Community-supported teaching on the topic of transgender identity in undergraduate medical education - a pilot project.

Introduction and objectives: Future physicians are insufficiently prepared for the topic of transgender identity during their studies. Relevant courses during undergraduate medical education are heterogeneous and not widely established within the curricula. At our university, we investigated if students' knowledge of transgender identity could be increased through medical specialist teaching and teaching delivered by representatives of the trans* community (community-supported teaching). Methods: During summer semester 2021 (SS21), the knowledge level on transgender identity of 134 medical students in their fifth clinical semester was evaluated (phase 1). In addition, knowledge gain on gender incongruence through the module "psychiatry" was retrospectively surveyed across two dimensions: 1. diagnostic criteria, 2. treatment/care. During winter semester 2021/22 (WS 21/22), a 90-minute seminar on transgender identity was held either community-supported or by medical specialists (phase 2). Following the psychiatry exam, a re-evaluation was carried out by 115 students (phase 3). Results: The students in SS21 did not feel sufficiently educated in the topic of transgender identity through their studies, but rated the relevance of the topic for their later profession as high. Learning gain improved after the introduction of the seminar in WS21/22 compared to the previous semester (both dimensions p<.001). Community-supported and specialist teaching achieved equivalent results. Conclusion: One 90-minutes seminar led to a significant learning gain regarding the topic of transgender identity. Community-supported teaching is a promising way to impart knowledge in a qualified manner: Medical faculties should use this form of teaching to convey established knowledge to students in future curricula.

Baseline levels of miR-223-3p correlate with the effectiveness of electroconvulsive therapy in patients with major depression.

There is a strong medical need to develop suitable biomarkers to improve the diagnosis and treatment of depression, particularly in predicting response to certain therapeutic approaches such as electroconvulsive therapy (ECT). MicroRNAs are small non-coding RNAs that have the ability to influence the transcriptome as well as proteostasis at the systems level. Here, we investigate the role of circulating microRNAs in depression and response prediction towards ECT. Of the 64 patients with treatment-resistant major depression (MDD) who received ECT treatment, 62.5% showed a response, defined as a reduction of ≥50% in the MADRS total score from baseline. We performed smallRNA sequencing in blood samples that were taken before the first ECT, after the first and the last ECT. The microRNAome was compared between responders and non-responders. Co-expression network analysis identified three significant microRNA modules with reverse correlation between ECT- responders and non-responders, that were amongst other biological processes linked to inflammation. A candidate microRNA, namely miR-223-3p was down-regulated in ECT responders when compared to non-responders at baseline. In line with data suggesting a role of miR-223-3p in inflammatory processes we observed higher expression levels of proinflammatory factors Il-6, Il-1b, Nlrp3 and Tnf-α in ECT responders at baseline when compared to non-responders. ROC analysis of confirmed the diagnostic power of miR-223-3p demarcating ECT-responders from non-responder subjects (AUC = 0.76, p = 0.0031). Our data suggest that miR-223-3p expression and related cytokine levels could serve as predictors of response to ECT in individuals with treatment-resistant depressive disorders.

The myth of brain damage: no change of neurofilament light chain during transient cognitive side-effects of ECT.

Electroconvulsive therapy (ECT) is an effective, safe, and mostly well-tolerated treatment for patients with severe or difficult to treat depression or psychotic disorders. However, a relevant number of patients experience subjective and/or objective cognitive side-effects. The mechanism of these transient deficits is not yet clear. Thus, our study prospectively investigated neurofilament light chain (NfL) concentrations as a highly sensitive biomarker for neuroaxonal damage along with cognitive performance during a course of ECT. Serum NfL concentrations from 15 patients with major depressive disorder receiving ECT were analyzed (1) 24 h before the first ECT, (2) 24 h and (3) 7 days after the last ECT (45 measurements in total). Neuropsychological testing including memory, executive functions and attention was performed at each time-point. NfL concentrations did not change between the three time-points, while a temporary cognitive impairment was found. Even in the subset of patients with the strongest impairment, NfL concentrations remained unchanged. Neuropsychological testing revealed the common pattern of transient cognitive side-effects with reduced performance 24 h post-ECT (global cognition score: p < 0.001; memory: p = 0.043; executive functions: p = 0.002) and return to baseline after 7 days (all p < 0.001). Our study adds to the evidence that neither ECT per se nor the transient cognitive side-effects seem to be associated with an increase of NfL as a marker of neuroaxonal damage. In contrast, we discuss cognitive side effects to be potentially interpreted as a byproduct of ECT's neuroplastic effects.

