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Background: Particularly in rural regions, factors such as lower physician density and long travel distances complicate adequate outpatient care. However, urban regions can also be affected by deficits in care, for example, long waiting times. One model of care intending to improve the situation is the implementation of video consultations. The study protocol presents the methodology of the research project titled "Preference-based implementation of the video consultation in urban and rural regions" funded by the German Federal Joint Committee (funding number 01VSF20011)., Objective: This study aims to identify existing barriers to the use of video consultation and the preferences of insured individuals and physicians as well as psychotherapists in order to optimize its design and thus increase acceptance and use of video consultations in urban and rural regions., Methods: Built on a mixed methods approach, this study first assesses the status quo of video consultation use through claims data analysis and carries out a systematic literature review on barriers and promoting factors for the use of video consultations. Based on this preliminary work, focus groups are conducted in order to prepare surveys with insureds as well as physicians and psychotherapists in the second study phase. The central element of the survey is the implementation of discrete choice experiments to elicit relevant preferences of (potential) user groups and service providers. The summarized findings are discussed in a stakeholder workshop and translated into health policy recommendations., Results: The methodological approach used in this study is the focus of this paper. The study is still ongoing and will continue until March 2024. The first study phase has already been completed, in which preliminary work has been done on potential applications and hurdles for the use of video consultations. Currently, the survey is being conducted and analyses are being prepared., Conclusions: This study is intended to develop a targeted strategy for health policy makers based on actual preferences and perceived obstacles to the use of video consultations. The results of this study will contribute to further user-oriented development of the implementation of video consultations in German statutory health insurance. Furthermore, the iterative and mixed methods approach used in this study protocol is also suitable for a variety of other research projects., International Registered Report Identifier (irrid): DERR1-10.2196/50932., (©Lara Kleinschmidt, Anke Walendzik, Jürgen Wasem, Klemens Höfer, Beatrice Nauendorf, Matthias Brittner, Paul Brandenburg, André Aeustergerling, Udo Schneider, Anja Wadeck, Stephanie Sehlen, Sebastian Liersch, Katharina Schwarze, Carsten Schwenke, Theresa Hüer. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 11.04.2024.)

Background: In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients., Methods: Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients., Results: The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure., Conclusion: Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care., (© 2022. The Author(s).)

Background: Patients in Germany are free to seek care from any office-based physician and can always ask for multiple opinions on a diagnosis or treatment. The high density of physicians and the freedom to choose among them without referrals have led to a need for better coordination between the multiple health professionals treating any given patient. The objectives of this study are to (1) identify informal networks of physicians who treat the same patient population, (2) provide these physicians with feedback on their network and patients, using routine data and (3) give the physicians the opportunity to meet one another in facilitated network meetings., Methods: The Accountable Care Deutschland (ACD) study is a prospective, non-blinded, cluster-randomised trial comprising a process and economic evaluation of informal networks among 12,525 GPs and office-based specialists and their 1.9 million patients. The units of allocation are the informal networks, which will be randomised either to the intervention (feedback and facilitated meetings) or control group (usual care). The informal networks will be generated by identifying connections between office-based physicians using complete datasets from the Regional Associations of Statutory Health Insurance (SHI) Physicians in Hamburg, Schleswig Holstein, North Rhine and Westphalia Lip, as well as data from three large statutory health insurers in Germany. The physicians will (a) receive feedback on selected indicators of their own treatment activity and that of the colleagues in their network and (b) will be invited to voluntary, facilitated network meetings by their Regional Association of SHI physicians. The primary outcome will be ambulatory-care-sensitive hospitalisations at baseline, at the end of the 2-year intervention period, and at six months and at 12 months after the end of the intervention period. Data will be analysed using the intention-to-treat principle. A pilot study preceded the ACD study., Discussion: Cochrane reviews show that feedback can improve everyday medical practice by shedding light on previously unknown relationships. Providing physicians with information on how they are connected with their colleagues and what the outcomes are of care delivered within their informal networks can help them make these improvements, as well as strengthen their awareness of possible discontinuities in the care they provide., Trial Registration: German Clinical Trials Register DRKS00020884 . Registered on 25 March 2020-retrospectively registered., (© 2021. The Author(s).)

