Using brain structural neuroimaging measures to predict psychosis onset for individuals at clinical high-risk.

Machine learning approaches using structural magnetic resonance imaging (sMRI) can be informative for disease classification, although their ability to predict psychosis is largely unknown. We created a model with individuals at CHR who developed psychosis later (CHR-PS+) from healthy controls (HCs) that can differentiate each other. We also evaluated whether we could distinguish CHR-PS+ individuals from those who did not develop psychosis later (CHR-PS-) and those with uncertain follow-up status (CHR-UNK). T1-weighted structural brain MRI scans from 1165 individuals at CHR (CHR-PS+, n = 144; CHR-PS-, n = 793; and CHR-UNK, n = 228), and 1029 HCs, were obtained from 21 sites. We used ComBat to harmonize measures of subcortical volume, cortical thickness and surface area data and corrected for non-linear effects of age and sex using a general additive model. CHR-PS+ (n = 120) and HC (n = 799) data from 20 sites served as a training dataset, which we used to build a classifier. The remaining samples were used external validation datasets to evaluate classifier performance (test, independent confirmatory, and independent group [CHR-PS- and CHR-UNK] datasets). The accuracy of the classifier on the training and independent confirmatory datasets was 85% and 73% respectively. Regional cortical surface area measures-including those from the right superior frontal, right superior temporal, and bilateral insular cortices strongly contributed to classifying CHR-PS+ from HC. CHR-PS- and CHR-UNK individuals were more likely to be classified as HC compared to CHR-PS+ (classification rate to HC: CHR-PS+, 30%; CHR-PS-, 73%; CHR-UNK, 80%). We used multisite sMRI to train a classifier to predict psychosis onset in CHR individuals, and it showed promise predicting CHR-PS+ in an independent sample. The results suggest that when considering adolescent brain development, baseline MRI scans for CHR individuals may be helpful to identify their prognosis. Future prospective studies are required about whether the classifier could be actually helpful in the clinical settings.

Childhood trauma moderates schizotypy-related brain morphology: analyses of 1182 healthy individuals from the ENIGMA schizotypy working group.

BACKGROUND: Schizotypy represents an index of psychosis-proneness in the general population, often associated with childhood trauma exposure. Both schizotypy and childhood trauma are linked to structural brain alterations, and it is possible that trauma exposure moderates the extent of brain morphological differences associated with schizotypy. METHODS: We addressed this question using data from a total of 1182 healthy adults (age range: 18-65 years old, 647 females/535 males), pooled from nine sites worldwide, contributing to the Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) Schizotypy working group. All participants completed both the Schizotypal Personality Questionnaire Brief version (SPQ-B), and the Childhood Trauma Questionnaire (CTQ), and underwent a 3D T1-weighted brain MRI scan from which regional indices of subcortical gray matter volume and cortical thickness were determined. RESULTS: A series of multiple linear regressions revealed that differences in cortical thickness in four regions-of-interest were significantly associated with interactions between schizotypy and trauma; subsequent moderation analyses indicated that increasing levels of schizotypy were associated with thicker left caudal anterior cingulate gyrus, right middle temporal gyrus and insula, and thinner left caudal middle frontal gyrus, in people exposed to higher (but not low or average) levels of childhood trauma. This was found in the context of morphological changes directly associated with increasing levels of schizotypy or increasing levels of childhood trauma exposure. CONCLUSIONS: These results suggest that alterations in brain regions critical for higher cognitive and integrative processes that are associated with schizotypy may be enhanced in individuals exposed to high levels of trauma.

Cortical and subcortical neuroanatomical signatures of schizotypy in 3004 individuals assessed in a worldwide ENIGMA study.

