[Inpatient Psychiatric Treatment in the Corona-crisis by Psychologists and Psychiatrists in Home-office and in the Clinic]. / Stationäre psychiatrische Versorgung in der Corona-Krise durch Psychologen und Psychiater im Homeoffice und in der Klinik.

Since the emergence of the new coronavirus (COVID-19) pandemic in March 2020, many people in Germany have become ill. This meant a challenge for the care of mentally ill hospitalized patients. There was a social shut-down in Bavaria with a decrease in social contacts. The present study deals with psychiatric care provided to these patients by psychologists and psychiatrists working in the home office and in the clinic. Psychologists from the Department of Psychiatry and Psychotherapy at LMU Munich, together with physicians working in the clinic, established telephone-based patient care for inpatients during the acute crisis in the home office during quarantine, in which 23 patients with depressive and schizophrenic disorders participated. Psychologists then worked in the hospital with 98 hospitalized patients. Current distress and its stresses were addressed and new therapeutic components were integrated into care. The feasibility of home office, its possibilities and limitations are presented. In this study, care concepts for hospitalized patients with affective and schizophrenic disorders as well as current stress factors and psychotherapeutic concepts will be addressed. The current approach was positively evaluated by patients and physicians and is thus promising in the current situation. With the exception of patients in the acute ward, all patients and even older ones benefited from this measure. During the crisis from March to August, all psychologists worked on full-time positions with the usual treatment frequency of 1-2 sessions a week, which was especially important for elderly individuals. During the acute COVID-19 crisis, there was a pause only in the treatment of ward-wide groups and family groups. Psychologists, like physicians and nurses, had a system-relevant role to play.

Resurrection of the Follow-Back Method to Study the Transdiagnostic Origins of Psychosis.

There has been a major drive in research trying to understand the onset of psychosis. Clinical-high risk (CHR) studies focus on opportunistic help-seeking samples with non-psychotic disorders and a degree of psychosis admixture of variable outcome, but it is unlikely that these represent the population incidence of psychotic disorders. Longitudinal cohort studies of representative samples in the general population have focused on development and outcome of attenuated psychotic symptoms, but typically have low power to detect transition to clinical psychotic disorder. In this issue of Schizophrenia Bulletin, Cupo and colleagues resurrect a time-honored method to examine psychosis onset: the epidemiological follow-back study, modernizing it to fit the research framework of the early intervention era. The authors set out to investigate the hypothesis that psychotic disorder represents the poorest outcome fraction of initially non-psychotic, common mental disorders and present compelling findings, unifying previous opportunistic CHR and representative cohort-based work.

Promoting stigma coping and empowerment in patients with schizophrenia and depression: results of a cluster-RCT.

There is a need for interventions supporting patients with mental health conditions in coping with stigma and discrimination. A psycho-educational group therapy module to promote stigma coping and empowerment (STEM) was developed and tested for efficacy in patients with schizophrenia or depression. 30 clinical centers participated in a cluster-randomized clinical trial, representing a broad spectrum of mental health care settings: in-patient (acute treatment, rehabilitation), out-patient, and day-hospitals. As randomized, patients in the intervention group clusters/centers received an illness-specific eight sessions standard psychoeducational group therapy plus three specific sessions on stigma coping and empowerment ('STEM'). In the control group clusters the same standard psychoeducational group therapy was extended to 11 sessions followed by one booster session in both conditions. In total, N = 462 patients were included in the analysis (N = 117 with schizophrenia spectrum disorders, ICD-10 F2x; N = 345 with depression, ICD-10 F31.3-F31.5, F32-F34, and F43.2). Clinical and stigma-related measures were assessed before and directly after treatment, as well as after 6 weeks, 6 months, and 12 months (M12). Primary outcome was improvement in quality of life (QoL) assessed with the WHO-QOL-BREF between pre-assessment and M12 analyzed by mixed models and adjusted for pre-treatment differences. Overall, QoL and secondary outcome measures (symptoms, functioning, compliance, internalized stigma, self-esteem, empowerment) improved significantly, but there was no significant difference between intervention and control group. The short STEM module has proven its practicability as an add-on in different settings in routine mental health care. The overall increase in empowerment in both, schizophrenia and depression, indicates patients' treatment benefit. However, factors contributing to improvement need to be explored.The study has been registered in the following trial registers. ClinicalTrials.gov: https://register.clinicaltrials.gov/ Registration number: NCT01655368. DRKS: https://www.drks.de/drks_web/ Registration number: DRKS00004217.

Efficacy of extended clinical management, group CBT, and group plus individual CBT for major depression: Results of a two-year follow-up study.

