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Schröter R, Lambert M, Rohenkohl A, Kraft V, Rühl F, Luedecke D, Gallinat J, Karow A, Schmidt SJ. Mediators of quality of life change in people with severe psychotic disorders treated in integrated care: ACCESS II study. Eur Psychiatry 2022; 66:e1. [PMID: 36329654 PMCID: PMC9879911 DOI: 10.1192/j.eurpsy.2022.2332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Patients with severe psychotic disorders exhibit a severely reduced quality of life (QoL) at all stages of the disease. Integrated care often led to an improvement in QoL. However, the specific mediators of QoL change are not yet well understood. METHODS The ACCESS II study is a prospective, long-term study investigating the effectiveness of an integrated care program for people with severe psychotic disorders (IC-TACT) that includes Therapeutic Assertive Community Treatment within a care network of in- and outpatient services at the University Medical Center Hamburg-Eppendorf, Germany. We examined longitudinal associations between QoL and the hypothesized mediators of change (i.e., negative symptoms, depression, and anxiety), using cross-lagged panel models. RESULTS The sample includes 418 severely ill patients treated in IC-TACT for at least 1 year. QoL increased, whereas symptom severity decreased significantly from baseline to 6-month follow-up (p-values ≤ 0.001), and remained stable until 12-month follow-up. QoL and symptom severity demonstrated significant auto-correlated effects and significant cross-lagged effects from QoL at baseline to negative symptoms (6 months, β = -0.20, p < 0.001) to QoL (12 months, β = -0.19, p < 0.01) resulting in a significant indirect, mediated effect. Additionally, negative symptoms after 6 months had a significant effect on the severity of depression after 12 months (β = 0.13, p < 0.05). CONCLUSIONS Negative symptoms appear to represent an important mechanism of change in IC-TACT indicating that improvement of QoL could potentially be achieved through optimized intervention on negative symptoms. Moreover, this may lead to a reduction in the severity of depression after 12 months.
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Affiliation(s)
- Romy Schröter
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Lambert
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Rohenkohl
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vivien Kraft
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Rühl
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Luedecke
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jürgen Gallinat
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Karow
- Centre for Psychosis and Bipolar Disorders, Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefanie J Schmidt
- Department of Clinical Psychology and Psychotherapy, University of Bern, 3012Bern, Switzerland
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Bechdolf A, Bühling-Schindowski F, Nikolaidis K, Kleinschmidt M, Weinmann S, Baumgardt J. [Evidence on the effects of crisis resolution teams, home treatment and assertive outreach for people with mental disorders in Germany, Austria and Switzerland - a systematic review]. DER NERVENARZT 2021; 93:488-498. [PMID: 34114073 DOI: 10.1007/s00115-021-01143-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Based on international randomized controlled trials (RCT) the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) recommends acute treatment in the domestic environment (AHU) and intensive outreach treatment (IAB) with the highest level of evidence; however, due to large differences in national healthcare systems the transference of results from international studies to the healthcare systems in Germany, Austria and Switzerland could be limited. OBJECTIVE Evaluation of studies on outreach psychiatric treatment forms in Germany, Austria and Switzerland and discussion of the results in the light of international evidence. MATERIAL AND METHODS A systematic literature search for clinical trials on outreach community treatment from Germany, Austria and Switzerland was conducted in the PubMed database. RESULTS A total of 19 publications were identified which could be assigned to 5 publications on 4 studies with 2857 patients on AHU and 14 publications on 10 studies with 3207 patients on IAB. The studies on AHU showed this treatment form to be superior regarding the duration of inpatient stay and healthcare costs. The studies on IAB showed more positive outcomes in comparison to controls regarding symptoms, severity of illness, substance abuse, functioning level, remission, satisfaction with treatment, quality of life, healthcare costs, work and housing situations. CONCLUSION The studies from Germany, Austria, and Switzerland suggest that outreach community treatment is superior regarding several outcome parameters. Thus, there are no indications suggesting that international evidence could not be valid for these countries. Additionally, with one RCT for AHU and one for IAB the requirements for an evidence level of 1b for outreach community treatment in the healthcare systems in question are fulfilled.
