of patients with schizophrenia in all sectors of the German healthcare system, including decision makers and insurance funds. Starting with an introduction of the biological, clinical and epidemiological basis of the disorder, recommendations for the diagnostics of schizophrenia, the detection of comorbidities, the use of antipsychotic medication and other somatic procedures, for psychotherapy, psychosocial interventions, handling of special treatment conditions and rehabilitation are made. Finally, recommendations for an evidence-based and optimal coordination within the healthcare system are made, followed by a discussion of the cost-effectiveness of treatment and presentation of strategies for improved quality management. The most important aspect of the revised S3 guidelines on schizophrenia is the multiprofessional cooperation in all phases of the disorder and an empathic and respectful therapeutic alliance.

Dry eye disease (DED) is a multifactorial disease of the ocular surface that leads to symptoms of discomfort and reduces quality of life. Several studies have shown an association with depression. We investigated the prevalence of depressive symptoms and their severity in DED patients and examined whether depressive symptoms correlate with signs, symptoms, or subtypes of DED or with psychological factors (resilience, premorbid personality, and subjective well-being). This cross-sectional study (n = 64, mean age 56.72, 70% women) was conducted at the Dry Eye Clinic of the Department of Ophthalmology, University Hospital Dusseldorf. Psychological assessment included the Beck Depression Inventory, revised version (BDI-II); World Health Organization Well-Being Index (WHO-5); 13-item Resilience Scale (RS-13); and Munich Personality Test (MPT). DED parameters were assessed by the Ocular Surface Disease Index (OSDI), Schirmer test (ST), tear film break-up time (TBUT), and corneal fluorescein staining (CFS). As the reference for the BDI-II depression score, we used standard values from a German sample of healthy individuals (n = 582, 66% women). Multivariate logistic regression analysis was performed to investigate the effects of various parameters on depressive symptoms. Associations between variables were examined by Pearson or Spearman correlation tests. Among all participants, 61% had depressive symptoms (25% minimal, 14% mild, 17% moderate, and 5% severe). The mean BDI-II score (11.95, ± 8.46) was significantly higher than in the healthy reference group (p

The objective of the study was to evaluate an operational integrated care model (IC) aiming at optimized treatment of depression. It consisted of cooperation between a company and an external clinic with respect to early recognition of the disorder, early access to treatment and support for return to work.A retrospective group comparison of patients with depression receiving IC in a psychiatric outpatient clinic (N=64) and a control group with standard care in the same clinic (N=64) was performed. Primary outcome was return to work.Patients of the IC group returned to work significantly more often (Odds Ratio 11.9; p0.001) and 91.2 days earlier (p=0.010) than those of the group that received standard care.Specific measures of an IC program might accelerate the process of return to work.Ziel der Arbeit war die Evaluation eines betriebsnahen integrierten Versorgungsmodells (IGV) zur Optimierung der Behandlung depressiver Störungen. Es handelte sich um eine Kooperation zwischen einem Betrieb und einer externen Versorgungseinrichtung mit dem Ziel der Früherkennung, einem frühen Behandlungszugang sowie der Unterstützung bei der Rückkehr zur Arbeit. Methode: IGV-Patienten mit Depressionen (N=64) wurden mit einer parallelisierten Kontrollgruppe der Regelversorgung (N=64) retrospektiv verglichen. Die Evaluation erfolgte primär anhand der Messung der Rückkehr zur Arbeit. Ergebnisse: Patienten der IGV kehrten häufiger (Odds Ratio 11.9; p0,001) und 91,2 Tage früher (p=0,010) an den Arbeitsplatz zurück als Patienten aus der Regelversorgung. Schlussfolgerung: Betriebsnahe IGV-Maßnahmen könnten die Zeit bis zur Wiederaufnahme der Arbeit verkürzen.

Ziel der Studie: Einfluss des kognitiven Leistungsniveaus auf den Therapieerfolg bei Personen mit erhohtem Psychoserisiko. Methode: Multiple Regression in 2 Interventionsgruppen (n = 105): integrierte Psychologische Intervention mit Psychoedukation und supportive Beratung. Ergebnisse: Pradiktoren waren die Leistungsfahigkeit der exekutiven Kontrolle und Verarbeitungsgeschwindigkeit sowie des Arbeitsgedachtnisses und der Aufmerksamkeit. Schlussfolgerung: Eine Forderung des Leistungsniveaus ist bei Fruhinterventionen sinnvoll.