Neuroanatomical abnormalities have been reported along a continuum from at-risk stages, including high schizotypy, to early and chronic psychosis. However, a comprehensive neuroanatomical mapping of schizotypy remains to be established. The authors conducted the first large-scale meta-analyses of cortical and subcortical morphometric patterns of schizotypy in healthy individuals, and compared these patterns with neuroanatomical abnormalities observed in major psychiatric disorders. The sample comprised 3004 unmedicated healthy individuals (12-68 years, 46.5% male) from 29 cohorts of the worldwide ENIGMA Schizotypy working group. Cortical and subcortical effect size maps with schizotypy scores were generated using standardized methods. Pattern similarities were assessed between the schizotypy-related cortical and subcortical maps and effect size maps from comparisons of schizophrenia (SZ), bipolar disorder (BD) and major depression (MDD) patients with controls. Thicker right medial orbitofrontal/ventromedial prefrontal cortex (mOFC/vmPFC) was associated with higher schizotypy scores (r = 0.067, pFDR = 0.02). The cortical thickness profile in schizotypy was positively correlated with cortical abnormalities in SZ (r = 0.285, pspin = 0.024), but not BD (r = 0.166, pspin = 0.205) or MDD (r = -0.274, pspin = 0.073). The schizotypy-related subcortical volume pattern was negatively correlated with subcortical abnormalities in SZ (rho = -0.690, pspin = 0.006), BD (rho = -0.672, pspin = 0.009), and MDD (rho = -0.692, pspin = 0.004). Comprehensive mapping of schizotypy-related brain morphometry in the general population revealed a significant relationship between higher schizotypy and thicker mOFC/vmPFC, in the absence of confounding effects due to antipsychotic medication or disease chronicity. The cortical pattern similarity between schizotypy and schizophrenia yields new insights into a dimensional neurobiological continuity across the extended psychosis phenotype.

Cognitive Patterns and Conversion in a Representative Sample of Individuals at Risk for Psychosis.

ABSTRACT: Clinical high-risk (CHR) individuals belong to a heterogeneous group, of which only a few will cross the threshold for a clinical diagnosis. Cognitive disturbances are present in CHR subjects and may be indicative of transition. Our study aims to identify such deficits in a representative CHR for psychosis sample. Our sample comprised 92 CHR individuals and 54 controls from a representative cohort of the general population. They were followed up for a mean of 2.5 years, with 15 individuals converting to schizophrenia or other Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnoses. Neurocognitive assessment was performed with the University of Pennsylvania Computerized Neuropsychological Testing, and CHR status was assessed with the Structured Interview for Prodromal Syndromes (SIPS). Baseline scores were entered in a latent profile analysis model. Our study brought forward a four-class model on cognitive performance. One class displayed better performance, whereas the other three performed worse, all compared with controls. The class with lower executive function also had the highest score on disorganized communication (SIPS P5 = 1.36, p < 0.05), although unrelated to conversion. Among the low performers, the class significantly related to conversion (p = 0.023) had the highest score in decreased expression of emotion (SIPS N3 = 0.85, p < 0.05). Our study brings new and relevant data on non-help-seeking CHR individuals and the relationship between cognitive patterns and conversion. We have highlighted a specific cognitive signature, associated with negative symptoms, which represents a stable trait with presumed lower conversion to a psychiatric illness.

Impact of clinical decision-making participation and satisfaction on outcomes in mental health practice: results from the CEDAR European longitudinal study.

