Soziale Umweltrisikofaktoren und psychische Erkrankungen

Ambulatory assessment for precision psychiatry: Foundations, current developments and future avenues

Precision psychiatry stands to benefit from the latest digital technologies for assessment and analyses to tailor treatment towards individuals. Insights into dynamic psychological processes as they unfold in humans' everyday life can critically add value in understanding symptomatology and environmental stressors to provide individualized treatment where and when needed. Towards this goal, ambulatory assessment encompasses methodological approaches to investigate behavioral, physiological, and biological processes in humans' everyday life. It combines repeated assessments of symptomatology over time, e.g., via Ecological Momentary Assessment (e.g., smartphone-diaries), with monitoring of physical behavior, environmental characteristics (such as geolocations, social interactions) and physiological function via sensors, e.g., mobile accelerometers, global-positioning-systems, and electrocardiography. In this review, we expand on promises of ambulatory assessment in the investigation of mental states (e.g., real-life, dynamical and contextual perspective), on chances for precision psychiatry such as the prediction of courses of psychiatric disorders, detection of tipping points and critical windows of relapse, and treatment effects as exemplified by ongoing projects, and on future avenues of how ambulatory interventions can benefit personalized care for psychiatric patients (e.g., through real-time feedback in everyday life). Ambulatory assessment is a key contributor to precision psychiatry, opening up promising avenues in research, diagnoses, prevention and treatment.

[Mental disorders of working age : Evaluation of the administrative incidence and prevalence as well as regional differences in Lower Saxony on the basis of secondary data from a statutory health insurance provider]

BACKGROUND

Mental disorder is the subject of ever-increasing attention in the field of public health. However, the actual number of such cases is difficult to determine owing to the lack of comprehensive longitudinal studies.

OBJECTIVES

The administrative incidence and prevalence of mental disorders were estimated on the basis of data from 2010 to 2013 provided by the health insurance company AOK, Lower Saxony, and were assessed according to age and gender. Additionally, possible correlations between local conditions and the occurrence of diagnosed mental disorders were examined for both urban and rural districts.

MATERIALS AND METHODS

Analyses were conducted using the secondary datasets of 1.5 million persons born between 1940 and 1994 who had been continuously insured throughout the period specified. Only documented diagnoses from outpatient care were taken into account.

RESULTS

One third of the insured persons showed at least one documented diagnosis of a mental disorder within a 12-month period. In approximately 11 out of 100 cases, there was a newly documented diagnosis in 2012. With the exception of cases relating to psychotropic substance use, women were significantly more frequently affected than men. Age-specific differences were also determined. At a regional level, in relation to administrative prevalence, mental disorders showed positive correlations in the density of doctors and psychotherapists. Moreover, regions with a high rate of unemployment generally show a higher prevalence of mental disorders.

CONCLUSION

Despite certain limitations, the use of administrative incidence and prevalence data is a viable approach to assessing gender- and age-specific, and regional differences. Our regional analyses suggest a correlation between the local job situation and the level of regional administrative prevalence.

[Practice relevant research in biological psychiatry]

The practice of psychiatry would be unthinkable without modern psychopharmacology. Drug treatment, especially of severe psychiatric disorders, is often a precondition of community participation, societal reintegration and recovery. Seen in this context it is understandable that biological psychiatry has long been primarily defined by its close interconnection with psychopharmacology and has been perceived this way by practicing physicians. In recent years, however, the concept of what is "biological" has markedly expanded and so has the outreach of this approach into the practice of psychiatry. This article discusses examples showing that biological research methods provide new impulses for individualized medicine, psychotherapy and understanding environmental risks and therefore provide the basis for a preemptive and preventive approach that will be the key to master the challenges posed by the severe burden of mental illness.

The RAISE early treatment program for first-episode psychosis: background, rationale, and study design

OBJECTIVE

The premise of the National Institute of Mental Health Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) is to combine state-of-the-art pharmacologic and psychosocial treatments delivered by a well-trained, multidisciplinary team in order to significantly improve the functional outcome and quality of life for first-episode psychosis patients. The study is being conducted in non-academic (ie, real-world) treatment settings, using primarily extant reimbursement mechanisms.

METHOD

We developed a treatment model and training program based on extensive literature review and expert consultation. Our primary aim is to compare the experimental intervention to "usual care" on quality of life. Secondary aims include comparisons on remission, recovery, and cost-effectiveness. Patients 15-40 years old with a first episode of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic disorder not otherwise specified, or brief psychotic disorder according to DSM-IV and no more than 6 months of treatment with antipsychotic medications were eligible. Patients are followed for a minimum of 2 years, with major assessments conducted by blinded, centralized raters using live, 2-way video. We selected 34 clinical sites in 21 states and utilized cluster randomization to assign 17 sites to the experimental treatment and 17 to usual care. Enrollment began in July 2010 and ended in July 2012 with 404 subjects. The results of the trial will be published separately. The goal of the article is to present both the overall development of the intervention and the design of the clinical trial to evaluate its effectiveness.

CONCLUSIONS

We believe that we have succeeded in both designing a multimodal treatment intervention that can be delivered in real-world clinical settings and implementing a controlled clinical trial that can provide the necessary outcome data to determine its impact on the trajectory of early phase schizophrenia.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01321177.

[Psychopathology in the social context]

In his treatise "Allgemeine Psychopathologie"(1913) (general psychopathology), Karl Jaspers contrasted the avoidance of methodical one-sidedness, which today is described as being interdisciplinary, and the danger of making partial conceptions absolute. He argued in favor of the combined observation of the psychopathological phenomena of the "natural human being" to be analyzed and explained by scientific (and epidemiological) methods along with understanding the individual case study of the "cultural human being", which a person is as well, by using humanitarian hermeneutic methods. Because he discussed the social context only briefly, we will illustrate this in the following with specific examples: 1. social influences on the contents and forms of the appearance of psychopathological phenomena together with definitions that separate these pathological from abnormal psychic phenomena, 2. social conditions, i.e. imprinting of dispositions as risk factors and the social situation of psychopathological phenomena and 3. their social consequences. Taken together these are arguments for a biopsychosocial model, which, however, to date is seen as arbitrary in respect to causal explanations, which remains vague and which present no rules for weighting the relevance of individual determinants. However, the educational and didactic value of the model, to consider systematically the patient in its entirety, is undisputed and should encourage psychiatrists to investigate in depth the complex constellations of conditions of psychic disturbances on the microlevel.

Different conceptions of mental illness: consequences for the association with patients

Whenever partial knowledge is considered absolute and turned into ideological and dogmatic conceptions, the risk increases that the conditions for the people involved might become dangerous. This will be illustrated by casuistic examples of consequences of one-sided psychiatric conceptions such as social, biological, and psychological ideas about the treatment and care of the mentally ill. Present perspectives of an integrative model, i.e., an advanced bio-psycho-social conception about evidence-based characteristics on the social, psychological, and molecular-genetic level, require that all of these dimensions should be considered in order to personalize and thereby improve the care and treatment of the mentally ill.