Qualitatsindikatoren sollten vor einer flachendeckenden Implementierung hinsichtlich ihrer Praktikabilitat uberpruft werden. Die Evaluierung der Messbarkeit von sektorenubergreifenden Qualitatsindikatoren fur Depression und Schizophrenie anhand von Routinedaten war Ziel dieses multizentrischen Machbarkeitstests. Die Durchfuhrbarkeit der Qualitatsindikatoren wurde in 10 Fachkliniken fur Psychiatrie und Psychotherapie mithilfe retrospektiver Analysen von anonymisierten Routinedaten uberpruft. Als Datenquellen dienten die Daten der klinischen Dokumentationsroutine im Krankenhausinformationssystem und in einigen Kliniken zusatzlich die Daten aus den Aufnahme- und Entlassungsbogen der psychiatrischen Basisdokumentation (BADO). Die Auswertungen bezogen sich auf alle Falle von Erwachsenen mit diagnostizierter Depression oder Schizophrenie innerhalb definierter Erhebungszeitraume. Insgesamt wurden 5 Indikatoren fur Depression und 9 Indikatoren fur Schizophrenie – teils mit inhaltlichen Anpassungen der Indikatorformulierung – ausgewertet und als messbar oder eingeschrankt messbar bewertet. Aufgrund unterschiedlicher Dokumentationen konnten einige Indikatoren nicht in allen Kliniken erhoben werden. Die meisten Indikatoren konnten mit Daten aus der BADO erhoben werden. Eine Messung von Indikatoren, die qualitatsrelevante Versorgungsaspekte bei Depression und Schizophrenie messen, ist unter Verwendung der aktuellen Routinedatendokumentationen in den teilnehmenden Kliniken eingeschrankt realisierbar. Die unterschiedlichen Dokumentationsmethoden erschweren eine einheitliche Messung. Zur Durchsetzung bundesweiter Minimalstandards der Versorgungsqualitat bei psychischen Storungen sollten daher die fallbezogenen Krankenhausdokumentationen sektorenubergreifend an konsentierte Qualitatsindikatoren angepasst werden. Die BADO scheint dabei ein geeignetes Ausgangssystem darzustellen.

Anliegen: Es gibt Evidenz fur die Wirksamkeit aufsuchender auserklinischer Behandlung von akuten schweren psychischen Storungen. In Deutschland gibt es bisher nur wenig klar definierte Modelle. Methode: Vorstellung eines modularisierten Modells im Rahmen einer prospektiven Untersuchung. Die Definition und Verteilung spezifischer therapeutischer Aufgaben an einzelne Berufsgruppen soll eine hohe Manualtreue ermoglichen. Ergebnis und Diskussion: In 15 Monaten erfolgten rund 600 Hausbesuche bei 32 Patienten. Der Median lag bei 15,5 Hausbesuchen/Patient. Es zeigte sich eine signifikant erhohte Akzeptanz gegenuber dieser ambulanten Behandlungsform (Abbruchrate 16 %) im Vergleich zu vorangegangen stationaren Behandlungen (Abbruchrate 50 %) (Chi-Quadrat-Test, p = 0,003). Die Arbeit zeigt die Umsetzbarkeit und Akzeptanz dieses Modells einer aufsuchenden Therapie.

OBJECTIVE: The aim of this study was to assess associations between momentary stress and both affective and psychotic symptoms in everyday life of individuals at clinical high risk (CHR), compared to chronic psychotic patients and healthy controls, in search for evidence of early stress sensitization. It also assessed whether psychotic experiences were experienced as stressful.METHOD: The experience sampling method was used to measure affective and psychotic reactivity to everyday stressful activities, events and social situations in 22 CHR patients, 24 patients with a psychotic disorder and 26 healthy controls.RESULTS: Multilevel models showed significantly larger associations between negative affect (NA) and activity-related stress for CHR patients than for psychotic patients (P = 0.008) and for CHR compared to controls (P < 0.001). Similarly, the association between activity-related stress and psychotic symptoms was larger in CHR than in patients (P = 0.02). Finally, the association between NA and symptoms (P < 0.001) was larger in CHR than in patients.CONCLUSION: Stress sensitization seems to play a role particularly in the early phase of psychosis development as results suggest that CHR patients are more sensitive to daily life stressors than psychotic patients. In this early phase, psychotic experiences also contributed to the experience of stress.