One year of digital teaching in psychiatry as a response to the COVID-19 pandemic: Knowledge gain and content evaluation of medical students for two summer semesters in 2020 and 2021.

After the beginning of the COVID-19 pandemic in 2020, digital teaching had to be implemented by most universities at short notice and widely replaced classroom teaching. As a consequence, digital teaching further reduced direct social interaction for students. One year after the introduction of digital teaching formats at our university medical center (department of psychiatry and psychotherapy), teaching evaluation of students from summer semesters 2020 and 2021 (SS20, SS21) were compared. The main objective of this study was to objectify whether students evaluate digital teaching less favorably after one year of its implementation. Ratings of 311 medical students on (1) knowledge gain, (2) teaching contents and (3) subjective advantages of digital teaching were analyzed for the two separate cohorts SS20 (n = 175) and SS21 (n = 136). Students also rated their pandemic-related stress level, and if learning progress had been reduced by the pandemic in general. Significant knowledge gain was achieved for all included domains in psychiatry (all p < .001), and did not differ between SS20/SS21. Teaching contents in SS21 were rated worse in six out of eight domains compared to SS20 (p < .001 to .05). Also, subjective advantages of digital teaching vanished in most domains comparing the cohorts of SS21 and SS20 (p < .001 to .05). No differences were found for pandemic-related stress level and subjective learning progress. Limitations include the post-hoc design, possible bias from individual exam grades, and sampling bias. The present study showed that knowledge gain can be considered to be stable one year after the pandemic-related implementation of digital teaching. However, sustainability of this teaching format should be monitored critically: The subject of psychiatry and psychotherapy thrives on direct communication, which can be compromised when using digital formats only. In this light, implementation of more interactive formats in digital teaching is discussed.

Electroconvulsive Therapy in Children and Adolescents in Germany-A Case Series From 3 University Hospitals.

OBJECTIVE: Electroconvulsive therapy (ECT) is a well-established, safe, and efficacious treatment for severe psychiatric disorders. In children and adolescents, it is used much less frequently than in adults, likely because of a lack of knowledge. METHODS: We retrospectively analyzed all patients aged 12 to 17 years who completed a course of ECT at 3 psychiatric university hospitals in Germany between 2010 and 2020. Clinical Global Impression Severity (CGI-S) scores were assessed based on electronic medical records. Changes in CGI-S scores were assessed using a paired samples t test. Predictors for response and remission were assessed using binomial logistic regression. RESULTS: We included 32 patients. The CGI-S scores improved significantly from before to after ECT treatment (6.9 vs 3.9, t = 10.0, P < 0.01). A total of 40.6% of patients responded (CGI ≤ 3) and 21.9% remitted (CGI ≤ 2). The number of ineffective medication trials in the 6 months before ECT treatment was significantly associated with response (odds ratio, 0.54; P = 0.028) and remission (odds ratio, 0.31; P = 0.048). Five patients reported subjective cognitive adverse effects, 2 patients exhibited a prolonged seizure, 1 patient reported headaches, and 1 patient experienced a mild allergic reaction after anesthesia with etomidate. A total of 65.6% of patients experienced no adverse effects at all. CONCLUSIONS: This retrospective analysis found ECT to be effective and safe in children and adolescents irrespective of their main diagnosis. The reported data point to the importance of an early use of ECT for severe psychiatric diseases in child and adolescent psychiatry.