Background: Social isolation is one of the main risk factors associated with suicidal outcomes. The aim of this narrative review was to provide an overview on the link between social isolation and suicidal thoughts and behaviors., Methods: We used the PubMed database to identify relevant articles published until April 13, 2018. We focused on: (a) systematic reviews, meta-analyses, and narrative reviews; (b) original observational studies with large samples (N ≥ 500); and (c) qualitative studies. We included all relevant suicidal outcomes: suicidal ideation (SI), suicidal planning, non-suicidal self-injury, deliberate self-harm, suicide attempt (SA), and suicide., Results: The main social constructs associated with suicidal outcomes were marital status (being single, separated, divorced, or widowed) and living alone, social isolation, loneliness, alienation, and belongingness. We included 40 original observational studies, the majority of them performed on adolescents and/or young adults (k = 23, 57.5%). Both the objective condition (e.g., living alone) and the subjective feeling of being alone (i.e., loneliness) were strongly associated with suicidal outcomes, in particular with SA and SI. However, loneliness, which was investigated in most studies (k = 24, 60%), had a major impact on both SI and SA. These associations were transculturally consistent., Limitations: Confounding factors can limit the weight of the results obtained in observational studies., Conclusions: Data from the observational studies suggest that both objective social isolation and the subjective feeling of loneliness should be incorporated in the risk assessment of suicide. Interventional studies targeting social isolation for suicide prevention are needed., (Copyright © 2018. Published by Elsevier B.V.)

There has been extensive research on the use of acupuncture in adults with a wide array of conditions. Much less research has been conducted on the use of acupuncture in children. In this article, we review the history and philosophy of acupuncture, and the literature on its effectiveness and safety in children and adolescents, giving special attention to the pediatric and adolescent conditions that have been most studied in high-quality randomized controlled trials (RCTs)., (Copyright © 2016 Mosby, Inc. All rights reserved.)

Objectives: We used "hot spotting" to characterize the persons most frequently admitted to the New York City jail system in 2013., Methods: We used our Correctional Health Services electronic health record to identify 800 patients admitted in 2013 who returned most since November 2008. We compared them to a randomly selected control group of 800 others admitted in 2013, by using descriptive statistics and cross-tabulations, including data through December 2014., Results: The frequently incarcerated individuals had a median of 21 incarcerations (median duration 11 days), representing 18 713 admissions and $129 million in custody and health costs versus $38 million for the controls. The frequently incarcerated were significantly older (42 vs 35 years), and more likely to have serious mental illness (19% vs 8.5%) and homelessness (51.5% vs 14.7%) in their record. Significant substance use was highly prevalent (96.9% vs 55.6%). Most top criminal charges (88.7%) for the frequently incarcerated were misdemeanors; assault charges were less common (2.8% vs 10.4%)., Conclusions: Frequently incarcerated persons have chronic mental health and substance use problems, their charges are generally minor, and incarceration is costly. Tailored supportive housing is likely to be less costly and improve outcomes.