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Affiliation(s)
- Andreas Bechdolf
- Kliniken für Psychiatrie, Psychotherapie und Psychosomatik, Vivantes Klinikum Am Urban und Vivantes Klinikum im Friedrichshain - Akademische Lehrkrankenhäuser Charité-Universitätsmedizin Berlin, Dieffenbachstr. 1, 10967, Berlin, Deutschland. .,Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Köln, Köln, Deutschland. .,ORYGEN, National Center of Excellence of Youth Mental, Health, University of Melbourne, Melbourne, Australien.
| | - Felix Bühling-Schindowski
- Kliniken für Psychiatrie, Psychotherapie und Psychosomatik, Vivantes Klinikum Am Urban und Vivantes Klinikum im Friedrichshain - Akademische Lehrkrankenhäuser Charité-Universitätsmedizin Berlin, Dieffenbachstr. 1, 10967, Berlin, Deutschland
| | - Konstantinos Nikolaidis
- Kliniken für Psychiatrie, Psychotherapie und Psychosomatik, Vivantes Klinikum Am Urban und Vivantes Klinikum im Friedrichshain - Akademische Lehrkrankenhäuser Charité-Universitätsmedizin Berlin, Dieffenbachstr. 1, 10967, Berlin, Deutschland
| | - Martin Kleinschmidt
- Kliniken für Psychiatrie, Psychotherapie und Psychosomatik, Vivantes Klinikum Am Urban und Vivantes Klinikum im Friedrichshain - Akademische Lehrkrankenhäuser Charité-Universitätsmedizin Berlin, Dieffenbachstr. 1, 10967, Berlin, Deutschland
| | - Stefan Weinmann
- Klinik für Psychiatrie und Psychotherapie, Rudolf-Sophien-Stift, Stuttgart, Deutschland.,Universitätsspital Basel, Basel, Schweiz
| | - Johanna Baumgardt
- Kliniken für Psychiatrie, Psychotherapie und Psychosomatik, Vivantes Klinikum Am Urban und Vivantes Klinikum im Friedrichshain - Akademische Lehrkrankenhäuser Charité-Universitätsmedizin Berlin, Dieffenbachstr. 1, 10967, Berlin, Deutschland
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Report of the ACBS Task Force on the strategies and tactics of contextual behavioral science research. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2021. [DOI: 10.1016/j.jcbs.2021.03.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Vidal S, Correa L, Perroud N, Huguelet P. [Difficult-to-engage patients: What evolution after discharge from Assertive Community Programs?]. Encephale 2021; 47:426-434. [PMID: 33648751 DOI: 10.1016/j.encep.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Beneficial effects of Assertive Community Treatment (ACT) programs on patients with severe mental disorders are well established over short or medium term. However, studies that investigate long term clinical and psychosocial outcomes are remarkably scarce, and it is not known whether the support and intensive care delivered by these programs maintain their benefits over time, especially after discharge. Thus, the present study sought further understanding on this issue by evaluating long term clinical and psychosocial evolution of patients who had been treated by an ACT team in 2007. We investigated the nature of treatment interventions and the level of care since discharge from ACT, especially in terms of adherence to care and number of psychiatric hospitalizations. We also examined factors, at inclusion in the ACT program and after six months of treatment, that could predict better long-term outcomes. METHODS Twenty-nine patients with severe mental disorders, characterized by the heavy use of inpatient facilities and refusal of care, were treated by an ACT team which was implmented between 2007 and 2009. They participated at that time in an initial study on the effect of the program and were therefore assessed at inclusion and again after six months of treatment. Between 2016 and 2017, the present follow up took place and patients were assessed again on their current psychosocial functioning, quality of life and intensity of symptoms, using the same scales as those administered in the initial study. This design allowed us to compare baseline with "early" (after six months) and "late" (after a mean of 8.7 years) effects of ACT program on patients. In order to assess adherence to care since discharge from ACT, data on nature and level of psychiatric treatment was systematically reviewed, including all public and private inpatient and outpatient treatments since the end of the ACT program. RESULTS Detailed tables on hospitalizations before, during and after ACT treatment are reported, as well as tables summarizing the level of care and nature of treatment since discharge from ACT. During the mean of 8.7 years of evolution and 6.3 years after discharge from ACT, these patients, characterized by severe mental disorders, heavy use of inpatient facilities and refusal of care, sustained a reduced rate of hospitalizations and a minor rate of disengagement from outpatient care (6.9 %). Both severity of symptoms, poorer quality of life and worst functioning in the community at inclusion (baseline) as well as early improvements (after six month of ACT treatment) of the same outcomes were significantly associated with long term improvements. Results also show other baseline predictors of long term improvement: fewer years since disorder onset was associated with improvement of functioning in the community; further advancement in the recovery process predicted better enhancement in quality of life, and a better initial functioning in the community was associated with a better improvement of symptomatology. CONCLUSIONS This study provides insight on the sustainability of the benefits of ACT programs, suggesting that these interventions can help patients who are refractory to care to gain clinical and psychosocial improvement in the long term. Our results also suggest that baseline severity as well as early improvements after six months of treatment were associated with larger improvement at follow up. These clinical predictors provide some help to distinguish which patients are more likely to benefit from an ACT approach.