The present study aimed to assess: (1) whether a more active involvement of patients is associated with an improvement of clinical symptoms, global functioning, and quality-of-life; and (2) how patients' satisfaction with clinical decisions can lead to better outcome after 1 year. Data were collected as part of the study 'Clinical decision-making and outcome in routine care for people with severe mental illness (CEDAR)', a longitudinal observational study, funded by the European Commission and carried out in six European countries. Patients' inclusion criteria were: (a) aged between 18 and 60 years; (b) diagnosis of a severe mental illness of any kind according to the Threshold Assessment Grid (TAG) ≥ 5 and duration of illness ≥ 2 years; (c) expected contact with the local mental health service during the 12-month observation period; (d) adequate skills in the language of the host countries; and (e) the ability to provide written informed consent. The clinical decision-making styles of clinicians and the patient satisfaction with decisions were assessed using the Clinical Decision Making Style and the Clinical Decision Making Involvement and Satisfaction scales, respectively. Patients were assessed at baseline and 1 year after the recruitment. The sample consisted of 588 patients with severe mental illness, mainly female, with a mean age of 41.69 (±10.74) and a mean duration of illness of 12.5 (±9.27) years. The majority of patients were diagnosed with psychotic (45.75%) or affective disorders (34.01%). At baseline, a shared CDM style was preferred by 70.6% of clinicians and about 40% of patients indicated a high level of satisfaction with the decision and 31% a medium level of satisfaction. Higher participation in clinical decisions was associated with improved social functioning and quality-of-life, and reduced interpersonal conflicts, sense of loneliness, feelings of inadequacy, and withdrawal in friendships after 1 year (p < 0.05). Moreover, a higher satisfaction with decisions was associated with a better quality-of-life (p < 0.0001), reduced symptom severity (p < 0.0001), and a significantly lower illness burden associated with symptoms of distress (p < 0.0001), interpersonal difficulties (p < 0.0001), and problems in social roles (p < 0.05). Our findings clearly show that a higher involvement in and satisfaction of patients with clinical decision-making was associated with better outcomes. More efforts have to be made to increase the involvement of patients in clinical decision-making in routine care settings.

Epigenetic mechanisms in schizophrenia and other psychotic disorders: a systematic review of empirical human findings.

Schizophrenia and other psychotic disorders are highly debilitating psychiatric conditions that lack a clear etiology and exhibit polygenic inheritance underlain by pleiotropic genes. The prevailing explanation points to the interplay between predisposing genes and environmental exposure. Accumulated evidence suggests that epigenetic regulation of the genome may mediate dynamic gene-environment interactions at the molecular level by modulating the expression of psychiatric phenotypes through transcription factors. This systematic review summarizes the current knowledge linking schizophrenia and other psychotic disorders to epigenetics, based on PubMed and Web of Science database searches conducted according to the PRISMA guidelines. Three groups of mechanisms in case-control studies  of human tissue (i.e., postmortem brain and bio-fluids) were considered: DNA methylation, histone modifications, and non-coding miRNAs. From the initial pool of 3,204 records, 152 studies met our inclusion criteria (11,815/11,528, 233/219, and 2,091/1,827 cases/controls for each group, respectively). Many of the findings revealed associations with epigenetic modulations of genes regulating neurotransmission, neurodevelopment, and immune function, as well as differential miRNA expression (e.g., upregulated miR-34a, miR-7, and miR-181b). Overall, actual evidence moderately supports an association between epigenetics and schizophrenia and other psychotic disorders. However, heterogeneous results and cross-tissue extrapolations call for future work. Integrating epigenetics into systems biology may critically enhance research on psychosis and thus our understanding of the disorder. This may have implications for psychiatry in risk stratification, early recognition, diagnostics, precision medicine, and other interventional approaches targeting epigenetic fingerprints.

[Debts, loans and unpaid bills among day patients and inpatients in psychiatric care in Berlin, Germany]. / Schulden, Kredite und unbezahlte Rechnungen unter Nutzer*Innen teilstationärer und stationärer psychiatrischer Behandlung in Berlin.

BACKGROUND: Previous studies among the general population indicated an association between mental illnesses and different forms of financial difficulties, such as indebtedness. OBJECTIVE: Investigation of the financial burden and associated factors among inpatients and day clinic patients in psychiatric care. MATERIAL AND METHODS: A total of 488 patients in psychiatric care in the catchment area of the Psychiatric University Hospital Charité at St. Hedwig Hospital participated in a cross-sectional patient survey carried out with a structured interview regarding financial burden, sociodemographic and clinical variables. RESULTS: Of the participants 269 (55.1%) showed outstanding debts, loans or unpaid bills. Among the participants who were willing to give information about the amount of debts, the majority (47.0%) had debts between 1000 € and 9999 € and 36.3% between 10,000 € and 99,999 €. In the binary regression models, younger age and substance use disorders were factors significantly associated with outstanding debts. Of the participants 22.3% had outstanding debts >10,000 € and were depending on social welfare, so that indebtedness could be assumed. CONCLUSION: Financial burdens and outstanding debts among patients in psychiatric care should be inquired about and considered more intensively in practice. Suitable models of support need to be developed and evaluated.

