[Influence of guideline recommendations, care structures and individual factors on the use of psychosocial therapies in severely mentally ill people]

OBJECTIVE

The influence of guideline recommendations and other factors on the utilization of psychosocial interventions in people with severe mental illness was examined.

METHODS

Data from a cross-sectional study of 397 people with severe mental illness were analysed descriptively.

RESULTS

Patients are less likely to receive therapies with a strong recommendation compared to other levels of recommendation. Various other factors are diffusely associated with utilization rates, but no ubiquitous predictors could be identified across all therapies.

CONCLUSION

Current practice in the use of psychosocial interventions does not follow guideline recommendation strength. Interventions with strong recommendations are probably not available across services. Consequently, routine practice is not able to follow guideline recommendations according to their strength. Other consistent predictors could not be identified.

Moderators and mediators of effects of interventions to reduce stress in hospital employees: A systematic review

This systematic review examines moderators and mediators tested in evaluations of stress management interventions for hospital employees to determine their significance for intervention outcomes. To be included, studies had to comprise a moderator or mediator analysis and a quantitative assessment of stress or mental well-being, and to be published in English or German language. Five databases (APA PsycInfo, APA PsycArticles, Embase, Medline, and Web of Science) were searched. Moderators and mediators were categorised thematically and examined using effect direction plots. Study quality was assessed using RoB 2 and ROBINS-I. In fifteen included studies, 22 moderators and ten mediators were identified. Moderators and mediators were categorised into individual psychological factors (14), socio-economic status (6), work situation (5), intervention (3), and duration of employment (3). Two moderators (perceived stressfulness of residency, job control) had a positive, two a negative impact (spirituality, socially desirable responding). One moderator (years of professional experience) had a positive and negative impact. Three moderators measured on categorical scales (gender, profession, and shiftwork) also had effects, favouring women, physicians and night-shift employees. Five mediators (adherence to intervention, mindfulness, non-reactivity to inner experience, total observing, and self-compassion) had a positive impact, while three (isolation, over-identification, psychological inflexibility) had a negative impact. In conclusion, effects of interventions were predominantly driven by individual psychological factors, while the role of other variables seems to be limited. Interventions focussing on primary or tertiary prevention were rare. Also processes through which organisational-level interventions can be most effective have been hardly investigated. Larger and methodologically robust studies are needed to better understand causal pathways and optimise matching of interventions to target groups.

Does the peer-led Honest, Open, Proud program reduce stigma's impact for everyone? An individual participant data meta-regression analysis

PURPOSE

Many people with mental illness experience self-stigma and stigma-related stress and struggle with decisions whether to disclose their condition to others. The peer-led Honest, Open, Proud (HOP) group program supports them in their disclosure decisions. In randomized controlled trials, HOP has shown positive effects on self-stigma and stigma stress on average. This study examined individual predictors of HOP outcomes and tested the hypothesis that stigma stress reduction at the end of HOP mediates positive HOP effects at follow-up.

METHODS

Six RCTs were included with data at baseline, post (after the HOP program) and at 3- or 4-week follow-up. Baseline variables were entered in meta-regression models to predict change in self-stigma, stigma stress, depressive symptoms and quality of life among HOP participants. Mediation models examined change in stigma stress (post) as a mediator of HOP effects on self-stigma, depressive symptoms, and quality of life at follow-up.

RESULTS

More shame at baseline, and for some outcomes reduced empowerment, predicted reduced HOP effects on stigma stress, self-stigma, depressive symptoms, and quality of life. Younger age was related to greater improvements in stigma stress after the HOP program. Stigma stress reductions at the end of HOP mediated positive effects on self-stigma, depressive symptoms and quality of life at follow-up.

CONCLUSION

Participants who are initially less burdened by shame may benefit more from HOP. Stigma stress reduction could be a key mechanism of change that mediates effects on more distal outcomes. Implications for the further development of HOP are discussed.

[Patient Preferences for Exercise Therapy in People with Severe Mental Illness in Germany]

PURPOSE

Assessing the experience with and the attitudes towards exercise therapy in persons with severe mental illness (SMI). Furthermore, potential variables of high preference towards exercise therapy are investigated.

METHODS

Cross-sectional observational study of SMI patients aged between 18 and 65 years (n=385). Patients were interviewed by trained staff using standardised instruments. Potential variables were analysed using a hierarchic binary logistic regression model.

RESULTS

84,4% of SMI patients had a high preference for exercise therapy; of these, 44,1% exercised regularly. Among patients with severe mental illness especially a higher value in the GAF-assessment (p=0,041) and living in a metropolitan area (p=0,011) predict a high preference for exercise therapy.

CONCLUSION

Most of the patients with severe mental illness interviewed in this study place a surprisingly high value on sports and exercise therapy. Due to the increasing evidence with regard to positive effects of these therapies, it may be an excellent starting point to expand sports and exercise therapy as part of a comprehensive treatment plan. At the same time, strategies for everyday transfer need to be implemented more rigorously.

Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey

Importance

The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear.

Objective

To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey.

Design, Setting, and Participants

This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group.

Interventions

The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees.