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Affiliation(s)
- S Vidal
- Service de psychiatrie adulte, Centre Ambulatoire de Psychiatrie et Psychothérapie Intégrées (CAPPI) des Eaux-Vives, Hôpitaux Universitaires de Genève, Département de santé mentale et de psychiatrie, rue du 31-Décembre 6-8, 1207 Genève, Suisse.
| | - L Correa
- Service de psychiatrie adulte, Centre Ambulatoire de Psychiatrie et Psychothérapie Intégrées (CAPPI) des Eaux-Vives, Hôpitaux Universitaires de Genève, Département de santé mentale et de psychiatrie, rue du 31-Décembre 6-8, 1207 Genève, Suisse.
| | - N Perroud
- Service de psychiatrie adulte, Centre Ambulatoire de Psychiatrie et Psychothérapie Intégrées (CAPPI) des Eaux-Vives, Hôpitaux Universitaires de Genève, Département de santé mentale et de psychiatrie, rue du 31-Décembre 6-8, 1207 Genève, Suisse.
| | - P Huguelet
- Service de psychiatrie adulte, Centre Ambulatoire de Psychiatrie et Psychothérapie Intégrées (CAPPI) des Eaux-Vives, Hôpitaux Universitaires de Genève, Département de santé mentale et de psychiatrie, rue du 31-Décembre 6-8, 1207 Genève, Suisse.
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Abstract
PURPOSE OF REVIEW Assertive Community Treatment is an established evidenced based practice that provides intensive community treatment for individuals with severe mental illness with recurrent hospitalizations and/or homelessness. Emerging evidence indicates limitations in its implementation in terms of to the original ACT model and its current relevance. RECENT FINDINGS Findings from recent studies (2018-2020) reveals challenges with implementation centered around basic implementation activities, such as changes in the psychosocial context of individuals with SMI, clinicians' abilities to demonstrate competencies with new practices, and ongoing evolution of mental health systems of care worldwide. Intermediary and purveyor organizations (IPO) can provide the infrastructure to support the spread of EBPs while addressing challenges and opportunities. Thus, implementation of ACT can be accomplished when employing a rigorous framework and infrastructure that can synthesize and translate science relevant for practice. SUMMARY The relevance of ACT depends on its implementation that is responsive to change. An implementation science-informed approach is key to providing ACT to individuals in the critical space between the hospital and community. With this approach, we can optimize ACT as a service delivery vehicle by careful analysis of how best to furnish and evaluate the latest, most effective and efficient treatments, rehabilitation and support services.
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Assertive Community Programs for Patients with Severe Mental Disorders: Are Benefits Sustained After Discharge? Community Ment Health J 2020; 56:559-567. [PMID: 31807993 DOI: 10.1007/s10597-019-00513-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
The benefits of assertive community treatment (ACT) on patients with severe mental disorders are well established over short or medium term. However, studies that investigate long term outcomes are remarkably scarce. Thus, this study aimed to evaluate patient's long term clinical and psychosocial evolution after discharge from ACT. An assessment was conducted on 29 patients characterized by inpatient facilities heavy use and refusal of care, who were included in an ACT program 8.7 (SD = 0.7) years ago and discharged 6.3 (SD = 1.8) years ago. Results of the follow up showed decreased rates of hospitalizations and symptomatology, as well as sustained improvement in adherence to care, in quality of life and in social functioning. This data suggests that ACT programs can help refractory to care patients to gain clinical and psychosocial improvement and lay foundation for better long-term adherence to care. Results also suggest that ACT didn't imply a lifetime treatment.
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Hartmann JA, Schmidt SJ, McGorry PD, Berger M, Berger GE, Chen EY, de Haan L, Hickie IB, Lavoie S, Markulev C, Mossaheb N, Nieman DH, Nordentoft M, Polari A, Riecher-Rössler A, Schäfer MR, Schlögelhofer M, Smesny S, Thompson A, Verma SK, Yuen HP, Yung AR, Amminger GP, Nelson B. Trajectories of symptom severity and functioning over a three-year period in a psychosis high-risk sample: A secondary analysis of the Neurapro trial. Behav Res Ther 2020; 124:103527. [DOI: 10.1016/j.brat.2019.103527] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/31/2019] [Accepted: 11/20/2019] [Indexed: 11/26/2022]
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Nemoto T, Uchino T, Aikawa S, Saito J, Matsumoto H, Funatogawa T, Yamaguchi T, Katagiri N, Tsujino N, Mizuno M. Social anxiety and negative symptoms as the characteristics of patients with schizophrenia who show competence-performance discrepancy in social functioning. Psychiatry Clin Neurosci 2019; 73:394-399. [PMID: 30968478 DOI: 10.1111/pcn.12848] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/20/2019] [Accepted: 04/03/2019] [Indexed: 11/30/2022]
Abstract
AIM Although competence and performance in relation to social functioning usually go hand in hand, it is not uncommon to observe a discrepancy between the two in patients with schizophrenia. The present study was aimed at examining the characteristics of patient groups showing such discrepancy. METHODS A total of 205 outpatients with schizophrenia aged ≤40 years old were enrolled. The symptomatology and social functioning were widely assessed. The patients were divided into four groups by the cut-off scores for competence and performance in relation to social functioning calculated using a comprehensive dataset. RESULTS The subjects were divided according to their level of competence and performance as follows: high competence and high performance (CP) group, 108 (52.7%) patients; high competence, but low performance (Cp) group, 40 (19.5%) patients; low competence, but high performance (cP) group, 13 (6.3%) patients; low competence and low performance (cp) group, 44 (21.5%) patients. One-way analysis of variance and post-hoc comparisons revealed significantly worse negative symptoms, general psychopathology scores, global functioning, and quality of life in the Cp group than in the CP group, and significantly better social anxiety symptoms, global functioning, and quality of life in the cP group than in the cp group. CONCLUSION In patients who are capable, but do not perform well, negative symptoms may be involved in the discrepancy. Patients who are able to maintain themselves well despite low social competence appear to have milder social anxiety symptoms as compared to patients who are neither competent nor perform well.