'Placement budgets' for supported employment: impact on employment rates in a multicentre randomised controlled trial.

BACKGROUND: The most effective rehabilitation model for job (re-)entry of people with mental illness is supported employment. A barrier to introducing supported employment into standard care is its temporally unlimited provision, which conflicts with health and social legislation in many European countries. AIMS: To test the impact of different 'placement budgets', i.e. a predefined maximum time budget for job seeking until take-up of competitive employment. METHOD: Participants (116) were randomly assigned to 25 h, 40 h or 55 h placement budgets in an intent-to-treat analysis. We applied the individual placement and support model over 24 months, following participants for 36 months. Primary outcome was employment in the labour market for at least 3 months. RESULTS: The proportion of participants obtaining competitive employment was 55.1% in the 25 h group, 37.8% in the 40 h group and 35.8% in the 55 h group. In a Cox regression analysis, time to employment was slightly lower in the 25 h group relative to the 40 h (hazard ratio 1.78, 95% CI 0.88-3.57, P = 0.107) and 55 h groups (hazard ratio 1.74, 95% CI 0.86-3.49, P = 0.122), but this was not statistically significant. The vast majority of all participants who found a job did so within the first 12 months (80.4%). CONCLUSION: A restricted time budget for job finding and placement does not affect the rate of successful employment. In accordance with legislation, a restriction of care provision seems justified and enhances the chances of supported employment being introduced in statutory services.

Relationship Between Symptomatic Dimensions and Global Functioning of Non-Help-Seeking Individuals at Risk for Psychosis.

This study aims to analyze the relationship between the symptomatic dimensions of psychosis and functioning of individuals at risk for psychosis (ultrahigh risk [UHR]) in a non-help-seeking UHR sample from the general population. The sample is the same as the one used in the Brazilian Subclinical Symptoms and Prodromal Psychosis cohort study. We applied questionnaires of functioning (Global Assessment of Functioning Scale) and symptomatic dimensions (Scale of Prodromal Symptoms). Next, we correlated the symptomatic dimensions with functioning. We found a significant relationship between avolition and uncommon thought content with poor functioning, whereas the remaining symptoms were not as relevant. Poor functioning was most related to avolition, a negative symptom, followed by unusual thought content, a positive symptom.

Rare copy number variants in individuals at clinical high risk for psychosis: Enrichment of synaptic/brain-related functional pathways.

Schizophrenia is a complex and chronic neuropsychiatric disorder, with a heritability of around 60-80%. Large (>100 kb) rare (<1%) copy number variants (CNVs) occur more frequently in schizophrenia patients compared to controls. Currently, there are no studies reporting genome-wide CNVs in clinical high risk for psychosis (CHR-P) individuals. The aim of this study was to investigate the role of rare genome-wide CNVs in 84 CHR-P individuals and 124 presumably healthy controls. There were no significant differences in all rare CNV frequencies and sizes between CHR-P individuals and controls. However, brain-related CNVs and brain-related deletions were significantly more frequent in CHR-P individuals than controls. In CHR-P individuals, significant associations were found between brain-related CNV carriers and attenuated positive symptoms syndrome or cognitive disturbances (OR = 3.07, p = .0286). Brain-related CNV carriers experienced significantly higher negative symptoms (p = .0047), higher depressive symptoms (p = .0175), and higher disturbances of self and surroundings (p = .0029) than noncarriers. Furthermore, enrichment analysis of genes was performed in the regions of rare CNVs using three independent methods, which confirmed significant clustering of predefined genes involved in synaptic/brain-related functional pathways in CHR-P individuals. These results suggest that rare CNVs might affect synaptic/brain-related functional pathways in CHR-P individuals.

Differences between unipolar mania and bipolar-I disorder: Evidence from nine epidemiological studies.