[Implementation of digital teaching in psychiatry as consequence of COVID-19: a comparative evaluation with classroom teaching]. / Einführung digitaler Lehre im Fach Psychiatrie als Reaktion auf COVID-19: eine vergleichende Evaluation zur Präsenzlehre.

BACKGROUND: In response to the coronavirus pandemic, most universities implemented digital teaching at short notice for the summer semester 2020 (SS20), whereas they simultaneously shut down classroom teaching. In the psychiatric clinic of the University Medical Center Göttingen, students' ratings concerning the learning effect and their substantive assessment for both forms of teaching were comparatively evaluated to determine the quality of this process. MATERIAL AND METHODS: Overall, 350 students who had visited classroom teaching (winter semester, WS18/19 to WS19/20) vs. digital teaching (SS20) assessed their form of teaching post hoc, within a standardized survey. They rated the individual learning effect in seven psychiatric subjects and did a substantive assessment on eight dimensions. In addition, they rated their expenditure of time. RESULTS: For digital teaching, the individual learning effect was rated as either being equivalent or superior (subjects: psychotherapy, schizophrenia). Despite a significantly heightened expenditure of time, digital teaching was substantively assessed as being equivalent to classroom teaching or superior (dimensions: independent processing of learning goals, overall format of lecture). Concerning their anticipated preparation for the professional practice, students rated digital teaching as being inferior to classroom teaching. CONCLUSION: A pandemic-driven conversion from classroom to digital teaching did not result in a loss of quality on the dimensions measured in this comparative evaluation. With a view to professional practice, digital teaching should complement classroom teaching and be part of future curricula.

Effectiveness of maintenance electroconvulsive therapy-Evidence from modifications due to the COVID-19 pandemic.

OBJECTIVE: Continuation and maintenance ECT (c-/m-ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c-/m-ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c-/m-ECT schedules. METHODS: In the context of the COVID-19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c-/m-ECT in March and April 2020 at our department (n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c-/m-ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued. RESULTS: Both reduced frequency and discontinuation of c-/m-ECT were associated with significant clinical deterioration as measured by CGI-I (Clinical Global Impression Scale - Global Improvement) during the six-month follow-up when compared to the subgroup of patients without any treatment modification (p = 0.005, p = 0.011). Furthermore, patients with discontinued or reduced c-/m-ECT showed significantly higher rates of rehospitalizations (p = 0.028) and new acute courses of ECT (p = 0.018). CONCLUSION: Despite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c-/m-ECT in a real-world population. Especially, patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction.

[Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany]. / Elektrokonvulsionstherapie im Kindes- und Jugendalter.

Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany Abstract. Abstract. Background: Electroconvulsive therapy (ECT) is a highly effective and well-researched therapy in adult psychiatry and has been successfully used especially as a treatment for severe depressive, catatonic, and psychotic disorders. Although severe disease progressions also occur in child and adolescent psychiatry, ECT is used much less frequently there. This may be because hardly any data have been collected on the use, effectiveness, and tolerability of ECT in child and adolescent psychiatric patients. This article outlines the application, effectiveness, and tolerability of ECT when applied to young adolescents in Germany. Methods: A retrospective survey on ECT in 29 patients under 18 years of age was conducted at three German university centers. All documented cases were recorded and evaluated for effectiveness and tolerability. In addition, a comprehensive PubMed-based database search was carried out. Results and conclusions: Internationally, there are no meta-analyses or randomized controlled studies and hardly any published cases on electroconvulsive therapy in German child and adolescent psychiatry. Our data on ECT show high efficacy in previously treatment-resistant and severely ill patients. Side effects occurred rarely. There was no evidence of differences between adults and adolescents in indication (depression, catatonia, schizophrenia), effectiveness, tolerability, and negative predictors of response to ECT. The results also suggest that the use of ECT in adolescents should be considered earlier in the treatment course.

[Importance of electroconvulsive therapy (ECT) in forensic psychiatry]. / Stellenwert der Elektrokonvulsionstherapie (EKT) in der forensischen Psychiatrie.

