Treatment of adult attention-deficit hyperactivity disorder (ADHD) with transcranial direct current stimulation (tDCS): study protocol for a parallel, randomized, double-blinded, sham-controlled, multicenter trial (Stim-ADHD).

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation treatment used as an alternative or complementary treatment for various neuropsychiatric disorders, and could be an alternative or add-on therapy to psychostimulants in attention-deficit hyperactivity disorder (ADHD). Previous studies provided some evidence for improvements in cognition and clinical symptoms in pediatric and adult ADHD patients. However, data from multi-center randomized controlled trials (RCTs) for this condition are lacking. Thus, our aim is to evaluate short- and mid-term effects of tDCS in this multi-center, randomized, double blind, and sham-controlled, parallel group clinical trial with a 1:1 randomization ratio. Primary endpoint is the total score of DSM-IV scale of the internationally established Conners' Adult ADHD Rating Scales (German self-report screening version, CAARS-S-SR), at day 14 post-intervention (p.i.) to detect short-term lasting effects analyzed via analyses of covariance (ANCOVAs). In case of significant between-groups differences at day 14 p.i., hierarchically ordered hypotheses on mid-term lasting effects will be investigated by linear mixed models with visit (5 time points), treatment, treatment by visit interaction, and covariates as fixed categorical effects plus a patient-specific visit random effect, using an unstructured covariance structure to model the residual within-patient errors. Positive results of this clinical trial will expand the treatment options for adult ADHD patients with tDCS and provide an alternative or add-on therapy to psychostimulants with a low risk for side effects.Trial Registration The trial was registered on July 29, 2022 in the German Clinical Trials Register (DRKS00028148).

The impact of emotional dysregulation and comorbid depressive symptoms on clinical features, brain arousal, and treatment response in adults with ADHD.

Introduction: The role of emotional dysregulation (ED) in attention-deficit/hyperactivity disorder (ADHD) has become an important issue. This study, in which we analyzed data from a predictive pharmaco-EEG-trial, aimed to examine whether symptoms of ED in adult ADHD affect ADHD symptom severity, brain arousal regulation as measured by resting EEG, and the response to stimulant medication. Methods: ED is defined as having a sex- and age-corrected T-score of >70 on the emotional lability subscale of the German version of Conners' Adult ADHD Rating Scale. A total of 115 participants were included in the study, 56 of whom had ED. Participants with ED were more impaired in terms of the severity of core ADHD symptoms, especially inattentive symptoms, comorbid depressive symptoms, interpersonal relationships, and quality of life. In addition, participants with ED were more likely to report a total score above 13 on the Beck Depression Inventory-II, which was considered to be the cutoff for mild depression. Results: No differences were found between the ED and non-ED groups in response to stimulant medication or in brain arousal regulation. In addition, there was no significant effect of ED with comorbid depressive symptoms on treatment response. There was a trend for subgroups that showed a change in brain arousal regulation associated with symptom improvement. Discussion: Our findings may support the assumption that ED may be an important feature of ADHD. The use of EEG-based brain arousal regulation as a diagnostic and predictive tool in ADHD in the presence of ED and comorbid depressive symptoms should be further investigated.

The role of comorbid depressive symptoms on long-range temporal correlations in resting EEG in adults with ADHD.

Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder, characterized by core symptoms of inattention, hyperactivity and impulsivity. Comorbid depression is commonly observed in ADHD-patients. Psychostimulants are recommended as first-line treatment for ADHD. Aberrant long-range temporal correlations (LRTCs) of neuronal activities in resting-state are known to be associated with disorganized thinking and concentrating difficulties (typical in ADHD) and with maladaptive thinking (typical in depression). It has yet to be examined whether (1) LRTC occur in ADHD-patients, and if so, (2) whether LRTC might be a competent biomarker in ADHD comorbid with current depression and (3) how depression affects psychostimulant therapy of ADHD symptoms. The present study registered and compared LRTCs in different EEG frequency bands in 85 adults with ADHD between groups with (n = 28) and without (n = 57) additional depressive symptoms at baseline. Treatment-related changes in ADHD, depressive symptoms and LRTC were investigated in the whole population and within each group. Our results revealed significant LRTCs existed in all investigated frequency bands. There were, however, no significant LRTC-differences between ADHD-patients with and without depressive symptoms at baseline and no LRTC-changes following treatment. However, depressed ADHD patients did seem to benefit more from the therapy with psychostimulant based on self-report.