Die Qualitat der psychiatrischen, psychotherapeutischen und psychosomatischen Versorgung hangt von verschiedenen Einflussfaktoren ab. Kontinuierliche strukturelle Veranderungen, wie die Einfuhrung eines neuen, pauschalierten Entgeltsystems und die Entwicklung der personellen Ressourcen, beeinflussen die Qualitat der Versorgung (Pollmacher 2014). Die begleitende und dauerhafte Anwendung von geeigneten, evidenzbasierten Instrumenten im Rahmen des externen und internen Qualitatsmanagements gewinnt dabei an Bedeutung. Methodisch hochwertige Leitlinien werden kontinuierlich entwickelt und aktualisiert. Um einen positiven Einfluss auf die Versorgungsqualitat ausuben zu konnen, mussen diese mithilfe effektiver Strategien und leitlinienbasierten Qualitatsindikatoren implementiert und evaluiert werden. Mit der Entwicklung von Qualitatsindikatoren durch das AQUA-Institut (Institut fur angewandte Qualitatsforderung und Forschung im Gesundheitswesen) und das IQTIG (Institut fur Qualitatssicherung und Transparent im Gesundheitswesen) wird die gesetzliche Qualitatssicherung vorangetrieben. Einheitliche Qualitatsindikatoren sollen hierbei in Zukunft einrichtungsubergreifend erhoben werden und einen Beitrag zur Verbesserung der Transparenz der Versorgung liefern. Zentrale Herausforderung bei der Umsetzung der sektorenubergreifenden Qualitatssicherung sind die Fragmentierung der Versorgungsstrukturen und deren unterschiedliche Finanzierungs- und Datenstrukturen.

Patienten mit psychotischen Storungen, die gem. PsychKG wegen Fremdgefahrdung untergebracht waren, konnen als Risikopopulation fur kunftige Fremdgefahrdung, weitere unfreiwillige Unterbringungen und forensische Entwicklungen gelten. Spezifische Nachsorgekonzepte fehlen bisher. Die vorliegende Pilotstudie untersucht die Durchfuhrbarkeit eines modularen, fur die Belange der Zielklientel spezifizierten Therapieprogramms, das ambulant uber sechs Monate angewandt wird, und betrachtet explorativ die stationaren Wiederaufnahmeraten wahrend der Intervention. Konsekutives Screening aller nach PsychKG in der Allgemeinpsychiatrie untergebrachten Patienten hinsichtlich einer moglichen Studienteilnahme im Zeitraum 05 – 11/2012. Eingeschlossene Patienten erhielten eine sechsmonatige Studienintervention. Erfassung der individuellen Inanspruchnahmen der Therapiemodule und der Zahl der stationaren Wiederaufnahmen, differenziert nach Rechtsgrundlagen. Studieneinschlussquote: 17,4 % aller gescreenten Patienten (115) und 57 % aller moglichen Studienteilnehmer. Abbrecherquote: 15 %. Durchschnittliche Inanspruchnahme: 23,5 therapeutische Kontakte/6 Monate. Stationare Wiederaufnahmerate: 50 %, davon 60 % auf freiwilliger Rechtsgrundlage. Die Ergebnisse belegen die Machbarkeit und Akzeptanz der Studienintervention in der untersuchten Population. Ein Uberwiegen von freiwilligen stationaren Wiederaufnahmen wahrend der Intervention deutet darauf hin, dass bei der Mehrzahl der Patienten ein hoherer Grad an therapeutischer Zusammenarbeit erreicht werden kann. Die weitergehende Untersuchung zur Reduktion unfreiwilliger stationarer Wiederaufnahmen und zur Vermeidung forensischer Verlaufe unter Verwendung des hier vorgestellten Interventionsansatzes in Verbindung mit Methoden des Risikoassessments in einem sich anschliesenden Hauptprojekt erscheint gerechtfertigt.

OBJECTIVE High utilisers of psychiatric services are defined as a group of patients showing a great amount of service use, especially inpatient care, consequently causing immense costs. There is a lack of studies investigating differences between East and West Germany. METHODS Service use and psychopathology were examined in 350 high utilisers receiving inpatient treatment in one East German and three West German psychiatric hospitals. RESULTS Whereas current length of stay was higher in participants from West Germany, readmissions were more frequent in the East German participants who also exhibited higher psychopathology. CONCLUSION Presumably, the deficient situation of outpatient health care in East Germany is compensated by increased stationary admission, consequently leading to a structural promotion of high utilisation.

Zink M, Schirmbeck F, Rausch F, Eifler S, Elkin H, Solojenkina X,Englisch S, Wagner M, Maier W, Lautenschlager M, Heinz A,Gudlowski Y, Janssen B, Gaebel W, Michel TM, Schneider F, LambertM, Naber D, Juckel G, Krueger-Oezguerdal S, Wobrock T, Hasan A,Riedel M, M€uller H, Klosterk €otter J, Bechdolf A. Obsessive–compulsive symptoms in at-risk mental states for psychosis:associations with clinical impairment and cognitive function.Objective: Obsessive–compulsive symptoms (OCS) constitute a majorcomorbidity in schizophrenia. Prevalence estimations of OCS forpatients with at-risk mental states (ARMS) for psychosis vary largely. Itis unclear how ARMS patients with or without comorbid OCS differregarding general psychosocial functioning, psychotic and affectivesymptoms and neurocognitive abilities.Method: At-risk mental states patients (n = 233) from theinterventional trial PREVENT (Secondary Prevention ofSchizophrenia) were stratified according to the presence or absence ofcomorbid OCS and compared on several clinical variables.Results: Patients, who fulfilled the criteria for obsessive–compulsivedisorder (OCD) or presented with subclinical OCS (ARMSposOCSsample), did not significantly differ from patients without OCS(ARMSnegOCS) with regard to gender, age, premorbid verbalintelligence and levels of education. Furthermore, similar severity ofdepressive syndromes, basic cognitive, attenuated psychotic and brieflimited intermittent psychotic symptoms were found. However,ARMSposOCS patients showed more impairment of psychosocialfunctioning and higher general psychopathology. In contrast, theyscored higher in cognitive tasks measuring working memory andimmediate verbal memory.Conclusion: Findings extend upon previous results due to themultidimensional assessment. Subsequent longitudinal studies mightelucidate how comorbid OCS influence differential treatment response,especially to cognitive behavioural interventions and the transition ratesto psychosis.