OBJECTIVES: Although clinical evidence suggests important differences between unipolar mania and bipolar-I disorder (BP-I), epidemiological data are limited. Combining data from nine population-based studies, we compared subjects with mania (M) or mania with mild depression (Md) to those with BP-I with both manic and depressive episodes with respect to demographic and clinical characteristics in order to highlight differences. METHODS: Participants were compared for gender, age, age at onset of mania, psychiatric comorbidity, temperament, and family history of mental disorders. Generalized linear mixed models with adjustment for sex and age as well as for each study source were applied. Analyses were performed for the pooled adult and adolescent samples, separately. RESULTS: Within the included cohorts, 109 adults and 195 adolescents were diagnosed with M/Md and 323 adults and 182 adolescents with BP-I. In both adult and adolescent samples, there was a male preponderance in M/Md, whereas lifetime generalized anxiety and/panic disorders and suicide attempts were less common in M/Md than in BP-I. Furthermore, adults with mania revealed bulimia/binge eating and drug use disorders less frequently than those with BP-I. CONCLUSIONS: The significant differences found in gender and comorbidity between mania and BP-I suggest that unipolar mania, despite its low prevalence, should be established as a separate diagnosis both for clinical and research purposes. In clinical settings, the rarer occurrence of suicide attempts, anxiety, and drug use disorders among individuals with unipolar mania may facilitate successful treatment of the disorder and lead to a more favorable course than that of BP-I disorder.

Prevalence of seasonal depression in a prospective cohort study.

The prevalence of autumn/winter seasonality in depression has been documented in the longitudinal Zurich cohort study by five comprehensive diagnostic interviews at intervals over more than 20 years (N = 499). Repeated winter major depressive episodes (MDE-unipolar + bipolar) showed a prevalence of 3.44% (5× more women than men), whereas MDE with a single winter episode was much higher (9.96%). A total of 7.52% suffered from autumn/winter seasonality in major and minor depressive mood states. The clinical interviews revealed novel findings: high comorbidity of Social Anxiety Disorder and Agoraphobia within the repeated seasonal MDE group, high incidence of classic diurnal variation of mood (with evening improvement), as well as a high rate of oversensitivity to light, noise, or smell. Nearly twice as many of these individuals as in the other MDE groups manifested the syndrome of atypical depression (DSM-V), which supports the prior description of seasonal affective disorder (SAD) as presenting primarily atypical symptoms (which include hypersomnia and increase in appetite and weight). This long-term database of regular structured interviews provides important confirmation of SAD as a valid diagnosis, predominantly found in women, and with atypical vegetative symptoms.

Epidemiology of gastrointestinal symptoms in young and middle-aged Swiss adults: prevalences and comorbidities in a longitudinal population cohort over 28 years.

BACKGROUND: Although subacute and chronic gastrointestinal symptoms are very common in primary care, epidemiological date are sparse. The aim of the study was to examine and quantify the prevalence of subacute and chronic gastrointestinal symptoms and their associations with somatic and mental disorders in the general population. METHODS: Data were collected prospectively between 1981 (age m = 22, f = 23) and 2008 (age 49/50) from the Zurich Cohort Study (n = 292 men, 299 women), a representative general population survey. The participants were assessed using a semi-structured interview, the "Structured Psychopathological Interview and Rating of the Social Consequences of Psychological Disturbances for Epidemiology" (SPIKE). Prevalence rates were computed to be representative of the general population aged 22-50. Associations were quantified by odds ratios (ORs) and their 99% confidence intervals (CI). RESULTS: The prevalences of intestinal and of gastric symptoms were significantly higher among women in all categories examined. For example, any gastric symptoms: f. 26.4% vs m.15.2%; any intestinal symptoms: 27.6% vs 14.6%; nausea/vomitus: 19.1% vs 4.5%; constipation: 15.8% vs 6.5% (all p < 0.001). Strong associations (all p < 0.0001) were found between fatigue (1 month) and chronic stomach (OR = 9.96, 99%-CI: 5.53-17.94) and chronic intestinal symptoms (OR = 9.02, 99%-CI: 4.92-16.54). Panic attacks were associated with subacute intestinal symptoms (OR = 4.00, 99%-CI: 2.43-6.59). Anxiety was more strongly associated with subacute intestinal symptoms (OR = 3.37, 99%-CI: 2.23-5.08) than with subacute stomach symptoms (OR = 1.85, 1.20-2.86). Bipolar disorders were associated with subacute stomach symptoms (OR = 1.83, 1.18-2.17) and unipolar depression with subacute intestinal symptoms (OR = 2.05, 1.34-3.15). CONCLUSIONS: Remarkably high prevalence rates of gastric and intestinal complaints were observed in women (over 1/4; men 1/7). Fatigue/neurasthenia was the strongest co-factor in both conditions. Various syndromes related to anxiety, phobia, and panic disorders showed further significant associations. The integration of psychiatric and/or psychological treatment could help address the functional part of gastric and intestinal syndromes.