Introduction: Ketamine's efficacy in depressive disorders has been established in several controlled trials. The aim of the present study was to determine whether or not ketamine administration significantly improves depressive symptomatology in depression and more specifically in major depressive disorder (MDD), bipolar depression, resistant depression (non-ECT studies), and as an anesthetic agent in electroconvulsive therapy (ECT) for resistant depression (ECT studies). Secondary outcomes were the duration of ketamine's effect, the efficacy on suicidal ideations, the existence of a dose effect, and the safety/tolerance of the treatment., Methods: Studies were included if they met the following criteria (without any language or date restriction): design: randomized controlled trials, intervention: ketamine administration, participants: diagnosis of depression, and evaluation of severity based on a validated scale. We calculated standardized mean differences (SMDs) with 95 % confidence intervals (CIs) for each study. We used fixed and random effects models. Heterogeneity was assessed using the I2 statistic., Results: We included nine non-ECT studies in our quantitative analysis (192 patients with major depressive disorder and 34 patients with bipolar depression). Overall, depression scores were significantly decreased in the ketamine groups compared to those in the control groups (SMD = -0.99; 95 % CI -1.23, -0.75; p < 0.01). Ketamine's efficacy was confirmed in MDD (resistant to previous pharmacological treatments or not) (SMD = -0.91; 95 % CI -1.19,-0.64; p < 0.01), in bipolar depression (SMD = -1.34; 95 % CI -1.94, -0.75), and in drug-free patients as well as patients under medication. Four ECT trials (118 patients) were included in our quantitative analysis. One hundred and three patients were diagnosed with major depressive disorder and 15 with bipolar depression. Overall, depression scores were significantly improved in the 58 patients receiving ketamine in ECT anesthesia induction compared to the 60 patients (SMD = -0.56; 95 % CI -1.10, -0.02; p = 0.04; I2 = 52.4 %). The duration of ketamine's effects was assessed in only two non-ECT studies and seemed to persist for 2-3 days; this result needs to be confirmed. Three of four studies found significant decrease of suicidal thoughts and one found no difference between groups, but suicidal ideations were only studied by the suicide item of the depressive scales. It was not possible to determine a dose effect; 0.5 mg/kg was used in the majority of the studies. Some cardiovascular events were described (mostly transient blood pressure elevation that may require treatment), and ketamine's use should remain cautious in patients with a cardiovascular history., Conclusion: The present meta-analysis confirms ketamine's efficacy in depressive disorders in non-ECT studies, as well as in ECT studies. The results of this first meta-analysis are encouraging, and further studies are warranted to detail efficacy in bipolar disorders and other specific depressed populations. Middle- and long-term efficacy and safety have yet to be explored. Extrapolation should be cautious: Patients included had no history of psychotic episodes and no history of alcohol or substance use disorders, which is not representative of all the depressed patients that may benefit from this therapy.

We report the case of a 35-year-old patient suffering from schizo-affective disorder since the age of 19 years, treated by a combination of first-generation antipsychotics, zuclopenthixol (100 mg/day) and lithium (1200 mg/day) (serum lithium=0.85 mEq/l). This patient had no associated personality disorder (particularly no antisocial disorder) and no substance abuse disorder. Within the 48 h following the gradual introduction of quetiapine (up to 600 mg/day), the patient presented severe agitation without an environmental explanation, contrasting with the absence of a history of aggressiveness or personality disorder. The diagnoses of manic shift and akathisia were dismissed. The withdrawal and the gradual reintroduction of quetiapine 2 weeks later, which led to another severe agitation, enabled us to attribute the agitation specifically to quetiapine., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Context: Depression is a frequent, severe and expensive illness. Approximately 20% of depressive episodes are resistant to classic antidepressants. Glutamatergic antagonists, in particular ketamine, established a new, rapid and robust therapeutic approach in resistant depression., Results: The main results in the literature show a rapid and robust antidepressant effect of ketamine, with infra-anesthesic posology (0.5mg/kg) administered in intravenous way. Positive effects are observed on depressive symptoms, suicidal thoughts, and there is a potential synergic action when used in the induction of anesthesia for electroconvulsive therapy. However, effects only last shortly. Side effects are mostly reversible and of mild intensity, no severe consequences were reported., Limits: Limits are the lack of power of the included studies, due to small sample sizes, and the scarcity of studies. Misuse of ketamine is an important issue to be taken into account, and few data about ketamine addiction