OBJECTIVE: Cognitive therapy has gained prominence in the treatment of major depression, however, little is known about its long-term benefits when delivered during inpatient treatment or combined with outpatient treatment with severely ill inpatients (HAM-D > 20). METHOD: To evaluate this question, we conducted a randomized controlled trial investigating the efficacy of extended clinical management (E-CM), psychoeducational cognitive behavioural group therapy (PCBT-G) or PCBT-G and 16 outpatient individual treatment sessions (PCBT-G+I). All patients were treated with pharmacotherapy. 177 inpatients with DSM-IV major depression were randomized either to E-CM or PCBT-G or PCBT-G+I. Outcome measures were collected in the hospital at pre- and posttreatment and following discharge into the community every six months for two years. We compared the study groups on symptom changes, psychosocial functioning, knowledge about depression and rehospitalization. RESULTS: All three treatment interventions are equally effective at reducing depressive symptoms and increasing psychosocial functioning at posttreatment. There was significant group by time interaction for knowledge about depression in favor of PCBT-G and PCBT-G+I over E-CM. We did not find significantly lower rehospitalisation rates at the two-year follow-up for PCBT-G+I compared to E-CM, however, comparing PCBT-G to E-CM. CONCLUSIONS: We conclude that with cognitive psychoeducational group therapy a successful, in the long-term other interventions superior psychological intervention for major depression is available as gains were sustained for two years following discharge from the hospital. More research is needed to evaluate the long-term impact of group treatment starting in inpatient treatment.

[Practicals in a psychiatric clinic for occupational orientation in pupils]. / Praktikum in einer psychiatrischen Klinik zur beruflichen Orientierung von Schülern.

This pilot study investigates the implementation of a practical program for pupils including psychoeducation aimed to educate them about professions in psychiatry. 29 persons aged between 16-21 years were included in the program for vocational orientation at the Department of Psychiatry and Psychotherapy, University of Munich, from 2013-2016. The 1-2-week program provides information about job descriptions of psychologists and physicians. On average the pupils performed at M=2.75, SD=0.64 and they were motivated. At the end of their practical course, they reported that their fear of contact with inpatients decreased. Their knowledge in psychiatry and psychotherapy increased. 59 % of the participants reported that they plan to study medicine or psychology. All young adolescents reported that they satisfied with the program. Enhancing contact with patients and their caretakers may serve to decrease anxiety and prejudices as well as to increase interest and knowledge in this area.

Special Supplement Introduction: The Fourth Kraepelin Symposium-Cognitive Dysfunction in Schizophrenia: Origins and Innovative Treatment.

This Special Supplement presents reports from working groups meeting at the Fourth Kraepelin Symposium in Munich, Germany, in September 2014. It covers the origins and therapy of cognitive dysfunction in schizophrenia. Cognitive deficits are core symptoms of schizophrenia being decisive for the long-term prognosis only improved moderately by antipsychotic treatment, however, showing more evidence for cognitive remediation. The authors refer to neurobiological and psychological underpinnings of cognitive deficits and to innovative treatment interventions aimed at improving cognitive dysfunction in order to improve outcome and to support coping with the illness. Therapeutic approaches include aerobic exercise, cognitive training, psychoeducation, cognitive therapy, noninvasive brain stimulation and pharmacotherapy in acute to post-acute patients. The supplement also presents novel diagnostic tools for early recognition, such as biomarkers, as well as cognitive training to prevent worsening of symptoms in individuals at clinical high risk for psychosis. In recent years there has been progress in basic science and outcomes research as well as psychopharmacological and psychological treatment options. Despite of this, treatment of cognitive deficits needs significant improvement and further research is needed.

A Randomized Controlled Trial of Group Coping-Oriented Therapy vs Supportive Therapy in Schizophrenia: Results of a 2-Year Follow-up.

OBJECTIVE: Over the past 30 years, illness management programs and cognitive-behavioral therapy for psychosis have gained prominence in the treatment of schizophrenia. However, little is known about the long-term benefits of these types of programs when delivered during inpatient treatment following a symptom exacerbation. To evaluate this question, we conducted a randomized controlled trial comparing the long-term effects of a group-based coping-oriented program (COP) that combined the elements of illness management with cognitive behavioral-therapy for psychosis, with an equally intensive supportive therapy (SUP) program. METHOD: 196 inpatients with DSM-IV schizophrenia were randomized to COP or SUP, each lasting 12 sessions provided over 6-8 weeks. Outcome measures were collected in the hospital at baseline and post-assessment, and following discharge into the community 1 and 2 years later. We compared the groups on rehospitalizations, symptoms, psychosocial functioning, and knowledge about psychosis. RESULTS: Intent-to-treat analyses indicated that patients in COP learned significantly more information about psychosis, and had greater reductions in overall symptoms and depression/anxiety over the treatment and follow-up period than patients in SUP. Patients in both groups improved significantly in other symptoms and psychosocial functioning. There were no differences between the groups in hospitalization rates, which were low. CONCLUSIONS: People with schizophrenia can benefit from short-term COPs delivered during the inpatient phase, with improvements sustaining for 2 years following discharge from the hospital. More research is needed to evaluate the long-term impact of coping-oriented and similar programs provided during inpatient treatment.