Main Outcomes and Measures

The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021.

Results

Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone.

Conclusions and Relevance

This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.

The role of migration in mental healthcare: treatment satisfaction and utilization

Migration rates increase globally and require an adaption of national mental health services to the needs of persons with migration background. Therefore, we aimed to identify differences between persons with and without migratory background regarding (1) treatment satisfaction, (2) needed and received mental healthcare and (3) utilization of mental healthcare.In the context of a cross-sectional multicenter study, inpatients and day hospital patients of psychiatric settings in Southern Germany with severe affective and non-affective psychoses were included. Patients' satisfaction with and their use of mental healthcare services were assessed by VSSS-54 and CSSRI-EU; patients' needs were measured via CAN-EU.In total, 387 participants (migratory background: n = 72; 19%) provided sufficient responses for analyses. Migrant patients were more satisfied with the overall treatment in the past year compared to non-migrant patients. No differences between both groups were identified in met and unmet treatment needs and use of supply services (psychiatric, psychotherapeutic, and psychosocial treatment).Despite a comparable degree of met and unmet treatment needs and mental health service use among migrants and non-migrants, patients with migration background showed higher overall treatment satisfaction compared to non-migrants. The role of sociocultural and migrant-related factors may explain our findings.

Predictors of competitive employment in individuals with severe mental illness: results from an observational, cross-sectional study in Germany

Background

Employment is of great importance as it is associated with various positive effects. Individuals with severe mental illness (SMI) are often excluded from competitive employment. Current data on employment of individuals with mental illness are rare, and influencing factors are under-researched. The present study examines possible predictors of competitive employment among individuals with SMI.

Methods

This was a cross-sectional and multicentered study of 300 individuals with SMI aged 18 to 65 years. The following inclusion criteria were used: (I) diagnosis of schizophrenia, schizotypal and delusional disorders (ICD-10 F2x), or affective disorders (ICD-10 F3x), (II) duration of psychiatric illness ≥ 2 years, and (III) substantial impact of illness on social functioning. Participants were interviewed by trained staff using standardised instruments. The relationship between potential predictors (age, sex, education, marital status, living situation, migration background, psychosocial functioning, age at first mental problem, physical illness, work ability) and employment was analysed using a hierarchic binary logistic regression model.

Results

Only one-third (34%) of participants were competitively employed. Almost one-third were unemployed (30%), and 28% reported early retirement due to mental illness. Psychosocial functioning was positively associated with competitive employment (OR = 1.09, 95% CI: 1.05 – 1.13, p < 0.001); concurrent chronic physical illness was negatively associated with competitive employment (OR = 0.38, 95% CI: 0.21 – 0.71, p = 0.002).

Conclusions

Findings confirm a high risk of exclusion from competitive employment among individuals with SMI. Nonetheless, a substantial proportion of individuals are employed. Findings call for efforts to maintain or enhance workforce participation among individuals with SMI. A special focus should be placed on improving physical health and strengthening psychosocial functioning.

Trial registration

The study was registered in the German Clinical Trials Register (DRKS) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

[Peer Support: Utilization and Benefit in Severe Mental Illness - Results from an Observational, Cross-Sectional Study]

OBJECTIVE

Peer support is playing an increasing role in the treatment of severely mentally ill people. International findings are available on its effectiveness. However, little is known about knowledge, use and benefit assessment in Germany. This paper addresses this question and presents results from an observational study with 10 participating clinics in southern Germany.

METHODS

As part of the observational cross-sectional study with people with severe mental illness (IMPPETUS, N=359), sociodemographic and illness- and treatment-associated data were collected by trained study staff between March 2019 and September 2019. Binary logistic regression was used to analyse a possible association with peer support use.

RESULTS

38% (N=138) of respondents reported knowledge about the possibility of peer support; 15% (N=55) affirmed its use. Use of peer support varied across sites (between 6.5 and 37.5%) and was associated with household income. Significantly less frequent use of peer support was among those with high versus low household income (OR=0.20 [95% CI: 0.06-0.68], p=0.01). Of respondents with peer support use (N=55), 78% reported perceiving peer support to be helpful or highly helpful.

DISCUSSION

Peer support not only proves to be effective under study conditions with regard to various outcomes, but is also assessed as beneficial under routine conditions in a defined care region by the majority of users. However, only a few respondents knew and used the possibility of peer support.

CONCLUSION

In order to implement peer support more strongly, information about this kind of service should be provided more effectively and a dialogue about successful implementation experiences should be initiated on a regional level.

Honest, Open, Proud to support disclosure decisions and to decrease stigma's impact among people with mental illness: conceptual review and meta-analysis of program efficacy

PURPOSE

Honest, Open, Proud (HOP; formerly "Coming Out Proud"/COP) is a peer-led group program to support people with mental illness in their disclosure decisions and in their coping with stigma. The aims of this study were to provide (i) a conceptual review of HOP, including versions for different target groups and issues related to outcome measurement and implementation; and (ii) a meta-analysis of program efficacy.

METHODS

Conceptual and empirical literature on disclosure and the HOP program was reviewed. Controlled trials of HOP/COP were searched in literature databases. A meta-analysis of HOP efficacy in terms of key outcomes was conducted.