[Documentation, Application and Efforts to Reduce Involuntary Admissions and Coercive Measures - Results from a Nationwide Study on Acute Psychiatric Hospitals in Germany]. / Dokumentation, Anwendung und Ansätze zur Reduktion von unfreiwilligen Unterbringungen und Zwangsmaßnahmen ­ Ergebnisse einer bundesweiten Befragung akutpsychiatrischer Krankenhäuser in Deutschland.

OBJECTIVE: This nationwide full census survey investigated the documentation status regarding involuntary admissions and coercive measures in psychiatric hospitals in Germany. METHODS: As part of the ZIPHER study, a questionnaire survey on the documentation, application and reduction of coercion was conducted (N = 147, response rate = 34.4 %). RESULTS: The majority of participating hospitals reported a comprehensive documentation of the use of coercion. However, substantial regional differences could be found in this regard as well as for the use of guidelines. The involuntary admission quote was M = 13.4 % (±â€Š10.9). Of those, 33.9 % (±â€Š22.2) were affected by mechanical restraint, 8.9 % (±â€Š17.2) by seclusion, and 11.8 % (±â€Š18.0) by compulsory medication. CONCLUSION: The regional differences plead for a unification of legal bases and applied practice as well as for a merge of respective data on a nationwide level of the relevant stakeholders.

[As the Sunday Evening Crime-TV Leads to Death]. / Wie der Sonntags-Tatort zum Tode führte  .

We report on a special case of suicide, which took place in near timely relationship to the broadcast of Sunday evening crime-tv-episode and copyed directly the therein displayed method of death. The problem of such presentations will be discussed either on behalf of the background of the german presscodex.

[Changes in the Practice of Involuntary Hospitalization During the COVID-19 Pandemic - Experiences and Opinions of Chief Psychiatrists]. / Veränderungen in der psychiatrischen Unterbringungspraxis während der COVID-19-Pandemie.

OBJECTIVE: To collect experiences and opinions of chief psychiatrists in relation to changes in the practice of involuntary hospitalization during the COVID-19 pandemic. METHODS: Online survey among members of the Association of Chief Physicians for Psychiatry and Psychotherapy in North Rhine-Westphalia (LLPP) and analysis of protocols of LLPP board meetings. RESULTS: Changes in the practice of involuntary hospitalization have been perceived in contexts with and without direct reference to COVID-19. These changes have affected, among other things, judicial hearings as well as decisions about the use of coercive measures. CONCLUSION: Procedural standards for involuntary hospitalization must be maintained and coercive measures may only be used if they meet the applicable ethical and legal requirements. It must be ensured that people with mental disorders are not treated unequally both when taking and withdrawing restrictive measures to contain the pandemic.

The "VIP-ADHD trial": Does brain arousal have prognostic value for predicting response to psychostimulants in adult ADHD patients?

EEG studies have shown that adult ADHD patients have less stable brain arousal regulation than age and gender matched controls. Psychostimulants have brain arousal stabilising properties evident in EEG patterns. The aim of this study was to investigate whether the stability of brain arousal regulation has prognostic value in predicting response to methylphenidate therapy in adult ADHD patients. In an open-label, single-arm, multi-centre, confirmatory trial, 121 adult ADHD patients were recruited and 112 qualified for the full analysis set. All participants received an initial dose of 20 mg extended release methylphenidate at baseline. After a titration phase of up to 4 weeks, patients remained on a weight-based target dose of extended release methylphenidate for 4 weeks. Using the Vigilance Algorithm Leipzig (VIGALL 2.1), we assessed brain arousal regulation before the treatment with methylphenidate, based on a 15-min EEG at quiet rest recorded at baseline. Using automatic stage-classification of 1 s segments, we computed the mean EEG-vigilance (indexing arousal level) and an arousal stability score (indexing arousal regulation). The primary endpoint was the association between successful therapy, defined by a 30% reduction in CAARS, and stable/unstable brain arousal. 52 patients (46%) showed an unstable brain arousal regulation of which 23% had therapy success. In the stable group, 35% had therapy success, implying an absolute difference of 12 percentage points (95% CI -5 to 29, p = 0.17) in the direction opposite to the hypothesized one. There were no new findings regarding the tolerability and safety of extended release methylphenidate therapy.

The somatic care situation of people with mental illness.