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Affiliation(s)
- Takahiro Nemoto
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Takashi Uchino
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Sayaka Aikawa
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Junichi Saito
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Hiroshi Matsumoto
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Tomoyuki Funatogawa
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Taiju Yamaguchi
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Naoyuki Katagiri
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Naohisa Tsujino
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Masafumi Mizuno
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
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Fleury MJ, Fortin M, Rochette L, Grenier G, Huỳnh C, Pelletier É, Vasiliadis HM. Assessing quality indicators related to mental health emergency room utilization. BMC Emerg Med 2019; 19:8. [PMID: 30646847 PMCID: PMC6332534 DOI: 10.1186/s12873-019-0223-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 01/04/2019] [Indexed: 01/13/2023] Open
Abstract
Background This descriptive study compared 2014–15 to 2005–06 data on the quality of mental health services (MHS) in relation to emergency room (ER) use to assess the impact of the 2005 Quebec MH reform regarding access, continuity and appropriateness of care for patients with mental illnesses (PMI). Methods Data emanated from the Quebec Integrated Chronic Disease Surveillance System (Quebec/Canada). Participants (865,255 for 2014–15; 817,395 for 2005–06) were age 12 or over, with at least one MI, including substance use disorders (SUD), diagnosed during an ER visit, outpatient treatment or hospitalization. Variables included: access (ER use/frequency, hospitalization rates, outpatient consultations preceding an ER visit), care continuity (outpatient consultations following an ER visit/hospitalization, consecutive returns to the ERs), and care appropriateness (high ER use, recurrence of yearly ER visits, length of hospitalization). Frequency distributions were calculated on sex, age and geographic area for ER visits/hospitalizations in 2014–15, and between 2014 and 15 and 2005–06. Results PMI accounted for 12 % of the Quebec population in 2014–15 (n = 865,255), of whom 39% visited an ER for any reason. Amount and frequency of ER use and number/length of hospitalizations were almost twice as high for PMI versus patients without MI; 17% of PMI were also high/very high ER users and were frequently hospitalized. Among PMI, ER users were also frequent users of outpatient services despite a lack of follow-up appointments after ER visits or hospitalizations. Findings revealed some positive changes over time, such as decreased ER and hospitalization rates; yet overall access, continuity and appropriateness of care, as measured in this study, remained low. Conclusions This study demonstrated that the Quebec reform did not produce a substantial impact on ER use or substantially improved care, as hypothesized. Better access and continuity of care should be promoted to reduce the high prevalence of ER use among PMI. Quality improvement in MHS may be realized if ERs are supported by substantial and well-integrated community MH networks.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada. .,Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada.
| | - Marilyn Fortin
- Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Louis Rochette
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Christophe Huỳnh
- Centre de recherche et d'expertise en dépendance, Montréal, QC, Canada.,Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Ile-de-Montréal, Montréal, QC, Canada
| | - Éric Pelletier
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Helen-Maria Vasiliadis
- Département des sciences de la santé communautaires, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche de l'hôpital Charles LeMoyne, Longueuil, QC, Canada
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Deister A. Die Region als Kooperationsrahmen in der psychiatrischen Versorgung. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 62:150-155. [DOI: 10.1007/s00103-018-2864-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Is schizophrenia still one entity with similar symptomatic patterns, neurobiological characteristics, and treatment perspectives? Eur Arch Psychiatry Clin Neurosci 2018; 268:525-527. [PMID: 30056559 DOI: 10.1007/s00406-018-0926-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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