RESULTS

HOP program adaptations for different target groups (e.g. parents of children with mental illness; veterans or active soldiers with mental illness) exist and await evaluation. Recruitment for trials and program implementation may be challenging. A meta-analysis of five HOP RCTs for adults or adolescents with mental illness or adult survivors of suicide attempts found significant positive effects on stigma stress (smd = - 0.50) as well as smaller, statistically non-significant effects on self-stigma (smd = - 0.17) and depression (smd = - 0.11) at the end of the HOP program. At 3- to 4-week follow-up, there was a modest, not statistically significant effect on stigma stress (smd = - 0.40, 95%-CI -0.83 to 0.04), while effects for self-stigma were small and significant (smd = - 0.24). Long-term effects of the HOP program are unknown.

CONCLUSION

There is initial evidence that HOP effectively supports people with mental illness in their disclosure decisions and in their coping with stigma. Implementation issues, future developments and public health implications are discussed.

Systematic evaluation of the 'efficacy-effectiveness gap' in the treatment of depression with venlafaxine and duloxetine

OBJECTIVE

Evidence of larger drug effects in highly standardized studies (efficacy) compared to clinical routine (effectiveness) is discussed as efficacy-effectiveness gap. This study aimed to quantify effect size differences of RCTs and non-RCTs in the treatment of depression with venlafaxine and duloxetine and to identify effect modifying predictors.

METHODS

A comprehensive systematic review and meta-analysis was conducted, including all prospective trials, which evaluated the treatment effects of duloxetine or venlafaxine in patients with depression. The primary outcome was the pre-post effect size after acute therapy, which were compared between RCTs and non-RCTs. Moreover, an exploratory analysis of predictors in a mixed meta-regression model within an information-theoretic approach was performed.

RESULTS

171 RCTs and 74 non-RCTs were included. The pre-post effect size differed significantly between RCTs and non-RCTs (-3.04 vs. -2.62, Δ = 0.41, p = 0.012, high heterogeneity). Study characteristics were very similar between RCTs and non-RCTs. Most important variables to predict effect sizes were 'depression severity', 'dose' and 'number of participants'.

CONCLUSION

Despite differences in effect sizes between RCTs and non-RCTs, study design is not clearly an important predictor for the effect sizes. Our results question the common assumption that non-RCTs are generally better suited to describe a drug's effectiveness in clinical practice than RCTs. Future studies and their reporting should put more emphasis on the description of external validity, in order to allow better assessments of clinical relevance.

Multifactorial barriers in the implementation of schizophrenia and psychosocial therapies guidelines: A quantitative study across different professions

BACKGROUND

Clinical guidelines can facilitate the transfer of scientific evidence into clinical practice, yet their implementation still faces difficulties. The aim of this study was to examine the implementation status of the current German evidence- and consensus-based guidelines for schizophrenia (2019) and psychosocial therapies (2019) and to identify barriers as well as facilitators in guideline adherence.

METHODS

We used a quantitative approach by developing an online questionnaire, focusing on the current implementation status as well as barriers and facilitators in guideline adherence. The questionnaire was sent to 100 hospitals for psychiatry and psychosomatics and 52 professional associations in mental healthcare in Germany (investigation period: 10/2019-01/2020).

RESULTS

In total, 657 mental healthcare professionals (MHCP, e.g. medical doctors, psychologists, psychosocial therapists, caregivers) provided sufficient responses for analyses. Less than half (47%) of our participants were aware of the existence of the guideline for psychosocial therapies, while 74% exhibited awareness of the schizophrenia guideline. A minority reported to adhere to the current guidelines for schizophrenia (41%) and psychosocial interventions (18%). Profession-related differences in the implementation-status were detected. Specifically, medical doctors exhibited higher awareness rates than psychosocial therapists and caregivers and additionally higher adherence rates than psychologists and caregivers. Medical doctors were less exposed to knowledge-related barriers (e.g. lack of guideline familiarity), while no differences across professions were found in external/behavior-related barriers (e.g. long versions).

DISCUSSION AND CONCLUSION

Our findings indicate that the implementation of guidelines as well as related barriers vary between professions. To prevent a growing gap in guideline adherence between MHCP, target-specific implementation strategies should be considered.

Employment status and desire for work in severe mental illness: results from an observational, cross-sectional study

PURPOSE

People with a severe mental illness (SMI) are at particular risk of occupational exclusion. Among the approaches to occupational rehabilitation, supported employment (SE) has been proven to be the most effective. A requirement to enter SE-programs is that individuals must want to seek competitive employment. The aim of this work is to investigate the relationship between serious mental illness and the desire to work including potential predictors.

METHODS

This is a cross-sectional observational study of patients with SMI aged 18-65 years (n = 397). Patients were interviewed by trained staff using standardised instruments. The relationship between potential predictors and a strong preference for employment were analysed using a hierarchic binary logistic regression model.