Articulation and testing of a personality-centred model of psychopathology: evidence from a longitudinal community study over 30 years.

Advances in psychopathological research advocate a personality-centred model of common mental disorders (CMD). We tested four hypotheses to test such a model. First, personality relates to critical life events; second, both personality and critical life events relate to CMD; third, interaction effects between personality and critical life events relate to CMD; fourth, neuroticism explains the majority of variance in psychopathology. We analysed data (n = 453) based on seven semi-structured interviews from a longitudinal epidemiologic cohort study over 30 years spanning years 1979 (age 20) to 2008 (age 50). CMD and critical life events were assessed seven times between 1979 and 2008 and personality domains of neuroticism, extraversion and aggressiveness in 1988 and 1993. Aggressiveness and neuroticism related to partnership rupture and job loss. Neuroticism related significantly to major depression, anxiety disorders, substance-use disorders (SUD) and severity of psychopathology. Both partnership rupture and job loss related to major depression and severity of psychopathology, but not to anxiety disorder or SUD. An interaction effect between neuroticism and partnership rupture pointed towards significantly increased SUD prevalence. All associations held when additionally adjusted for childhood adversity and familial socio-economic status. According to a pseudo-R 2, neuroticism explained 51% of total variance in severity of psychopathology over time, while all three personality domains along with both partnership rupture and job loss explained 59% of total variance. In conclusion, personality, especially neuroticism, relates consistently to repeated measures of psychopathology. These associations are independent of and more pervasive than the effects of partnership rupture and job loss. Partnership rupture in interaction with neuroticism may further increase the risk for SUD. We conclude that neuroticism is a fundamental aetiological factor for severe psychopathology, but further testing of this model in other longitudinal studies is required.

Involuntary hospitalization, stigma stress and suicidality: a longitudinal study.

People with severe mental illness and a history of involuntary hospitalization may experience stigma-related stress and suffer negative consequences as a result. However, the long-term impact of stigma stress on suicidality in this population remains unknown. This longitudinal study therefore examined stigma stress, self-stigma, self-esteem and suicidal ideation among 186 individuals with mental illness and recent involuntary hospitalization. After adjusting for age, gender, diagnoses and symptoms, more stigma stress at baseline predicted suicidal ideation after 2 years, mediated by increased self-stigma and decreased self-esteem after 1 year. Anti-stigma interventions that reduce stigma stress and self-stigma could therefore support suicide prevention.

Epidemiology of Back Pain in Young and Middle-Aged Adults: A Longitudinal Population Cohort Survey From Age 27-50 Years.