AimThe concept of coping is relevant to recent models of psychosis, and people with established psychotic disorders have been found to predominately use maladaptive coping strategies. This study aimed to examine the general coping patterns of people at clinical high risk of psychosis (CHR) and to investigate whether pre-therapy coping behaviour plays a role in predicting responsiveness to early interventions. MethodsOne hundred twenty-eight help-seeking CHR outpatients were randomized into two treatment groups: either receiving integrated psychological intervention (IPI), including cognitive behaviour therapy, or supportive counselling (SC) for 12 months. Of those, 91 persons completed a Stress Coping Questionnaire (SCQ) at intake: 45 in the IPI group and 46 in the SC group. General coping behaviour in this sample was analysed and several regressions were conducted separately for each treatment group to examine coping as a predictor of outcome after 12 months of different forms of treatment. ResultsParticipants relied significantly more on negative than on positive coping strategies, t(90)=-7.185, P

OBJECTIVES Although guidelines usually recommend monotherapy, in clinical practice, antipsychotic polypharmacy is common especially with chronically ill patients. We therefore assessed the current practice of antipsychotic polypharmacy in "high-utilising" patients with schizophrenia in Germany. METHODS Antipsychotic medication was assessed using a representative sample of 638 patients with schizophrenia from two multi-centre studies. RESULTS Antipsychotic combination treatment was administered to 43.9 % of the patients. Combination treatment not including clozapine was apparent in 36.2 %. CONCLUSIONS Antipsychotic polypharmacy is prevalent in the treatment of patients with schizophrenia showing high service use also when excluding such combinations with clozapine. Differences between the study samples indicate possible influences linked with therapy resistance or treatment setting.

Anliegen: Prozessevaluation einer bedarfsorientierten Entlassplanungsintervention fur Patienten mit hoher Inanspruchnahme stationarer psychiatrischer Behandlung. Methode: Analyse von Interventions-Drop-outs vs. Interventions-Inanspruchnehmer und des Einflusses von Parametern auf die Entwicklung ungedeckter Hilfebedarfe. Ergebnisse: Schwerer Erkrankte wurden von der Intervention nicht erreicht. Gute Umsetzung der Losungsvorschlage und Zufriedenheit mit Losungsvorschlagen waren mit einer Reduktion ungedeckter Bedarfe assoziiert. Schlussfolgerung: Schwachen der Intervention konnten zur fehlenden Uberlegenheit gegenuber der Standardbehandlung beigetragen haben.

Hintergrund Die Deutsche Gesellschaft fur Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) entwickelte vier sektorenubergreifende Qualitatsindikatorensets fur die haufigen psychischen Storungsbilder Alkoholabhangigkeit, Demenzen, Depression und Schizophrenie.

BackgroundPatients with psychosis display the so-called ‘Jumping to Conclusions’ bias (JTC) – a tendency for hasty decision-making in probabilistic reasoning tasks. So far, only a few studies have evaluated the JTC bias in ‘at-risk mental state’ (ARMS) patients, specifically in ARMS samples fulfilling ‘ultra-high risk’ (UHR) criteria, thus not allowing for comparisons between different ARMS subgroups.MethodIn the framework of the PREVENT (secondary prevention of schizophrenia) study, a JTC task was applied to 188 patients either fulfilling UHR criteria or presenting with cognitive basic symptoms (BS). Similar data were available for 30 healthy control participants matched for age, gender, education and premorbid verbal intelligence. ARMS patients were identified by the Structured Interview for Prodromal Symptoms (SIPS) and the Schizophrenia Proneness Instrument – Adult Version (SPI-A).ResultsThe mean number of draws to decision (DTD) significantly differed between ARM -subgroups: UHR patients made significantly less draws to make a decision than ARMS patients with only cognitive BS. Furthermore, UHR patients tended to fulfil behavioural criteria for JTC more often than BS patients. In a secondary analysis, ARMS patients were much hastier in their decision-making than controls. In patients, DTD was moderately associated with positive and negative symptoms as well as disorganization and excitement.ConclusionsOur data indicate an enhanced JTC bias in the UHR group compared to ARMS patients with only cognitive BS. This underscores the importance of reasoning deficits within cognitive theories of the developing psychosis. Interactions with the liability to psychotic transitions and therapeutic interventions should be unravelled in longitudinal studies.