RESULTS

Only about one-quarter (27.9%) of SMI patients is in competitive employment. Another quarter is unemployed (25.9%). Results show that the desire for competitive employment is strong among more than half of the SMI patients. Among the unemployed, two-thirds express a strong desire for work. These individuals are an ideal target group for SE interventions. Comorbid chronic physical illness, diagnosis, and the subjectively judged ability to work are associated with the desire for work.

CONCLUSION

Our data confirm a substantial exclusion of individuals with SMI from the workforce. In general, care needs for workplace interventions are not being met and leave much room for improvement. In addition to employment status, the desire for work should be routinely assessed.

STUDY REGISTRATION

The study was registered in the German Clinical Trials Register (DRKS) ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015801 ) and under the WHO-Platform "International Clinical Trials Registry Platform" (ICTRP) ( https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00015801 ) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

Development and implementation of guidelines for the management of depression: a systematic review

Objective

To evaluate the development and implementation of clinical practice guidelines for the management of depression globally.

Methods

We conducted a systematic review of existing guidelines for the management of depression in adults with major depressive or bipolar disorder. For each identified guideline, we assessed compliance with measures of guideline development quality (such as transparency in guideline development processes and funding, multidisciplinary author group composition, systematic review of comparative efficacy research) and implementation (such as quality indicators). We compared guidelines from low- and middle-income countries with those from high-income countries.

Findings

We identified 82 national and 13 international clinical practice guidelines from 83 countries in 27 languages. Guideline development processes and funding sources were explicitly specified in a smaller proportion of guidelines from low- and middle-income countries (8/29; 28%) relative to high-income countries (35/58; 60%). Fewer guidelines (2/29; 7%) from low- and middle-income countries, relative to high-income countries (22/58; 38%), were authored by a multidisciplinary development group. A systematic review of comparative effectiveness was conducted in 31% (9/29) of low- and middle-income country guidelines versus 71% (41/58) of high-income country guidelines. Only 10% (3/29) of low- and middle-income country and 19% (11/58) of high-income country guidelines described plans to assess quality indicators or recommendation adherence.

Conclusion

Globally, guideline implementation is inadequately planned, reported and measured. Narrowing disparities in the development and implementation of guidelines in low- and middle-income countries is a priority. Future guidelines should present strategies to implement recommendations and measure feasibility, cost–effectiveness and impact on health outcomes.

Implementation of the patient version of the evidence-based (S3) guideline for psychosocial interventions for patients with severe mental illness (IMPPETUS): study protocol for a cluster randomised controlled trial

BACKGROUND

The German guideline on psychosocial interventions for people with severe mental disorders recommends a broad spectrum of evidence-based treatments. Structured implementation of the associated patient version of the guideline is missing to date. The study aims to assess whether structured implementation of a patient guideline improves the empowerment of patients with severe mental disorders, as well as knowledge, attitudes and experiences regarding psychosocial interventions, service use, treatment satisfaction, treatment needs, quality of life and burden of care.

METHODS

The study is a multicentre, cluster-randomised, controlled study with two parallel groups. Inpatients and day hospital patients (all sexes; 18-65 years) with severe mental disorders will be included. Additionally, relatives of patients with mental disorders (all sexes; ≥ 18 years) will be included. In the experimental group, the patient guideline will be implemented using a multimodal strategy. Participants in the control group will receive treatment as usual but will be made aware of the patient guideline. The primary outcome is the change of empowerment, assessed by using the 'empowerment in the process of psychiatric treatment of patients with affective and schizophrenia disorders' (EPAS) scale. In addition, knowledge, attitudes and experiences regarding psychosocial interventions will be assessed as secondary outcomes, as well as service use, satisfaction with care, patient need and quality of life and participation and social inclusion. For relatives, the perceived burden of care also will be recorded. Results will be analysed using hierarchical linear models. For the health economic evaluation, the incremental cost-utility ratios will be computed using the differences in total costs of illness and the differences in quality-adjusted life years (QALY) between study groups.

DISCUSSION

The study will be the first to assess the effects of a structured implementation of the patient version of a psychiatric treatment guideline. The study has some limitations regarding the transferability of the results to other patients and other regions. Furthermore, problems with the recruitment of patients and relatives and with the implementation of intervention could occur during the study.

TRIAL REGISTRATION

The study is registered in the German Clinical Trials Register (DRKS) and the WHO International Clinical Trials Registry Platform (ICTRP) under registration number DRKS00017577 (Date of registration: 23 October 2019.

pymzML v2.0: introducing a highly compressed and seekable gzip format

Motivation

In the new release of pymzML (v2.0), we have optimized the speed of this established tool for mass spectrometry data analysis to adapt to increasing amounts of data in mass spectrometry. Thus, we integrated faster libraries for numerical calculations, improved data retrieving algorithms and have optimized the source code. Importantly, to adapt to rapidly growing file sizes, we developed a generalizable compression scheme for very fast random access and applied this concept to mzML files to retrieve spectral data.

Results

pymzML performs at par with established C programs when it comes to processing times. However, it offers the versatility of a scripting language, while adding unprecedented fast random access to compressed files. Additionally, we designed our compression scheme in such a general way that it can be applied to any field where fast random access to large data blocks in compressed files is desired.