potential and its long-term effects are published at the moment., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Introduction: New challenges arise in medicine, particularly in psychiatry. In the near future, psychiatrists' role may evolve into management of mental health care teams (GPs, nurses, psychologists…) thus creating the need for charisma and leadership. Charisma is defined as « a quality that allows it's possessor to exercise influence, authority over a group »; leadership as « the function, the position of chief, and by extension, a dominant position »., Aim of the Study: To offer some reflections on charisma and leadership and the ways to develop them in three situations common in clinical practice: dual communication (between caregivers or with patients), oral communication (e.g., during a symposium) and managing a mental health care team., Method: Medline (1966-hits) and Web of Science (1975-hits) were explored according to the PRISMA criteria. The research paradigm was [(psychiatrist OR physician) AND mental health AND (leadership OR charisma)]., Results: Two hundred and eighty articles were found, but only 34 corresponded to our subject and were included in the qualitative analysis. The leader must first ask himself/herself about his/her vision of the future, so as to share it with passion with his/her mental health team. Charisma and leadership are based on several values, among which we can mention: providing understandable, personalized care for the patient, in continuity and confidentiality; adapting care to the general population's request, maintaining one's own physical and mental health, submitting one's daily practice to peer review, engaging in continuous improvement of one's practices in response to new requirements, and recognizing that research and instruction are part of an M.D's professional obligations. The clinician will work on ways to develop his/her own charisma, through interactions with peers and team members, the care of his/her appearance (especially for first meetings) and workplace, and through positive reinforcement (some cognitive-behavioral techniques like assertiveness have been proposed to enhance the charisma, e.g., visualization and affirmation). Leadership does not depend on hierarchical position and administrative responsibilities: leaders should learn to manage and harmonize the different types of personalities within his/her team, paying special attention to passive-aggressive attitudes. We recall here some techniques to improve charisma during oral communication, such as making relationships with people by calling them by their names, making reference to things and people that the audience can identify with (like sport or cooking), using one's own style without trying to imitate someone else, focusing on one major idea, being brief and using anecdotes, using silences effectively and finally having good non-verbal communication. The conclusion should never be neglected, as an audience especially remembers the beginning and the end of a presentation. Although some features are common to all charismatic leaders (dominance, self-confidence, high energy level), a recent theory of leadership (called contingency theory) seeks to examine how different leadership styles can adapt to circumstances. This theory focuses more on the vision, passion, determination and courage of the leader and depends not only on their intrinsic qualities. No research has indeed shown individual characteristics that differentiate leaders from followers. However, doctors have not been prepared in their training to acquire leadership skills that they can use to adapt to the circumstances of their clinical practice. The most important qualities expected of a leader according to the current leadership theorists are: listening, communication, stress management, development of other's capacities, feedback, introspection and risk taking. Moreover, leadership involves positive reinforcement of the team while maintaining the feeling of individual autonomy, and being able to take an innovative decision alone with shared optimism. There is no need to have great management responsibilities in order to succeed in leadership. We reiterate the importance for a charismatic leader to smile, to be able to mock oneself and to regulate one's emotions., Conclusion: Charisma seems to be an essential dimension for effective leadership and team management. Beyond psychiatry, we believe these reflections to be useful for all branches of medicine., (Copyright © 2012 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Seventy-five percent of patients with blood-injection-injury phobia (BII-phobia) report a history of fainting in response to phobic stimuli. This specificity may lead to medical conditions remaining undiagnosed and untreated, incurring considerable cost for the individual and society. The psychophysiology of BII-phobia remains poorly understood and the literature on effective treatments has been fairly sparse. Aims of the systematic review: to synthesize the psychophysiology of BII-phobia and to propose a systematic review of the literature on effectiveness of different treatments evaluated in this indication., Results: Firstly, the most distinct feature of the psychophysiology of BII-phobia