Bisher liegen wenige Studien zur Wirksamkeit von Psychoedukation bei jungen Erwachsenen mit erhohtem Psychoserisiko vor, wahrend der Nutzen psychoedukativer Interventionen bei bereits manifestierten Psychosen mehrmals bestatigt wurde. Ziel der vorgestellten Studie war es, die Effekte von Psychoedukation bei Personen mit erhohtem Psychoserisiko im psychosefernen Prodrom zu evaluieren. Es wurde eine randomisierte, kontrollierte multizentrische Studie mit 128 hilfesuchenden Risikopatienten durchgefuhrt, die fur 12 Monate entweder eine Psychoedukation als Teil einer integrierten psychologischen Intervention (IPI) oder eine supportive Beratung (SB) erhielten. Dabei wurden die Zeit bis zum Ubergang in eine Psychose zu den „Follow-up“-Erhebungen (12 und 24 Monate) sowie die soziale Anpassung anhand der Social Adjustment Scale-II (SAS-II) initial, zum Zeitpunkt des Ubergangs und nach Abschluss der Intervention erhoben. Die spezifische Intervention war der SB sowohl in der 12-Monate- (3,2 vs. 16,9%; p =0,008) als auch in der 24-Monate-Follow-up-Erhebung (6,3 vs. 20,0% p =0,019) in der Pravention von Ubergangen signifikant uberlegen. Dagegen zeigte sich keine Uberlegenheit in den SAS-II-Werten der Patienten. Vielmehr konnten die Patienten beider Interventionen die soziale Anpassung im Pra-post-Vergleich signifikant verbessern. Psychoedukation als Teil eines Gesamtbehandlungsprogramms scheint in der Pravention von Psychosen uber einen 24-Monate-Zeitraum effektiv zu sein. Daruber hinaus profitieren Patienten sowohl von der die Psychoedukation umfassenden IPI als auch von der SB im Hinblick auf die soziale Anpassung.

The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.

BackgroundYoung people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred.AimsTo investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive–behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS.MethodA randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up.ResultsA total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019).ConclusionsIntegrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.

Objective: There are presently no instruments available in German language to assess the therapeutic relationship in psychiatric care. This study validates the German version of the Scale to Assess the Therapeutic Relationship in Community Mental Health Care (D-STAR). Method: 460 persons with severe mental illness and 154 clinicians who had participated in a multicenter RCT testing a discharge planning intervention completed the D-STAR. Psychometric properties were established via item analysis, analyses of missing values, internal consistency, and confirmatory factor analysis. Furthermore, convergent validity was scrutinized via calculating correlations of the D-STAR scales with two measures of treatment satisfaction. Results: As in the original English version, fit indices of a 3-factor model of the therapeutic relationship were only moderate. However, the feasibility and internal consistency of the D-STAR was good, and correlations with other measures suggested reasonable convergent validity. Conclusions: The psychometric properties of the D-STAR are acceptable. Its use can be recommended in German-speaking countries to assess the therapeutic relationship in both routine care and research.

Background: Although there are encouraging results from clinical trials focusing on second generation antipsychotics, omega-3-fatty acids or psychotherapy for the prevention of psychosis, their empirical evidence remains uncertain and it is unknown whether these interventions are comparable in reducing the risk of conversion to psychosis in persons at clinical high risk (CHR).

Antipsychotics, cognitive behavioral therapy (CBT), and omega-3-fatty acids have been found superior to control conditions as regards prevention of psychosis in people at-risk of first-episode psychosis. However, no large-scale trial evaluating the differential efficacy of CBT and antipsychotics has been performed yet. In PREVENT, we evaluate CBT, aripiprazole, and clinical management (CM) as well as placebo and CM for the prevention of psychosis in a randomized, double-blind, placebo-controlled trial with regard to the antipsychotic intervention and a randomized controlled trial with regard to the CBT intervention with blinded ratings. The hypotheses are first that CBT and aripiprazole and CM are superior to placebo and CM and second that CBT is not inferior to aripiprazole and CM combined. The primary outcome is transition to psychosis. By November 2010, 156 patients were recruited into the trial. The subjects were substantially functionally compromised (Social and Occupational Functioning Assessment Scale mean score 52.5) and 78.3% presented with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition axis I comorbid diagnosis. Prior to randomization, 51.5% of the participants preferred to be randomized into the CBT arm, whereas only 12.9% preferred pharmacological treatment. First, assessments of audiotaped treatment sessions confirmed the application of CBT-specific skills in the CBT condition and the absence of those in CM. The overall quality rating of the CBT techniques applied in the CBT condition was good. When the final results of the trial are available, PREVENT will substantially expand the current limited evidence base for best clinical practice in people at-risk (prodromal) of first-episode psychosis.