Psychoeducational and Cognitive Behavioral Treatment Programs: Implementation and Evaluation From 1995 to 2015 in Kraepelin's Former Hospital.

OBJECTIVE: Programs that view individuals as capable of taking an active role in managing their illness have gained importance in Europe and the United States. This article describes the implementation and evaluation of group psychoeducational and cognitive behavioral treatment programs at the Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany, over the past 20 years. METHODS: Implementing psychoeducational programs was the first step to establish cognitive behavioral psychotherapy and dispel the myth of schizophrenia for patients. Programs are also provided for patients with mood disorders, substance use disorders, or both. These groups include topics such as psychoeducation about the illness, establishing rewarding activities, stress management, cognitive therapy, and relapse prevention. RESULTS: More than 1000 patients with schizophrenia or mood disorders (380 schizophrenia, 563 major depression, and 110 bipolar) have participated in illness management groups to learn about their illness and its treatment, and to learn skills to manage their illness. Patients have expressed satisfaction with the programs, and research has supported their effectiveness. CONCLUSIONS: Individuals with severe disorders can benefit from psychoeducational and cognitive treatment programs if the programs are adapted to the level of neuropsychological functioning and compensate for cognitive deficits and emotional overload. These findings suggest that providing information about the illness and coping skills for patients and relatives are important for treatment outcome.

First results of a refeeding program in a psychiatric intensive care unit for patients with extreme anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is associated with a high mortality rate. This study describes a compulsory re-feeding program established in Munich for extremely underweight patients. METHODS: The contract between the patient and the therapeutic team included mandatory inpatient status, establishment of guardianship and compulsory re-feeding with a percutaneous gastric feeding tube, as indicated. The predefined target was a body mass index (BMI) of 17 kg/m(2). Data on the first 68 patients with AN are presented. RESULTS: 65 (95.6%) patients were female and mean age at admission was 26.5 ± 8.5 years. BMI increased from 12.3 ± 1.4 kg/m(2) at admission to 16.7 ± 1.7 kg/m(2) at discharge. Thirty-two (47.1%) patients had the restrictive subtype (ANR) and 36 (52.9%) had the binging and purging subtype (ANBP). Duration of illness before admission (p = .004), days of treatment until discharge (p = .001) and weight increase (p = .02) were significantly different between subgroups in favor of patients with ANR. Also, seasonal differences could be found. Comparison of feeding methods showed that percutaneous tube feeding was superior. Almost half of the patients were treated with psychotropic medication. To date, however, the number of patients included in this program is too small to assess rare complications of this acute treatment program and long term outcomes of AN. CONCLUSIONS: An intensive care program for severely ill AN patients has been successfully established. Besides averting physical harm in the short term, this program was designed to enable these patients to participate in more sophisticated psychotherapeutic programs afterwards. To our knowledge, this is the first such program that regularly uses percutaneous feeding tubes.

Neuropsychological functioning in inpatients with major depression or schizophrenia.

BACKGROUND: Studies that compare neuropsychological functioning in inpatients with mood disorder or schizophrenia come to heterogeneous results. This study aims at investigating the question whether there are different neuropsychological test profiles in stabilised post-acute inpatients with affective disorders or schizophrenia. METHOD: We were interested in evaluating impairment in specific areas of cognitive functioning in patients with schizophrenia or depression. In clinical reality, patients with depression and schizophrenia are often treated together with little attention to their specific needs. 74 patients with major depression and 38 patients with schizophrenia were assessed in a comprehensive neuropsychological battery. All patients were in a post-acute stage of their illness, i.e. remission of acute symptoms. RESULTS: In spite of a comparable mean score of psychopathological symptoms in the Brief Psychiatric Rating Scale-Expanded (BPRS-E) as well as in the Global Assessment Functioning Scale (GAF), patients with depressive disorder showed significantly better results in verbal and visual short-term memory, verbal fluency, visual-motor coordination, information processing in visual-verbal functioning and selective attention compared to patients with schizophrenia. No significant differences between both samples were found in practical reasoning, general verbal abstraction, spatial-figural functioning, speed of cognitive processing. CONCLUSIONS: These results show that there are differences in scores in psychopathology (BPRS-E, GAF) in patients with affective disorders or schizophrenia and different neuropsychological test profiles in the post-acute stage of their illness.

Reduced hippocampal volume correlates with executive dysfunctioning in major depression.