BACKGROUND: Back pain is extremely common and a huge burden for both individuals and health care services. OBJECTIVE: The aim was to determine the prevalence and incidence of lumbar and cervical back pain over 23 years and to quantify associations with concomitant disorders. METHODS: Data on lumbar and cervical back pain, and mental disorders from the Zurich study, collected between 1986 (age men: 27/women: 28 years) and 2008 (age 49/50) were analyzed. Epidemiological parameters were representative rates for the general population. Associations were quantified by odds ratios (ORs). RESULTS: Of 499 subjects, 68.9% ever experienced lumbar pain and 60.7% ever experienced cervical back pain; the 23-year prevalences were 66.9% and 54.9% and the 23-year incidences 52.3% and 48.9% for lumbar and cervical back pain, respectively. Annual prevalences varied between 28.4% and 47.2% for lumbar and 18.3% and 54.7% for cervical back pain; the corresponding annual incidences varied by 5.8-13.3% (lumbar) and 7.8-12.6% (cervical). Lumbar back pain was significantly associated with cardiovascular disease (OR = 4.58), obesity (OR = 3.99), asthma spectrum (OR = 5.76), tranquillizer dependence (OR = 5.84), and other comorbidities (ORs = 1.47-3.27). Significant associations with cervical back pain were observed for specific phobia (OR = 5.10), panic attacks (OR = 4.79), and other comorbidities (ORs = 1.61-2.62). CONCLUSIONS: This study contributes to the refinement of epidemiological data on lumbar and cervical back pain. Some associations with treatable disorders were high, which may offer hope for the indirect management of lumbar and cervical back pain.

Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study.

BACKGROUND: Clinical decision-making is the vehicle of health care provision, and level of involvement predicts implementation and satisfaction. The aim of this study was to investigate the impact of decision-making experience on recovery. METHODS: Data derived from an observational cohort study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR). Adults (aged 18-60) meeting standardised criteria for severe mental illness were recruited from caseloads of outpatient and community mental health services in six European countries. After consenting, they were assessed using standardised measures of decision-making, clinical outcome and stage of recovery at baseline and 1 year later. Latent class analysis was used to identify course of recovery, and proportional odds models to investigate predictors of recovery stage and change. RESULTS: Participants (n = 581) clustered into three stages of recovery at baseline: Moratorium (N = 115; 19.8%), Awareness/Preparation (N = 145; 25.0%) and Rebuilding/Growth (N = 321; 55.2%). Higher stage was cross-sectionally associated with being male, married, living alone or with parents, and having better patient-rated therapeutic alliance and fewer symptoms. The model accounted for 40% of the variance in stage of recovery. An increased chance of worse outcome (change over 1 year to lower stage of recovery) was found for patients with active involvement compared with either shared (OR = 1.84, 95% CI 1.15-2.94) or passive (OR = 1.71, 95% CI = 1.00-2.95) involvement. Overall, both process (therapeutic relationship) and outcome (symptomatology) are cross-sectionally associated with stage of recovery. CONCLUSIONS: Patient-rated decision-making involvement and change in stage of recovery are associated. Joint consideration of decision practise within the recovery process between patient and clinician is supposed to be a useful strategy to improve clinical practice (ISRCTN registry: ISRCTN75841675. Retrospectively registered 15 September 2010).

Sleep disturbances in young and middle-aged adults - Empirical patterns and related factors from an epidemiological survey.

BACKGROUND: Previous research suggests that sleep disorders are highly associated with other mental health problems. However, sleep problems even below the diagnostic threshold of sleep disorders are very common in the general population, which highly affects wellbeing and functioning. In order to broaden the focus beyond those severe cases we explored empirical patterns across the whole spectrum of sleep problems as well as associated clinical and other factors. METHOD: A representative community sample of N=1274 residents from the canton of Zurich was interviewed for sleep problems and diagnostic criteria for mental disorders as well as was given a number of mental health-related psychometrical checklists. Based on a broader spectrum of sleep problems we conducted a latent class analysis (LCA) to derive distinct classes of such disturbances. Classes were compared regarding their associations to mental health-relevant and other risk factors. RESULTS: The LCA revealed four classes - no sleep disturbances (72.6%), difficulties initiating and maintaining sleep (15.8%), delayed sleep (5.3%), and severe sleep problems (6.4%). Severe sleep problems were related to female gender and generalized anxiety disorder, while depression was linked to all sleep problem classes. Persons with difficulties initiating and maintaining sleep and severe sleep problems reported higher levels of psychopathology, burnout and neuroticism, while all sleep problem types were tied to stress-related variables, but not alcohol use disorder. DISCUSSION: Sleep problems are highly prevalent among the young and middle-aged adults in our representative sample of young and middle-aged adults and as such represent a serious public mental health problem. Our findings indicate sleep problems to have a multi-dimensional structure with some differential associations. While all subtypes were associated with poorer mental health and particularly more depression, severe sleep problems appeared to be the sleep subtype seen in agoraphobia and GAD, while delayed sleep had no specific associations. The variety of associations assessed leads one to assume that likewise a variety of sleep interventions is required.