BACKGROUND AND AIMS: People with mental illness have worse physical health and reduced life expectancy compared to the general population. Nevertheless, their medical care is often insufficient. The present study aimed to investigate the somatic status of people with mental illness with a focus on somatic diagnoses, metabolic risk factors, regular somatic care, and routine check-ups. METHODS: This study used a 14-item questionnaire to survey the somatic care situation of psychiatric university hospital patients. Main survey topics were psychiatric and somatic diagnoses, metabolic risk factors, regular somatic care, and routine check-ups. RESULTS: Four-hundred and thirty-five people with mental illness (48.3% male, mean age 45.4 years) were included. More than three quarters of the participating people with mental illness had access to a general practitioner. People with affective and anxiety disorders reported significantly more contact with medical specialists for somatic diseases, but schizophrenic patients did not receive enough care. Not all people with mental illness and on psychiatric medication received regular somatic care. Somatic diseases increased with number of diagnoses, and the duration of the psychiatric illness was positively correlated with treatment motivation. CONCLUSION: The observed unmet medical needs in this study might reflect the lack of treatment motivation in people with mental illness, but could also represent their obstacles to access care as well as a suboptimal communication between the treating psychiatrist and the referring general practitioner. Increasing awareness of somatic diseases in psychiatric patients and easier access to somatic care have to be implemented in psychiatric clinical routine. The risk of stigmatization in somatic institutions and the lack of self-care management in people with mental illness are complicating factors.

The social-psychiatric service and its role in compulsory hospitalization.

Coercive measures are a sensitive, much-discussed ethical and legal issue in the psychiatric context. Hence, the identification of their predictors and ways of prevention are of utmost importance. The present study aimed to determine the impact of the social-psychiatric services (SPS) in North Rhine Westphalia (NRW) on involuntary admissions according to the German Mental Health Act and to identify predictors for the reduction of these involuntary admissions. A dataset including details from 31 districts and 23 towns in NRW over a time period of 10 years (2005-2014) was analysed regarding the number of involuntary admissions, gender and age of admitted patients, and person/institution initiating the compulsory act. All 56 SPS in NRW were contacted for information on the number of clients/contacts, home visits, areas of responsibility and their involvement in involuntary admissions. Thirty SPS participated in the survey. We found a significant increase of involuntary admissions over time with significantly higher proportions of male patients and patients younger than 60 years in every year. Regarding the characteristics of SPS, a negative correlation between the number of clients contacting the SPS on their own initiative and low-income households was observed. Additionally, the number of clients contacting the SPS on their own initiative was significantly higher in districts/towns associated with lower involuntary admission rates. These data suggest that patient-based factors were of great importance in the context of involuntary admissions. Furthermore, the SPS and home treatment should be strengthened and intensified to achieve lower involuntary admission rates.

The Role of Dietary Supplements in Depression and Anxiety - A Narrative Review.

INTRODUCTION: Dietary supplements are very widely used in the general population and there is a growing market for them, which is against the recommendations of the German Society for Nutrition. There is some evidence that dietary supplements are useful additions in the treatment of psychiatric disorders. This review is an overview of available practical knowledge regarding the use of supplements in psychiatric treatment. In particular, the review focused on the diagnosis of depression and anxiety in terms of supplement treatment. METHODS: This is a narrative review of the evidence regarding supplements for treating anxiety and depression. We searched PubMed to 2018. Two reviewers screened the citations and abstracted the data. Phytopharmaceutical attends and animal-based data were excluded. RESULTS: There are strong indications regarding the impact of supplements on the selected psychiatric disorders, but at this time, there only a few randomized clinical studies available, so evidence for these findings is quite low. However, it must be noted that there are strong hints for a relationship between vitamin D level and depression. Furthermore, various supplements have got potentially an influence on the characteristics of depression. DISCUSSION: This review summarizes the current knowledge about supplements when used for some psychiatric conditions, but the data does not provide compelling evidence in any direction. There are only indications that there is an influence of supplements on psychiatric diseases. In support of this, there is further need for high-quality studies in this field. Reviews on other diagnoses, such as schizophrenia and dementia, will be part of further work.

Kinematic Analysis of Handwriting Movements in Individuals with Intellectual Disabilities with and without Obsessive Compulsive Symptoms.