OBJECTIVE: Dysfunction of neuronal plasticity or remodelling seems to contribute to the pathopysiology of major depression and may cause the well-documented hippocampal changes in depression. We aimed to investigate whether reduced hippocampal volumes correlate with executive dysfunctioning or memory dysfunctioning or with depression severity. METHODS: We recruited 34 inpatients with a previous or current episode of major depression from the department of psychiatry at the Ludwig-Maximilians University of Munich, Germany. We examined the 34 patients and 34 healthy control subjects with structural high resolution MRI. We assessed cognitive functions with the Wisconsin Card Sorting Test (WCST) and the Rey Auditory Verbal Learning Test (RAVLT) and severity of depression with the Hamilton Depression Rating Scale. RESULTS: Hippocampal volumes and frontal lobe volumes were significantly smaller in patients, compared with healthy control subjects. Furthermore, lower hippocampal volumes were correlated with poorer performance in the WCST. No significant correlations were found between hippocampal volumes and RAVLT performance or severity of depression. CONCLUSIONS: The present findings emphasize that patients with reduced hippocampal volumes show more executive dysfunctions than their counterparts. Thus, the mechanisms resulting in reduced hippocampal volumes seem to be related to the development of major depression.

Impact of cognitive-psychoeducational interventions in bipolar patients and their relatives.

BACKGROUND: In recent years, several controlled studies could show that psychoeducational interventions have been effective for relapse prevention in bipolar disorders. We therefore established a cognitive-psychoeducational group intervention with 14 sessions providing information about the illness, early warning signs, cognitive and behavioural strategies for stress management and social rhythm. Additionally we offered a group intervention for the patients' relatives. The objective of this study was to describe the outcome associated with our psychoeducational intervention in bipolar patients and their relatives. METHODS: Sixty-two bipolar patients attended 14 sessions (à 90 min) of cognitive-psychoeducational group therapy. Patients' knowledge of bipolar disorder and their satisfaction with the treatment were assessed using self-developed questionnaires before and after the group intervention. Additionally, 49 relatives of bipolar patients received two psychoeducational workshops of 4 hours each. We assessed demographic variables, burden, high expressed emotion and depressive symptoms of the relatives before and after the two workshops and at 1-year follow-up. RESULTS: Patients significantly improved their knowledge of bipolar disorder. They also have benefited from the discussions and the exchange of useful coping strategies. Burden and high expressed emotions showed no significant reductions at post-assessment, however they were significantly reduced at 1-year follow-up. Relatives also felt significantly better informed about the illness. CONCLUSIONS: These findings show that psychoeducational interventions in bipolar patients and their relatives improve patients' and their relatives' knowledge of the illness and the burden of the disorder as well as high expressed emotions are reduced in relatives at 1-year follow-up.

PUMA-G and HM74 are receptors for nicotinic acid and mediate its anti-lipolytic effect.

Nicotinic acid (niacin), a vitamin of the B complex, has been used for almost 50 years as a lipid-lowering drug. The pharmacological effect of nicotinic acid requires doses that are much higher than those provided by a normal diet. Its primary action is to decrease lipolysis in adipose tissue by inhibiting hormone-sensitive triglyceride lipase. This anti-lipolytic effect of nicotinic acid involves the inhibition of cyclic adenosine monophosphate (cAMP) accumulation in adipose tissue through a G(i)-protein-mediated inhibition of adenylyl cyclase. A G-protein-coupled receptor for nicotinic acid has been proposed in adipocytes. Here, we show that the orphan G-protein-coupled receptor, 'protein upregulated in macrophages by interferon-gamma' (mouse PUMA-G, human HM74), is highly expressed in adipose tissue and is a nicotinic acid receptor. Binding of nicotinic acid to PUMA-G or HM74 results in a G(i)-mediated decrease in cAMP levels. In mice lacking PUMA-G, the nicotinic acid-induced decrease in free fatty acid (FFA) and triglyceride plasma levels was abrogated, indicating that PUMA-G mediates the anti-lipolytic and lipid-lowering effects of nicotinic acid in vivo. The identification of the nicotinic acid receptor may be useful in the development of new drugs to treat dyslipidemia.

Illness management and recovery: a review of the research.

Illness management is a broad set of strategies designed to help individuals with serious mental illness collaborate with professionals, reduce their susceptibility to the illness, and cope effectively with their symptoms. Recovery occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness. The authors discuss the concept of recovery from psychiatric disorders and then review research on professional-based programs for helping people manage their mental illness. Research on illness management for persons with severe mental illness, including 40 randomized controlled studies, indicates that psychoeducation improves people's knowledge of mental illness; that behavioral tailoring helps people take medication as prescribed; that relapse prevention programs reduce symptom relapses and rehospitalizations; and that coping skills training using cognitive-behavioral techniques reduces the severity and distress of persistent symptoms. The authors discuss the implementation and dissemination of illness management programs from the perspectives of mental health administrators, program directors, people with a psychiatric illness, and family members.