Helping Alliance and Unmet Needs in Routine Care of People With Severe Mental Illness Across Europe: A Prospective Longitudinal Multicenter Study.

The helping alliance (HA) refers to the collaborative bond between patient and therapist, including shared goals and tasks. People with severe mental illness have a complex mixture of clinical and social needs. Using mixed-effects regression, this study examined in 588 people with severe mental illness whether an increase in the HA is associated with fewer unmet needs over time, and whether change in the HA precedes change in unmet needs. It was found that a reduction in unmet needs was slower in patients with higher HA (B = 0.04, p < 0.0001) only for patient-rated measures. Improvement in both patient-rated and staff-rated HA over time was associated with fewer subsequent patient-rated (B = -0.10, p < 0.0001) and staff-rated (B = -0.08, p = 0.0175) unmet needs. With positive changes in the HA preceding fewer unmet needs, findings provide further evidence for a causal relationship between alliance and outcome in the treatment of people with severe mental illness.

Effectiveness of a Web-Based Intervention in Reducing Depression and Sickness Absence: Randomized Controlled Trial.

BACKGROUND: Depression is highly prevalent in the working population and is associated with significant loss of workdays; however, access to evidence-based treatment is limited. OBJECTIVE: This study evaluated the effectiveness of a Web-based intervention in reducing mild to moderate depression and sickness absence. METHODS: In an open-label randomized controlled trial, participants were recruited from a large-scale statutory health insurance and were assigned to two groups. The intervention group had access to a 12 week Web-based program consisting of structured interactive sessions and therapist support upon request. The wait-list control group had access to unguided Web-based psycho-education. Depressive symptoms were self-assessed at baseline, post-treatment, and follow-up (12 weeks after treatment) using the Patient Health Questionnaire (PHQ-9) and Beck Depression Inventory (BDI-II) as primary outcome measures. Data on sickness absence was retrieved from health insurance records. Intention-to-treat (ITT) analysis and per-protocol (PP) analysis were performed. RESULTS: Of the 180 participants who were randomized, 88 completed the post-assessment (retention rate: 48.8%, 88/180). ITT analysis showed a significant between-group difference in depressive symptoms during post-treatment in favor of the intervention group, corresponding to a moderate effect size (PHQ-9: d=0.55, 95% CI 0.25-0.85, P<.001, and BDI-II: d=0.41, CI 0.11-0.70, P=.004). PP analysis partially supported this result, but showed a non-significant effect on one primary outcome (PHQ-9: d=0.61, 95% CI 0.15-1.07, P=.04, and BDI-II: d=0.25 95% CI -0.18 to 0.65, P=.37). Analysis of clinical significance using reliable change index revealed that significantly more participants who used the Web-based intervention (63%, 63/100) responded to the treatment versus the control group (33%, 27/80; P<.001). The number needed to treat (NNT) was 4.08. Within both groups, there was a reduction in work absence frequency (IG: -67.23%, P<.001, CG: -82.61%, P<.001), but no statistical difference in sickness absence between groups was found (P=.07). CONCLUSIONS: The Web-based intervention was effective in reducing depressive symptoms among adults with sickness absence. As this trial achieved a lower power than calculated, its results should be replicated in a larger sample. Further validation of health insurance records as an outcome measure for eHealth trials is needed. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 02446836; http://www.isrctn.com/ISRCTN02446836 (Archived by WebCite at http://www.webcitation.org/6jx4SObnw).