Theory/calculation: Movement disorders such as disturbances of coordination, clumsiness, and hand-related stereotypies are a frequent phenomenon in individuals with intellectual disabilities (ID). Obsessive-compulsive symptoms are also common in persons with ID. Our aim was to investigate hand motor dysfunction in persons with ID with and without OCD, using a digitizing tablet and the kinematic analysis of handwriting and drawing movements. METHODS: We examinedthe hand motor performance of 23 individuals (12 males, 11 females, 42.6 ± 13.7 years old) with ID of heterogeneous aetiology. All subjects were required to write a sentence and draw circles under various conditions. Kinematic parameters were calculated to quantify hand motion. RESULTS: Individuals with ID exhibit serious hand motor impairments suggestive of bradykinesia, irregularity, and micrographia. More than half of our ID patients (60.9%) displayed obsessive-compulsive symptoms of moderate severity (Y-BOCS total score: 16.6 ± 8.3). Interestingly, the ID patients with OCD displayed smaller amplitudes of hand motor movements than did patients with no obsessive-compulsive symptoms, while differences observed in the writing and drawing concentric circles trials were significant. CONCLUSIONS: The results of this pilot study support the use of kinematic analyses of handwriting movements to evaluate motor abnormalities in patients with ID and comorbid mental illnesses.

[The Promotion of Adherence to Psychodynamic Psychotherapy by Means of Psychoeducational Intervention]. / Die Förderung der Adhärenz durch eine psychoedukative Intervention für psychodynamische Psychotherapien.

OBJECTIVE: This study investigates the promotion of adherence of patients to a psychodynamic treatment program by means of a psycho educational program in the context of randomized field study. METHOD: A sample of a whole year of admittances of patients convicted for forensic treatment due to §â€Š64 of the german penal code were randomized assigned in two groups. An early intervention group received after a 6-week introduction period a specially designed modular psycho educational treatment program parallel to an psychodynamic treatment program. The late intervention group underwent the same psychodynamic treatment program but received psychoeducation 3 month later. The study investigated the drop-out rate and the differences of the two groups in relevant areas. RESULTS: After 7 month significantly more patients of the early intervention group are still in psychodynamic treatment CONCLUSIONS: The study shows positive effects concerning the adherence of forensic inpatients for a psychodynamic orientated therapy.

Preventing involuntary admissions: special needs for distinct patient groups.

BACKGROUND: Coercive measures in psychiatry are a controversial topic and raise ethical, legal and clinical issues. Involuntary admission of patients is a long-lasting problem and indicates a problematic pathway to care situations within the community, largely because personal freedom is fundamentally covered by the UN declaration of human rights and the German constitution. METHODS: In this study, a survey on a large and comprehensive population of psychiatric in-patients in the eastern part of North Rhine-Westphalia, Germany, was carried out for the years 2004-2009, including 230.678 treatment cases. The data were collected from the dataset transferred to health insurance automatically, which, since 2004 is available in an electronic form. In addition, a wide variety of information on treatment, sociodemographic and illness-related factors were collected and analysed. Data were collected retrospectively and analyses were calculated using statistical software (IBM SPSS Statistics 19.0®). Quantitative data are presented as mean and standard deviation. Due to the unequal group sizes, group differences were calculated by means of Chi-square tests or independent sample t tests. A Bonferroni correction was applied to control for multiple comparisons. RESULTS: We found an over-representation of involuntary admissions in young men (<21 years) suffering from schizophrenia and in female patients aged over 60 with a diagnosis of dementia. Most of our results are concordant with the previous literature. Also admission in hours out of regular out-patient services elevated the risk. CONCLUSION: The main conclusion from these findings is a need for a fortification of ambulatory treatment offers, e.g. sociopsychiatric services or ward round at home for early diagnosis and intervention. Further prospective studyies are needed.

The problems of long-term treatment with benzodiazepines and related substances.

BACKGROUND: Benzodiazepine abuse and dependence have been recognized and widely discussed for more than 40 years. With more than 230 million daily doses prescribed in Germany per year, the burden of reimbursement on the statutory health insurance carriers is high, albeit with a slight decline from year to year. At present, about 50% of all prescriptions in Germany are issued privately, even for patients who have statutory health insurance. METHODS: We selectively review the literature on the epidemiology and treatment of benzodiazepine dependence and abuse in Germany. RESULTS: Estimates of the number of benzodiazepine-dependent persons in Germany range from 128 000 to 1.6 million. Most estimates take no account of the large number of private prescriptions (i.e., those that are not reimbursed by the statutory health insurance scheme), while many exclude prescriptions for elderly persons, for whom these drugs are frequently prescribed. For the outpatient treatment of benzodiazepine withdrawal, it is recommended that the drug should first be switched to an equivalent dose of another benzodiazepine with an intermediate or long-acting effect; the dose should then, in general, be reduced weekly. In case of consumption of a high dose (≥ 20 mg diazepam equivalent), hospitalization and the additional administration of carbamazepine or valproic acid are recommended. Flumazenil treatment can improve with - drawal symptoms and leads to higher abstinence rates. Antidepressants should be given only if the patient is depressed. The dependence potential of nonbenzodiazepine drugs such as zolpidem and zopiclon must also be borne in mind. CONCLUSION: Benzodiazepines are generally highly effective when first given, but they should generally be given only for strict indications and for a limited time. If these drugs still need to be given beyond the short term, timely referral to a specialist is indicated, and possibly also contact with the addiction aid system.