Availability and implementation

pymzML is freely available on https://github.com/pymzML/pymzML under GPL license. pymzML requires Python3.4+ and optionally numpy. Documentation available on http://pymzml.readthedocs.io.

Parental military deployment as risk factor for children's mental health: a meta-analytical review

There is evidence that military service increases the risk of psychosocial burden for not only service members but also their spouses and children. This meta-analysis aimed to systematically assess the association between military deployment of (at least one) parent and impact on children's mental health. For this meta-analytic review, publications were systematically searched and assessed for eligibility based on predefined inclusion criteria (studies between 2001 until 2017 involving children with at least one parent working in military services). Measurements were determined by total problem scores of the children as well as symptoms of anxiety/depression, hyperactivity/inattention, and aggressive behavior. Meta-analyses aggregated the effect sizes in random-effect models and were calculated separately for the relation between parental deployment and civilian/normative data and for the relation between parental deployment and non-deployment. Age of the children was used as moderator variable to explore any potential source of heterogeneity between studies. Parental military deployment was associated with problems in children and adolescents compared to civilian/normative samples. Significant effect sizes reached from small to moderate values; the largest effect sizes were found for overall problems and specifically for anxious/depressive symptoms and aggressive behavior. Within the military group, children of deployed parents showed more problem behavior than children of non-deployed parents, but effect sizes were small. Age of the children had no moderating effect. The results emphasize that children of military members, especially with a deployed parent, should be assessed for emotional and behavioral problems.

Effectiveness of interventions to promote help-seeking for mental health problems: systematic review and meta-analysis

Help-seeking is important to access appropriate care and improve mental health. However, individuals often delay or avoid seeking help for mental health problems. Interventions to improve help-seeking have been developed, but their effectiveness is unclear. A systematic review and meta-analysis were therefore conducted to examine the effectiveness of mental health related help-seeking interventions. Nine databases in English, German and Chinese were searched for randomised and non-randomised controlled trials. Effect sizes were calculated for attitudes, intentions and behaviours to seek formal, informal and self-help. Ninety-eight studies with 69 208 participants were included. Interventions yielded significant short-term benefits in terms of formal help-seeking, self-help, as well as mental health literacy and personal stigma. There were also positive long-term effects on formal help-seeking behaviours. The most common intervention types were strategies to increase mental health literacy, destigmatisation (both had positive short-term effects on formal help-seeking behaviours) as well as motivational enhancement (with positive long-term effects on formal help-seeking behaviours). Interventions improved formal help-seeking behaviours if delivered to people with or at risk of mental health problems, but not among children, adolescents or the general public. There was no evidence that interventions increased the use of informal help. Few studies were conducted in low- and middle-income countries (LMICs). This study provides evidence for the effectiveness of help-seeking interventions in terms of improving attitudes, intentions and behaviours to seek formal help for mental health problems among adults. Future research should develop effective interventions to improve informal help-seeking, for specific target groups and in LMICs settings.

67 Influence of Metabolic Status and Genetic Merit for Fertility on Proteomic Composition of Bovine Uterine Luminal Fluid

Intensive selection strategies focusing on increased milk yield over several decades has been associated with a decline in fertility in dairy cows. To study the effect of the genetic merit for fertility and the metabolic status of the female on the oocyte, early embryo and the maternal environment, 2 animal models were established. The genetic merit model involved Holstein heifers with a low (LFH) and high fertility (HFH) index and heifers from the Montbéliarde breed (MBD), known to have good reproductive performance. The metabolic model comprised samples from maiden heifers (MH), postpartum lactating cows (Lact), and non-lactating cows (dried off immediately after calving; Dry). A common pool of Day 7 embryos recovered from superovulated and artificially inseminated Holstein heifers were transferred into synchronised recipients (1/recipient) of the above-mentioned animal models and uterine lumen fluid (ULF) of confirmed pregnant animals was recovered on Day 19 post-oestrus. As communication between the conceptus and the uterine environment is crucial for the successful establishment of pregnancy, we analysed uterine luminal fluid of pregnant cows from both models using a holistic proteomic approach. Using nano-liquid chromatography-tandem mass spectrometry analysis combined with a label-free quantification approach, we analysed the uterine luminal fluid from the uterine horn ipsilateral to the corpus luteum (where the conceptus was located in all cases). A total of 2127 proteins were quantified in all samples of both models. Among this set of proteins, 458 were found to differ significantly (P-value < 0.05) in abundance between the groups of the genetic model, and 141 were altered in abundance in the metabolic model. The majority of proteome differences in ULF samples was found comparing HFH to the LFH group (358) and between Dry and Lact cows (70) in the metabolic model. Evaluation of this dataset using bioinformatic tools comprising DAVID GO and gene set enrichment analysis revealed that the affected proteins were predominantly assigned to the terms “translation”, “monosaccharide metabolic process”, “enzyme inhibitor activity”, “lipid binding”, and “response to oxidative stress”. Our study revealed that metabolic status and genetic merit for fertility lead to quantitative molecular differences at the level of proteins in uterine fluid of pregnant animals, thus altering the microenvironment for the early conceptus. This research was funded by European Union Seventh Framework Programme FP7/2007-2013 under grant agreement no. 312097 (‘FECUND’).