BACKGROUND AND OBJECTIVE: Electroconvulsive therapy (ECT) is recommended in guidelines for the treatment of severe affective and psychotic disorders that also can be found in patients in forensic psychiatric commitment; however, there are no systematically collected data concerning the use of ECT in forensic psychiatry. The aim of this study was to investigate the current state and estimated need for ECT in forensic psychiatry in Germany. MATERIAL AND METHODS: A questionnaire was designed consisting of questions about the current practice and estimated need for ECT in this population. This questionnaire was sent electronically (and by post if needed) to the forensic psychiatric hospitals in Germany. RESULTS: We received replies from 52 hospitals (66%) and 29 of these hospitals stated that they were capable of treating patients with ECT. An indication for ECT treatment was seen in 3.4% of all detained patients across all forensic hospitals. In 1 year (2018) 32 ECT treatment courses were carried out with on average good effectiveness and a mean clinical global impressions (CGI) scale of 2.32. The most frequent reason for not using ECT was lack of structural requirements. Approximately one third of the forensic psychiatric hospitals stated that there was a medium or even high need for ECT in forensic psychiatry. CONCLUSION: The use of ECT in German forensic psychiatry is currently very limited. It is striking that the number of applied ECT treatments is eight times lower in comparison to the frequency of indications. Nevertheless, approximately two thirds of the forensic hospitals stated a medium or high need for ECT, which seems to suggest a shortage of ECT in the treatment of forensic psychiatry patients.

Overlooking the obvious? Influence of electrolyte concentrations on seizure quality parameters in electroconvulsive therapy.

Clinical response to electroconvulsive therapy (ECT) depends on eliciting a generalized seizure. Though there are multiple ictal and other parameters to assess seizure quality, factors that influence these parameters have only been identified to a limited extend in antecedent studies (e.g., stimulus dosage, age). In the context of ECT, electrolyte concentrations have hardly been investigated so far-although hyponatremia is one well-known clinical factor to increase the risk of spontaneous seizures. In 31 patients with unipolar or bipolar depressive disorder, blood concentrations of sodium (Na), potassium (K), and calcium (Ca) were measured immediately prior to repeated sessions of maintenance ECT. Generalized linear mixed models were used to analyze the influence of Na, K, and Ca on seven seizure quality parameters: postictal suppression index (PSI), maximum sustained coherence (MSC), midictal amplitude, average seizure energy index, seizure duration (EEG/motor), and peak heart rate. Results show a statistically significant relationship between the serum sodium level and MSC: in the model, a reduction of 1 mmol/l led to an increase in interhemispheric coherence of 0.678%. The further markers remained unaffected by changes in electrolyte concentrations. This finding provides first evidence that a lower blood concentration of sodium could enhance the quality of ECT-induced seizures in terms of higher interhemispheric coherence.

Serum neurofilament light chain (NFL) remains unchanged during electroconvulsive therapy.

Objectives: Although there is consistent evidence that electroconvulsive therapy (ECT) is safe and well tolerated by the majority of patients, some authors still accuse ECT to inevitably cause brain damage and permanent memory loss, assertions that may increase patients' worries about a useful treatment. Recently, the measurement of neurofilament light chain (NFL) in peripheral blood was technically implemented, permitting longitudinal analysis of this biomarker for axonal damage. NFL is part of the axonal cytoskeleton and is released into the CSF and peripheral blood in the context of neuronal damage.Methods: In our study, blood from 15 patients with major depressive disorder receiving ECT was collected before the first ECT as well as 24 h and seven days after the last ECT, respectively. NFL concentrations were analysed using the ultrasensitive single molecule array (Simoa) technology.Results: NFL concentrations did not differ between patients and healthy controls, and there was no significant change in NFL levels in the course of ECT. On the contrary, we even found a slight decrease in absolute NFL concentrations.Conclusions: Our study confirms the safety of ECT by using a most sensitive method for the detection of NFL in peripheral blood as a biomarker of neuronal damage.

Electroconvulsive Therapy in Incapable Patients Refusing Treatment: Prevalence, Effectiveness, and Associated Factors.