is its culmination in a vasovagal syncope, which has been described as biphasic. The initial phase involves a sympathetic activation as is typically expected from fear responses of the fight-flight type. The second phase is characterized by a parasympathetic activation leading to fainting, which is associated with disgust. Subjects with syncope related to BII-phobia have an underlying autonomic dysregulation predisposing them to neurally mediated syncope, even in the absence of any blood or injury stimulus. Many studies report that BII-phobic individuals have a higher level of disgust sensitivity than individuals without any phobia. Secondly, behavioral psychotherapy techniques such as exposure only, applied relaxation, applied tension, and tension only, have demonstrated efficacy with no significant difference between all these techniques. The disgust induction has not improved effectiveness of exposure., Conclusion: We have explained the psychophysiology of BII-phobia, the understanding of which is required to study and validate specific techniques, in order to improve the prognosis of this disorder, which is a public health issue., (Copyright © 2012 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

The processes underlying the ability to make decisions about recommended treatments remain poorly understood in schizophrenia. The aim of this study was to explore the relationships between capacity to consent to medication and cognitive biases in 60 schizophrenia patients. Main measures included the MacArthur Competence Assessment tool for Treatment (MacCAT-T) and the Beck Cognitive Insight Scale (BCIS). After Bonferroni's correction for multiple correlations, the Self-Reflectiveness dimension of the BCIS was significantly associated with the dimension "Reasoning" of the MacCAT-T. Cognitive therapy, by enhancing patients' Self-Reflectiveness and considering alternative explanations, could lead to better capacity to consent to treatment in schizophrenia., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Introduction: Toxoplasma gondii is the most common protozoan parasite in developed nations. Up to 43% of the French population may be infected, depending on eating habits and exposure to cats, and almost one third of the world human's population may be infected. Two types of infection have been described: a congenital form and an acquired form. Although the medical profession treats these latent cases as asymptomatic and clinically unimportant, results of animal studies and recent studies of personality profiles, behavior, and psychomotor performance have led to reconsider this assumption., Preclinical Data: Among rats: parasite cysts are more abundant in amygdalar structures than those found in other regions of the brain. Infection does not influence locomotion, anxiety, hippocampal-dependent learning, fear conditioning (or its extinction) and neophobia in rats. Rats' natural predator is the cat, which is also T. gondii's reservoir. Naturally, rats have an aversion to cat urine, but the parasite suppresses this aversion in rats, thus influencing the infection cycle. Tachyzoites may invade different types of nervous cells, such as neurons, astrocytes and microglial cells in the brain, and Purkinje cells in cerebellum. Intracellular tachyzoites manipulate several signs for transduction mechanisms involved in apoptosis, antimicrobial effectors functions, and immune cell maturation. Dopamine levels are 14% higher in mice with chronic infections. These neurochemical changes may be factors contributing to mental and motor abnormalities that accompany or follow toxoplasmosis in rodents and possibly in humans. Moreover, the antipsychotic haloperidol and the mood stabilizer valproic acid most effectively inhibit Toxoplasma growth in vitro with synergistic activity., Clinical Data: The effects of the parasite are not due to the manipulation in an evolutionary sense but merely due to neuropathological or neuroimmunological effects of the parasite's presence. Toxoplasmosis and schizophrenia: epidemiological studies point to a role for toxoplasmosis in schizophrenia's etiology, probably during pregnancy and early life, this association being congruent with studies in animal models indicating that animal exposures of the developing brain to infectious agents or immune modulating agents can be associated with behavioral changes that do not appear until the animal reaches full maturity. Psychiatric patients have increased rates of toxoplasmic antibodies, the differences between cases and controls being greatest in individuals who are assayed near the time of the onset of their symptoms. The increase of dopamine in the brain of infected subjects can represent the missing link between toxoplasmosis and schizophrenia. Toxoplasmosis and Obsessive Compulsive Disorder (OCD): the seropositivity rate for anti-T. gondii IgG antibodies among OCD patients is found to be significantly higher than the rate in healthy volunteers. Infection of basal ganglia may be implicated in the pathogenesis of OCD among Toxoplasma seropositive subjects. Toxoplasmosis and personality: infected men appear to be more dogmatic, less confident, more jealous, more cautious, less impulsive and more orderly than others. Conversely, infected