Challenging mental health related stigma in China: Systematic review and meta-analysis. I. Interventions among the general public

Mental illness stigma is widely endorsed by the general public in China. Evidence-based anti-stigma interventions to reduce public stigma are needed. However, most studies on the efficacy of anti-stigma interventions took place in Western countries and existing Chinese studies were often not included in recent systematic reviews. This review evaluates the efficacy of anti-stigma interventions among the general population in Mainland China, Hong Kong, Taiwan and Macau. Eight databases in English and Chinese were searched for randomized and non-randomized controlled trials. Subgroup analyses compared interventions with and without consumer contact. Standardized mean differences were calculated from eligible studies where possible. We included 9 trials involving 2041 participants. Interventions yielded a small effect on stereotypes reduction and a similar effect on improving mental health literacy. No study assessed discrimination outcomes. Interventions with consumer contact were not superior to those without. There were insufficient data on medium and long term effects. Heterogeneity across studies was moderate. Quality of studies was modest. Further research using rigorous methods is required.

Challenging mental health related stigma in China: Systematic review and meta-analysis. II. Interventions among people with mental illness

People with mental illness often face different types of mental illness stigma that may affect their lives, including perceived stigma, self-stigma, harmful coping strategies and poor quality of life. Although anti-stigma interventions for people with mental illness from Western countries have been identified by recent systematic reviews, their efficacy in China is unknown. This review evaluates the efficacy of anti-stigma interventions among people with mental illness in Mainland China, Hong Kong, Taiwan and Macau. A systematic search of 8 electronic databases in English and Chinese yielded 17 randomized and non-randomized controlled trials. Standardized mean differences (SMDs) were calculated wherever possible. Psychoeducation was the most commonly used intervention. SMDs were large and significant for perceived/experienced/anticipated stigma, self-prejudice and coping with stigma, as well as for depression and anxiety symptoms and quality of life. Both Cognitive Behavioral Therapy and psychoeducation had positive effects on perceived/experienced/anticipated stigma. The quality of studies was modest and heterogeneity across studies was high. Anti-stigma interventions demonstrated promise to reduce stigma's negative impact on people with mental illness in China, but more high-quality intervention research is needed.

Policies, guideline implementation and practice change - how can the process be understood?

Politics and policy: It is important to understand why, in the translational continuum from pilot research and randomised controlled efficacy trials to roll-out programmes and routine effectiveness studies, some service innovations are taken up by health service purchasers and providers, while others are not. Why do some innovative interventions or models of care get to the stage of implementation, while others fail to be funded?

Effectiveness of interventions for adults with mild to moderate intellectual disabilities and mental health problems: systematic review and meta-analysis

BACKGROUND

There is a lack of available evidence in relation to the effectiveness of interventions for adults with mild to moderate intellectual disability and mental health problems.

AIMS

To evaluate the efficacy of interventions for adults with mild to moderate intellectual disabilities and co-occurring mental health problems.

METHOD

An electronic literature search of the databases Medline, EMBASE, PsycINFO and EBM Reviews aimed at identifying randomised controlled trials (RCTs) and controlled trials testing any type of intervention (psychotherapy, biological or system level) for people with mild to moderate intellectual disabilities (IQ score 35-69) targeting comorbid mental health problems. Additionally a meta-analysis was conducted.

RESULTS

Twelve studies met the inclusion criteria. No significant effect was found for the predefined outcome domains behavioural problems, depression, anxiety, quality of life and functioning. The effect size for depression (d = 0.49) was moderate but non-significant. Quality of studies was moderate and heterogeneity was high.

CONCLUSIONS

There is no compelling evidence supporting interventions aiming at improving mental health problems in people with mild to moderate intellectual disability. The number of available trials is too low for definite conclusions. Some interventions are promising and should be evaluated further in larger and more rigorous trials.

Suicidality in emergency medicine: Results from a retrospective analysis of emergency documentation forms

BACKGROUND

To analyze suicidal care episodes in emergency medical responses in Germany.

METHOD

Anonymized data from emergency care episodes in Ulm from 2004 to 2013 were analyzed retrospectively.

RESULTS

158 of 933 psychiatric emergencies (16 %) were suicide related, including 14 completed suicides, 25 care episodes with suicidal ideation, and 119 suicide attempts. Significantly more men than women completed suicide (χ²(2,N = 934) = 12.70, p = 0.02). 93 % of the total psychiatric emergencies received any medication at all, and only about 33 % were transported to a psychiatric hospital.

CONCLUSION

Psychiatric treatment for suicidality in emergency medicine requires improvement to ensure that patients receive adequate therapy.

[Psychiatric Day Clinics--Evidence for and Importance of Patient-Centered Care]

OBJECTIVE

The aim of the study was to summarize and evaluate the recent literature on treatment in psychiatric day clinics, and to assess the importance of such clinics in the current healthcare system.

METHOD

We conducted a systematic review of recent studies in order to compare the efficacy and cost effectiveness of day clinics in relation to in- and outpatient treatment.

RESULTS

The evidence is still sparse and inconclusive.