Zusammenfassung Ziel dieses Projektes war die Verbesserung psychiatrischer Behandlungsstrategien und Behandlungsergebnisse bei akutstationaren Patienten in einem Verbund von neun psychiatrischen Fachkliniken des Landschaftsverbandes Rheinland (LVR) durch Einfuhrung eines Benchmarkings und dessen Verknupfung mit vorhandenen QM-Strukturen. Patientengruppen, die durch einen schwierigen klinischen Verlauf oder einen uberdurchschnittlichen stationaren Behandlungsbedarf charakterisiert sind (Alkoholabhangigkeit, Depression im Alter, Schizophrenie) wurden ausgewahlt und Optimierungspotentiale wurden sowohl klinikspezifisch, als auch verbundubergreifend ausgearbeitet. Das Projekt wurde zeitversetzt an zwei Patientenkohorten vor bzw. nach qualitatsbezogenen Interventionen durchgefuhrt. Die Interventionen wurden ebenfalls sowohl klinikspezifisch, als auch verbundubergreifend implementiert. Insgesamt wurden Behandlungsdokumentationen von 1.696 Patienten (1. Kohorte n = 1856, 2. Kohorte n = 1696) abgeschlossen. Obwohl eine statistisch signifikant quantifizierbare Qualitatsoptimierung fur die drei Problemgruppen, insbesondere verbundubergreifend, nicht durchgehend erreicht wurde, konnten hinsichtlich der Benchmarking-gestutzten Optimierung von zentralen Behandlungsprozessen Erfolge an einzelnen Kliniken und fur den gesamten Klinikverbund erreicht werden, insbesondere unter Berucksichtigung entsprechender Leitlinienempfehlungen. Zukunftige Projekte sollten insbesondere die „Leitlinienkonformitat“ anhand von Struktur- und Prozessmerkmalen als Ausgangspunkt und Evaluationskriterium von qualitatsbezogenen Interventionen definieren.

OBJECTIVE To evaluate feasibility of a structured discharge planning intervention for high utilisers of mental health care developed in a multicentre RCT. METHODS Data of N = 241 participants (discharge and 3-month follow-up) allocated to the intervention group are analysed with regard to the intervention's quality of implementation, acceptance, and changes in needs. RESULTS The intervention was well accepted among patients and staff. However, a subgroup of participants showed manual violations. Total and unmet needs could be reduced between baseline and follow-up. Amount and change of needs substantially varied by centre and there was a trend towards variation by dose. CONCLUSIONS The intervention was feasible. Further analyses are needed to explore differential efficacy.

PURPOSE OF REVIEW The German mental healthcare system is currently undergoing discussions regarding the assessment of mental healthcare quality and the identification of potentials for optimizing mental healthcare. Quality assurance projects play an important role in the optimization of the care for the mentally ill in Germany. This review describes the most recent results of quality assurance programs from Germany as identified by a systematic literature search covering the time span 1 January 2008 until 1 June 2009. RECENT FINDINGS The German mental healthcare system is characterized by a high degree of structural quality. Quality assurance research in German mental healthcare is multifaceted and several projects are underway to determine the cost-effectiveness of procedures in mental healthcare and the development of quality indicators. SUMMARY In Germany, mental healthcare research is a rapidly developing field. Potentials for improvements can be identified in the assessment of process and outcome quality, the regional distribution, and the coordination among service providers. More studies are needed to identify the best methods to assess quality in mental healthcare with a view to improve process and outcome quality.

OBJECTIVE Up to 50 % of patients suffering from major depression are not recognised by their general practitioners. On the other hand general practitioners do rate some of their patients as depressive despite the fact that psychiatric diagnostic instruments do not. In this study we wanted to not only analyse the number and proportion of concordant diagnoses between GP and an established psychiatric diagnostic instrument (PHQ-9), but also to analyse the modalities of non-concordant diagnostic classifications. METHODS 34 participating GPs asked all their patients visiting them at one ordinary work-day to fill in a questionnaire that included the German version of PHQ-9. Independently GPs documented their diagnostic judgement. If they saw a mental affection, they were asked to choose between eight different affections, with depression being just one of them. RESULTS 1 277 patients filled in the questionnaires; from these 902 questionnaires could be analysed, because a pair of GP and patient could be identified. The prevalence of major-depression in the study-population was 9 %. GPs and PHQ-9 diagnoses were concordant in 45 %. However, GPs rated two thirds of patients that were classified as depressed by the PHQ-9 as psychologically affected. In these patients they also devoted more than half of the consultation time to mental problems. CONCLUSIONS GPs do often not diagnose patients as depressive even though they clearly realise their mental affection. Simple explanations like lack of time or conscious or unconscious avoidance to make a psychiatric diagnosis cannot explain this phenomenon.