Impact of social-psychiatric services and psychiatric clinics on involuntary admissions.

BACKGROUND: Germany provides a wide range of highly developed mental health care to its citizens. The aim of this study was to identify factors influencing the voluntariness of admissions to psychiatric hospitals. Especially the impact of demographic factors of the region, characteristics of the psychiatric hospitals and characteristics of the psychosocial services was analyzed. METHOD: A retrospective analysis of hospital admission registers from 13 German adult psychiatric hospitals in 2009 was conducted. Public data on the regional psychiatric accommodation and demographic situation were added. Hospitals were dichotomously divided according to their index of involuntary admissions. Group comparisons were performed between the clinics with low and high involuntary admission indices. Analysis was conducted with clinical, psychiatric provision and demographic data related to inpatients in the Landschaftsverbands Westfalen-Lippe (LWL)-PsychiatryNetwork. RESULTS: Especially the range of services provided by the social-psychiatric services in the region such as number of supervised patients and home visits had an influence on the proportion of involuntary admissions to a psychiatric hospital. Some demographic characteristics of the region such as discretionary income showed further influence. Contrary to our expectations, the characteristics of the individual hospital seem to have no influence on the admission rate. CONCLUSION: Social-psychiatric services show a preventive impact on involuntary acute psychiatry interventions. Sociodemographic factors and patient variables play a role with regard to the number of involuntary hospitalizations, whereas characteristics of hospitals seemed to play no role.

Voluntary versus involuntary hospital admission in child and adolescent psychiatry: a German sample.

Involuntary psychiatric admission is a central issue in mental health care, especially in the treatment of children and adolescents. Its legal regulations do not only differ between European countries, but also on a federal level. Only few studies so far dealt with rates of involuntary admission (RIA), mainly focusing on adults, rather than children and adolescents. None of the studies analyzed this topic in a large cohort. The aim of this regional cross-sectional study was to compare voluntary and involuntary admissions in child and adolescent psychiatry (CAP) regarding personal and admission characteristics. Furthermore, risk factors and predictors of involuntary admission should be identified. A retrospective analysis of hospital admission registers from three major German CAP hospitals over a period of 6 years (2004-2009) was conducted (N = 10,547 inpatients). Group comparisons between involuntarily and voluntarily treated minors and a logistic regression to determine predictors of legal status were performed. Information on harm to self or others prior to the admission, medication and clinical outcome was not available due to data structure. 70.8 % of patients were voluntarily and 29.2 % involuntarily admitted. Both subsamples comprised more males. The RIA decreased consistently over the years, ranging from 25.7 to 32.4 %. The strongest predictor of being admitted involuntarily was suffering from mental retardation (OR = 15.74). Adolescence, substance abuse, psychotic disorders and admission on duty time were also strongly associated (OR > 3). In this first large cohort study on involuntary treatment of children and adolescents in Germany, about every fourth patient was treated involuntarily. Certain personal and disease-related factors increased the risk. Commitment laws and other legal instruments for regulating involuntary placements are inconsistent and a standardized description or systematic analysis is needed. The influence of demographic, institutional variables and care and health services aspects should also be investigated.

[Negative emotions and understanding - patients' perspective on coercion]. / Negative Emotionen und Verständnis - Zwangsmaßnahmen aus Patientensicht.

OBJECTIVE: This study evaluated involuntarily admitted psychiatric patients' and their perception of coercive measures (i. e. involuntary admission and physical or pharmacological restraint) by asking retrospectively which emotions were induced during the process of coercion. METHOD: Interviews were carried out around 3 weeks after coercion. The interview consisted of 31 items categorized into demographic, nosological and coercion-related themes. Patients were also asked about their subjective experiences of the coercion. 40 patients were recruited, with 72 % suffering from psychosis-related and 21 % with affective disorders. For 22.5 % of the patients, this was their first psychiatric hospitalization. The most frequently reported emotions were rage, anger and despair. Patients who were more stable, according to the Clinical Global Impressions scale (CGI), generally evaluated the coercion as being worse. CONCLUSION: More than half of the patients were satisfied with the treatment received during hospitalization. The potential suffering caused as a result of patients' perceptions of the coercion, and the impact of this on the course of the disease should be taken into account when developing new treatment strategies.