CONCLUSION

Psychiatric day clinics act as a link between inpatient and outpatient treatment in community mental healthcare. However, evidence in support of the efficacy and cost-effectiveness of day clinics is still sparse.

Preliminary study of patterns of medication use for depression treatment in China

This systematic review investigated drug utilization for depression and assessed trends in prescriptions in China. Major Western and Chinese electronic databases were searched without language restriction for studies reporting defined daily doses. A total of 76 studies published between 2000 and 2010 reporting data on prescriptions for depression in China between 1996 and 2008 were included. All studies were published in Chinese. Most trials were conducted in urban areas in south and east China. Twenty-nine drugs were reported as antidepressants. On the basis of defined daily doses, melitracen/flupentixol combination, fluoxetine, and paroxetine were the most frequently prescribed compounds. According to published evidence, selective serotonin reuptake inhibitors have become the most commonly prescribed class of antidepressant drugs in China.

[Changing attitude towards schizophrenia by psychiatric training of medical students]

OBJECTIVE

The aim of the study was to examine if psychiatric training of medical students is appropriate to change their attitude towards schizophrenia and reduce stigma.

METHOD

Students at Ulm University were asked to answer five questions regarding a short case vignette about a patient suffering from schizophrenia at the beginning and at the end of a two-week psychiatric training within their undergraduate medical education. For this purpose, the Attitudes to Mental Illness Questionnaire was used. Differences between attitudes before and after the training were examined (paired t-test) and effect sizes were calculated (Cohen's d).

RESULTS

Data were available of 100 students, 34 men and 66 women. There was a statistically significant improvement in the total means of the AMIQ score from - 3.09 at the beginning to - 2.31 at the end of the psychiatric training. The effect size (d) was 0.35. No significant differences were found with respect to the participants' age and gender.

CONCLUSION

A two-week psychiatric training appears to be an appropriate and effective teaching tool to reduce stigma. This is important because health care for patients with schizophrenia is strongly influenced by the practitioner's attitude towards them.

Psychopathological long-term outcome of schizophrenia -- a review

OBJECTIVE

In the past, the comparability of empirical studies that examined the course and outcome of schizophrenia was limited by their use of different diagnostic systems. Focussing on the psychopathological long-term outcome, the present article aims to review follow-up studies that used modern operationalized diagnostic criteria for schizophrenia (DSM-III, DSM-III-R, DSM-IV and ICD-10).

METHOD

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO and PSYNDEX for relevant studies up to the year 2011. Twenty-one studies were included in the final analysis.

RESULTS

The long-term outcome of schizophrenia was heterogeneous and included full remissions as well as severe chronic states. Schizophrenia, however, showed a considerably more unfavourable outcome than other diagnostic groups such as schizoaffective or affective disorders. Psychopathological symptoms remained relatively stable in the course of illness. Several predictors for a poor outcome were identified, such as male gender or pronounced negative symptoms.

CONCLUSION

Recent studies using modern diagnostic systems largely confirm the results of earlier studies. Current diagnostic criteria for schizophrenia identify a heterogeneous sample of patients. The influence of therapeutic interventions on long-term outcome remains unclear.

119 QUANTITATIVE PROTEOME ANALYSIS OF ENDOMETRIUM FROM PREGNANT AND NONPREGNANT PIGS

In mammals, an efficient exchange of molecular signals between the embryo and the maternal environment plays a crucial role for the implantation and development of early embryos as well as for recognition and maintenance of pregnancy. So far, only a few molecular signals involved in this process have been identified. To address the underlying biochemical processes in pigs at the protein level, we performed a quantitative proteome study with endometrial tissue samples from non-pregnant and pregnant (Day 14) sows. Endometrium samples (lamina epithelialis, lamina propria and tela submucosa; n = 4 per group) were taken from sites of embryonic attachment and from comparable locations in nonpregnant animals. Proteome data were generated by iTRAQ labelling and nano-LC-MS/MS measurements of tryptic endometrium peptides on a high-resolution Orbitrap XL mass spectrometer. To further address and visualize protein isoforms, LC-MS/MS experiments were complemented by 2D gel-based analyses. To enhance the accuracy of protein quantification, the 2D fluorescence difference gel electrophoresis (2D-DIGE) technique was used, including internal pooled standards for inter-gel matching and normalization. The statistical and bioinformatics analysis of 2D-DIGE and iTRAQ data revealed 14 proteins being significantly altered in abundance (fold-change values >1.5, maximum fold-change 13; P < 0.05) between the endometrium proteomes of pregnant and non-pregnant animals. Several of the affected proteins are already known to play an important role in embryo-maternal communication in other species; for example, signal transducer and activator of transcription 1 (STAT1), a protein mediating the cellular response of cells to interferons (IFN) or aldose reductase (AKR1B1), for which a key role in the synthesis of endometrial prostaglandin F is supposed. Several other proteins showing alterations in abundance between pregnant and nonpregnant endometrial tissues were not described previously and represent new and interesting targets for further functional studies addressing their role during early pregnancy.