Objective: Subjective quality of life (sQoL) and potentially contributing factors were investigated in individuals putatively in an early (EIPS) or late initial prodromal state (LIPS) and healthy controls (HC). Method: Participants comprised 58 EIPS individuals, 157 LIPS individuals and 87 HC individuals. sQoL was assessed together with locus of control (LoC), coping, demography and psychopathology. Results: Putatively prodromal groups exhibited markedly lower sQoL than HC (all domains P

Metabolic Syndrome (MetS) is one of the most common factors underlying the high rate of mortality observed in patients with schizophrenia. Recent research on this topic revealed that many of the patients studied were, in fact, in a medicated state. As such, it is unclear whether MetS is causally associated with the disorder itself or the medication used to treat it. In this study, patients with a clinically high risk of expressing first episode psychosis (CHR) were examined regarding the prevalence of MetS. N=144 unmedicated and antipsychotic-naive CHR patients, aged between 18 and 42years and suffering from unmanifested prodromal symptoms, were compared with a cohort of N=3995 individuals from the "German Metabolic and Cardiovascular Risk Study" (GEMCAS). A slightly higher prevalence of individual MetS criteria was observed in the CHR group compared to the GEMCAS sample; specifically, the following were noted: a higher blood pressure (35.0% vs. 28.0%), increased waist circumference (17.6% vs. 15.1%), and increased fasting blood glucose (9.4% vs. 4.0%) in CHR patients. Additionally, the rate of reduced HDL cholesterol concentrations was lower in the control group (20.2% vs. 13.3%).

Investigate whether treatment response in people at clinical high risk of psychosis (CHR) is predicted by their cognitive performance.128 CHR outpatients were randomized into two treatment groups, one receiving integrated psychological intervention (IPI), including psychoeducation, the other receiving supportive counselling (SC) for 12 months. Multiple regression analysis was used to identify neurocognitive predictors of treatment response in a subgroup of n = 105, measured by symptomatic and functional improvement at 1-year follow-up.In the IPI, treatment response was associated with performance of executive control and processing speed (R² = 0.27, p = 0.002). In both treatment groups, performance of working memory/attention was a significant predictor (IPI: R² = 0.15, p = 0.039, SC: R² = 0.19, p = 0.012).Cognitive performance is associated with treatment response in CHR people. The enhancement of cognitive performance is a useful target of early intervention.

Although there is growing evidence for clinical effectiveness of crisis resolution teams (also called Home Treatment Teams) for patients with severe psychotic disorders, a lot of studies suffer from poor model fidelity, which leads to an ignorance of specific effective factors.Here we present the implementation of an assessment-based Home Treatment in Germany. Assessment-derived therapeutic tasks are shared between team members by a manualized process.We visited 32 patients almost 600 times in 15 months. The median was 15.5 visits per patient. Adherence to Home Treatment intervention was significantly stronger (unplanned discharge 16 %) compared to prior hospitalization (unplanned discharge 50 %) (Chi-square test, p = 0.003).Applying this model, a detailed definition of specific tasks for team members leads to a high model fidelity and increases patients' compliance to therapy.

Purpose:To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.Methods:We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).Results:Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).Discussion:There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.Conclusion:Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.

Over the past decades, reductions of hospital beds and lengths of stay in general psychiatry are opposed to increases in detention cases and times in forensic psychiatric institutions. These developments raise the issue of trans-institutionalization of patient subgroups, whose particular needs of support are less accommodated by rationalized general psychiatry. While forensic psychiatric aftercare with a focus on risk assessment and assertive treatment has been largely established, preventive care of high-risk psychiatric patients to avert delinquency, compulsory hospitalization, or forensic courses has not yet been developed. Three outpatient studies addressing these issues have been conceptualized independently and were initiated in Germany and Switzerland. All three have similar study endpoints regarding incidence of violence, delinquency, compulsory hospitalization, and forensific sequelae. However, designs and methods differ with regard to inclusion criteria, assessment methods, foci of interventions, modes of delivering care, degrees of assertiveness, and times of follow-up. By the time of study completions, it can be expected that the joined information from all three studies will allow for a comprehensive appraisal of preventive treatment strategies and approaches in high-risk patients. In this paper, the study designs and methods of the three trials are outlined.