OBJECTIVES: Severe psychiatric disorders may be accompanied by life-threatening conditions, lack of insight, and treatment refusal. Involuntary treatment may be indicated in patients who lack capacity to consent and refuse treatment. In this context, there is a lack of systematic data regarding the use of electroconvulsive therapy (ECT) in Germany. METHODS: A questionnaire with 25 items comprising quantitative and qualitative data was sent to all psychiatric hospitals in Germany that perform ECT. Cases of ECT treatment in incapable patients refusing therapy were identified retrospectively in a 12-month period. RESULTS: Fifty-three hospitals completed the questionnaire, and 15 cases of ECT in incapable and refusing patients were reported. A marked clinical response was observed in 14 patients. Capacity to consent was restored in 11 patients. In contrast to this particularly good effectiveness, psychiatrists' attitudes revealed a widespread lack of experience as well as reservations and uncertainties regarding the use of ECT against the patient's wishes. CONCLUSIONS: In line with other recent publications, our data suggest a very good benefit-to-risk ratio for ECT in incapable patients refusing the treatment, while at the same time the provision of ECT in such patients is rare in Germany. In light of the scarcity of treatment alternatives and the possible consequences of a refusal to perform ECT in life-threatening conditions, a general rejection of involuntary ECT does not seem ethically appropriate.

Electroconvulsive therapy induced gray matter increase is not necessarily correlated with clinical data in depressed patients.

BACKGROUND: Electroconvulsive therapy (ECT) and depression have been associated with brain volume changes, especially in the hippocampus and the amygdala. METHODS: In this retrospective study we collected data from individual pre-post ECT whole brain magnetic resonance imaging scans of depressed patients from six German university hospitals. Gray matter volume (GMV) changes were quantified via voxel-based morphometry in a total sample of 92 patients with major depressive episodes (MDE). Additionally, 43 healthy controls were scanned twice within a similar time interval. RESULTS: Most prominently longitudinal GMV increases occurred in temporal lobe regions. Within specific region of interests we detected significant increases of GMV in the hippocampus and the amygdala. These results were more pronounced in the right hemisphere. Decreases in GMV were not observed. GMV changes did not correlate with psychopathology, age, gender or number of ECT sessions. We ruled out white matter reductions as a possible indirect cause of the detected GMV increase. CONCLUSION: The present findings support the notion of hippocampus and amygdala modulation following an acute ECT series in patients with MDE. These results corroborate the hypothesis that ECT enables primarily unspecific and regionally dependent neuroplasticity effects to the brain.

Influence of depressed patients' expectations prior to electroconvulsive therapy on its effectiveness and tolerability (Exp-ECT): a prospective study.

Electroconvulsive therapy (ECT) is the most effective therapy for severe depressive disorders. Though there are known clinical predictors of response (e.g., higher age, presence of psychotic symptoms), there is a lack of knowledge concerning the impact of patients' expectations on treatment outcome and tolerability in terms of possible placebo/nocebo effects. In 31 patients with unipolar or bipolar depressive disorder, we used a questionnaire to investigate the patients' expectations of ECT effectiveness and tolerability prior to and in the course of the treatment. Additionally, the questionnaire was used after the ECT course for a final assessment. Depressive symptoms and putative side-effects were measured at each time point. General linear models were used to analyze the course of depressive symptoms and patients' expectation of ECT effectiveness and tolerability. ECT significantly reduced depressive symptoms with large effect sizes. Patients' rating of ECT effectiveness decreased in parallel: While responders' rating of ECT effectiveness remained stable on a high level, non-responders' rating decreased significantly. Group difference was significant after, but not prior to and during the treatment. Regarding tolerability, there was a (temporary) significant increase in the severity of self-rated symptoms such as headache and memory impairment. In contrast, patients' expectation and assessment of ECT tolerability remained unchanged, and their expectations prior to ECT had no impact on the occurrence of side-effects. These findings contradict the presence of relevant placebo/nocebo effects in the context of ECT when investigating a population of mostly chronic or treatment resistant patients with moderate to severe depressive disorder.