Psychosocial interventions in people with severe mental illness: a Bleulerian perspective

BACKGROUND

Eugen Bleuler, in his book Dementia praecox oder Gruppe der Schizophrenien, discussed issues of social psychiatry, and he considered complex interventions pivotal in the care for people with schizophrenia. Bleuler emphasised the potential of therapeutic communities in providing care, the drawbacks of extended hospitalisation and the therapeutic potential of planned 'early discharge' and job integration.

METHODS

Some of the current evidence on therapeutic communities, planned early hospital discharge, alternatives to inpatient care and job integration in people with severe mental illness are reviewed.

RESULTS

(i) Current evidence suggests that therapeutic communities (and new forms of milieu therapy, e.g. Soteria) are an effective ingredient of care; (ii) the evidence on planned early discharge suggests that there is scope for early discharge if continuity of care is ensured, and (iii) the evidence on supported employment suggests that there is scope for early job placement/supported employment among people with schizophrenia with little risk to clinical stability.

CONCLUSION

Eugen Bleuler was a far-sighted social psychiatrist who concentrated on treatment issues and complex interventions that are considered cornerstones of care for people with severe mental illness one hundred years later.

Schizophrenia quality indicators for integrated care - results from a feasibility study

Introduction/objectives

There is currently a variety of initiatives to improve the quality of care for schizophrenia, but there is no established core set of quality indicators in schizophrenia. In 2009, Weinmann and Becker published a set of indicators for quality monitoring of schizophrenia care. This study aims to evaluate the feasibility of these indicators.

Methods

Adult schizophrenic patients insured by the Federal Association of Local Health Insurance Funds (AOK) were recruited in two large psychiatric hospitals. Participants were evaluated using PANSS, CGI, Camberwell Assessment of Need-European Version (CAN-EU) and the Verona Service Satisfaction Scale (VSSS) at discharge and after six month. Furthermore, 18-month AOK administrative data was available for all patients included. Feasibility of structural and quality indicators described by Weinmann and Becker (2009) will be tested by applying the full set of indicators.

Results

82 patients with a mean age of 40 and an average GAF score of 44.3 were included. We were able to calculate all indicators. Outpatient data was available with a delay of over six month. Patients had on average 1.6 additional psychiatric diagnoses (S1) and a mean length of stay of 44 days (S6). 67% of the patients were satisfied with the treatment received (Q17). 25% of the patients were re-admitted to an inpatient psychiatric care within 30 days after discharge.

Conclusions

The usage of Quality Indicators seems to be feasible in routine care. However, delay in the availability of outpatient data has to be considered if these indicators are implemented.

Discharge planning in mental health care: a systematic review of the recent literature

OBJECTIVE

To determine and estimate the efficacy of discharge planning interventions in mental health care from in-patient to out-patient treatment on improving patient outcome, ensuring community tenure, and saving costs.

METHOD

A systematic review and meta-analysis identified studies through an electronic search on the basis of defined inclusion and exclusion criteria and extracted data.

RESULTS

Of eleven studies included, six were randomised controlled trials, three were controlled clinical trials, and two were cohort studies. The discharge planning strategies used varied widely, most were limited to preparation of discharge during in-patient treatment. Pooled risk ratios were 0.66 (95% CI = 0.51 to 0.84; P < 0.001) for hospital readmission rate, and 1.25 (1.07 to 1.47; P < 0.001) for adherence to out-patient treatment. Effect sizes (Hedge's g) were -0.25 (-0.45 to -0.05; P = 0.02) for mental health outcome, and 0.11(-0.05 to 0.28; NS) for quality of life.

CONCLUSION

Discharge planning interventions are effective in reducing rehospitalisation and in improving adherence to aftercare among people with mental disorders.

Kinetics of photorefractive recording for circular light beams

We show, theoretically and experimentally, that the buildup of the space-charge field in photorefractive crystals is far from monoexponential for circular light beams. This is a general property of the two-dimensional (2D) case, in contrast to the one-dimensional case. The results form a basis for determination of the photoelectric parameters of photorefractive crystals within a wide intensity range, which is important, e.g., for solving of the optical-damage problem in LiNbO3 and LiTaO3 crystals.

High-temperature-recorded index gratings in periodically poled lithium niobate

Holographic index gratings based on a zero-electric-field photorefractive effect are recorded at high temperatures in copper-doped periodically poled lithium niobate crystals. The interplay between the domain structure and the index grating is studied: the fundamental grating with spatial frequency K is strongly suppressed. Pronounced sideband gratings with K(s)=K+sG appear, where G is the domain grating vector and s is an integer number. After development, an additional grating based on the electro-optic effect shows up. In contrast with the previously mentioned gratings, this grating allows anisotropic diffraction.

Frequency mixing of photorefractive and ferroelectric gratings in lithium niobate crystals

Holographically recorded photorefractive gratings in periodically poled lithium niobate crystals (PPLNs) are investigated. The principal spatial frequency K of the grating is strongly suppressed. Sideband gratings with grating vectors K +/- G appear. From the measurements the domain grating vector G and the duty cycle of the domain structure can be obtained. These findings allow for fast nondestructive quality inspection of PPLN and are of importance for any optical application combining holography and PPLN.