The positive effect of greater adherence to evidence-based guidelines on possibilities of optimizing diagnosis and therapy has been shown various times. Electronic systems for interactive support and systematization of physicians' decision-making represent a relatively new method for implementing guidelines. Introducing the "schizophrenia module", newly developed decision support software is presented combining electronic data processing-based, quality-oriented documentation and interactive decision support in the outpatient treatment for schizophrenic disorders. Structure, functionality, and options of use are presented. Besides classic measures of quality management (benchmarking), electronic decision support systems can contribute to improve process quality and outcome in the treatment of mental diseases.

ZusammenfassungDie Steigerung von Qualität und Effizienz in der gesundheitlichen Versorgung bildet ein Schwerpunktthema der aktuellen politischen Diskussion. Die Identifikation von Optimierungspotenzialen und ihre Erschließung durch stärkere ärztliche Leitlinienorientierung im Behandlungsprozess gewinnen daher auch im Bereich der neuro-psychiatrischen Erkrankungen zunehmend an Bedeutung. Auf Grund ihrer medizinischen, gesundheitspolitischen und ökonomischen Bedeutung erscheinen die schizophrenen Störungen in besonderer Weise geeignet zur exemplarischen Entwicklung und Erprobung von Verfahren des Qualitätsmanagements in der Psychiatrie. Psychiatriespezifischen Besonderheiten wie der schwierigen Operationalisierung des Behandlungsergebnisses sollte jedoch bei der Neuentwicklung von QMMethoden und Instrumenten beziehungsweise bei ihrer Übertragung aus den somatischen Fächern Rechnung getragen werden. Vor dem Hintergrund des aktuellen Standes des Qualitätsmanagements in der Psychiatrie wird eine Reihe von Projekten zur Qualitätsoptimierung in der Schizophreniebehandlung unter dem Dach des Kompetenznetzes Schizophrenie vorgestellt.

Zusammenfassung: Eine stärkere Orientierung der ärztlichen diagnostisch-therapeutischen Entscheidungsfindung an vorliegenden Leitlinien kann grundsätzlich einen entscheidenden Beitrag zur Erschließung von Optimierungspotenzialen in Psychiatrie und Psychotherapie leisten. Studien verweisen jedoch auf vielfach noch unzureichende Leitlinienkonformität und auf Varianzen in der Behandlungsqualität. Vor diesem Hintergrund werden zunächst Konzept und Methodik der Leitlinienentwicklung durch eine Fachgesellschaft am Beispiel der DGPPN vorgestellt. Anhand einer Reihe von Projekten aus den Kompetenznetzen Depression und Schizophrenie werden zudem aktuelle Befunde zu erfolgreichen Strategien der Dissemination und Implementation von Leitlinien diskutiert. Vorliegende erste positive Evaluationsergebnisse aus diesen Projekten verdeutlichen das Potenzial hinsichtlich Prozessqualität und Outcome der Behandlung, das von einer Verbesserung der Leitlinienkonformität auch unter Alltagsbedingungen zu erwarten ist.

BackgroundThe Early Detection and Intervention Programme of the German Research Network on Schizophrenia (GRNS) investigates the initial prodromal phase of psychosis in a multidimensional approach. Two intervention strategies are being studied by two large-scale multicentre projects.AimsTo present the concept of the intervention studies, and to provide an interim report of the recruitment procedure.MethodComprehensive cognitive-behavioural therapy has been developed for patients in the ‘early initial prodromal state’. For patients in the ‘late initial prodromal state’ the atypical neuroleptic amisulpride is explored. Both interventions are evaluated in randomised controlled trials using clinical management as the control condition.ResultsBetween January 2001 and March 2003, 1212 individuals seeking help for mental health problems were screened for putative prodromal symptoms at four university centres. More than 388 individuals fulfilled criteria for both interventions and 188 (48. 5%) gave informed consent to participate in the trials.ConclusionsThe screening procedure appears to be feasible and trial participation seems to be acceptable to a relevant proportion of people at increased risk of developing psychosis.

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.

In der ambulanten Depressionsbehandlung scheint das vorhandene diagnostisch-therapeutische Potenzial vielfach noch nicht ausgeschopft zu werden. Die Folge sind eine variierende Behandlungsqualitat und teilweise unzureichende Kosteneffektivitat. Eine Moglichkeit zur Verbesserung der Behandlungsqualitat konnte in der Implementierung leitlinienorientierter Vergutungssysteme liegen. Entsprechende Anreizsysteme wurden bereits fur die Versorgung somatischer Krankheitsbilder wie Diabetes mellitus formuliert und erprobt. Der vorliegende Beitrag greift diese Erfahrungen auf und versucht sie fur den Bereich der psychiatrischen Erkrankungen nutzbar zu machen. Am Beispiel der depressiven Storungen wird das Modell eines qualitatsorientierten, leitlinienbasierten ambulanten Vergutungssystems fur die allgemein- und facharztliche Praxis vorgestellt.