women seem warmest, more conscientious, more insecure, more sanctimonious and more persistent than others. It is possible that differences in the level of testosterone may be responsible for the observed behavioral differences between Toxoplasma-infected and Toxoplasma-free subjects., Conclusion: In the future two major avenues for research seem essential. On one hand, prospective studies and research efforts must still be carried out to understand the mechanisms by which the parasite induces these psychiatric disorders. On the other hand, it has not yet been demonstrated that patients with positive toxoplasmic serology may better respond to haloperidol's or valproic acid's antiparasitic activity. These results may appear as a major issue in the drug's prescribing choices and explain variability in response to the treatment of patients with schizophrenia that is not explained by the genetic polymorphism., (Copyright © 2012 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Developing effective recruitment and retention strategies in populations with traditionally high attrition rates is critical to the success of Randomized Controlled Trials (RCTs). Data on successful participation of women from low-income, minority populations in RCTs of behavioral interventions are limited. This is problematic given the multiplicity of Healthy People 2020 goals that target health disparities in these populations. This paper reports successful recruitment and retention methods from two separately funded NIH clinical trials of primary care-based prenatal interventions to increase breastfeeding among ethnically diverse, low-income women in urban medical centers in the Bronx, NY. It also presents the required staff effort necessary to conduct such a successful RCT, in terms of full-time equivalents (FTEs). Results include timely recruitment of 941 participants over 29 months, with 98.1% completing >¯¯1 follow-up interview. A recruitment and retention plan that maximized study staff access and availability to the participant, as well as strong study staff rapport with participants, addressed previously reported barriers in this population, optimizing follow-up rates. A qualitative assessment of the participants' study experience suggesting that high retention was due to strong rapport with participants, short interviews requiring little time commitment, and participants' perception of the study as informative, provides further evidence of our approach's effectiveness. Logistical protocol procedures and staff management strategies relating to successful recruitment/retention are provided to propose a practical, cost-effective and translational recruitment-retention plan for other researchers to adopt., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This systematic review summarizes and critically appraises the literature on the effect of erythropoietin (EPO) in schizophrenia patients and the pathophysiological mechanisms that may explain the potential of its use in this disease. EPO is mainly known for its regulatory activity in the synthesis of erythrocytes and is frequently used in treatment of chronic anemia. This cytokine, however, has many other properties, some of which may improve the symptoms of psychiatric illness. The review follows the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Three databases (Medline, Web of Science, and Cochrane) were searched combining the search terms 'erythropoietin AND (psychotic disorders OR schizophrenia)'. Seventy-eight studies were included in qualitative synthesis, a meta-analytic approach being prohibited. The findings suggest that several EPO cerebral potential properties may be relevant for schizophrenia treatment, such as neurotransmission regulation, neuroprotection, modulation of inflammation, effects on blood-brain barrier permeability, effects on oxidative stress and neurogenesis. Several potentially detrimental side-effects of EPO therapy, such as increased risk of thrombosis, cancer, increased metabolic rate and mean arterial blood pressure leading to cerebral ischemia could severely limit or halt the use of EPO. Overall, because the available data are inconclusive, further efforts in this field are warranted., (© 2012 The Authors. Psychiatry and Clinical Neurosciences © 2012 Japanese Society of Psychiatry and Neurology.)

Translating evidence-based research into practice requires data from clinical trials in real world settings. This paper presents "lessons learned" from the implementation of an RCT of breastfeeding promotion interventions at two busy, urban, prenatal care sites. Data were obtained via direct observations, qualitative interviews, and study statistics. Primary challenges include: time and space burdens, "research vs. service" mission conflict, and the provider learning curve for conducting interventions. Primary facilitators include: researcher presence for enhancing rapport with participants and staff, site staff labeling of both the research interview and intervention as "value added time," and the ability of research staff to assist the clinic beyond the scope of the clinical trial. Specific suggestions are given for building collaborative bonds between the research team, clinicians, administrators, and staff in busy urban practices.