[Challenges and current approaches in the development of psychiatric living guidelines in Germany]. / Herausforderungen und aktuelle Ansätze der Entwicklung psychiatrischer Living Guidelines in Deutschland.

Outdated guidelines can cause inadequate care. To counter this problem a dynamic updating process for guidelines is being internationally discussed (living guidelines). This process has specific challenges. The rhythm of updating has to be determined and a priori criteria have to be defined, which indicate that a substantial change of the medical practice is needed in order to then update individual recommendations. Digital tools have to be identified that can support a dynamic updating. Their (further) development has to be oriented to the specific requirements and needs of the trialogically composed guideline development teams. Recommendations have to be examined from the user perspective. The current guideline development methods that are still divergent, have to be harmonized and specific needs with respect to the cross-linking of guidelines have to be taken into account. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) supports and accompanies scientific projects dealing with the challenges of the dynamics of guideline development. From the first results of "Guide2Guide", a project funded by the Innovation Fund, it can be summarized that the development of living guidelines is a complex dynamic process that has only just started internationally and in Germany. It demands a special engagement of the guideline developers including representatives of patients and relatives, to responsibly work long term and flexibly. Digital tools can be useful in various process steps but at present they still have to be meaningfully linked into the process. Central elements of the development of S3 guidelines will continue to require substantial working time of the experts in the trialogue. In order for living guidelines to be actually used dissemination and implementation have to be integrated into the dynamic process.

[Concepts to support dynamic updating processes of guidelines and their practical implementation-Systematic literature review]. / Konzepte zur Unterstützung dynamischer Aktualisierungsprozesse von Leitlinien und ihre Implementierung in der Praxis ­ systematische Literaturrecherche.

BACKGROUND: Clinical practice guidelines (CPG), which are crucial for evidence-based healthcare, should be kept up to date, especially on topics where emerging evidence could modify one of the recommendations with implications for the healthcare service; however, an updating process, which is practicable for guideline developers as well as users represents a challenge. OBJECTIVE: This article provides an overview of the currently discussed methodological approaches for the dynamic updating of guidelines and systematic reviews. MATERIAL AND METHODS: As part of a scoping review, a literature search was conducted in the databases MEDLINE, EMBASE (via Ovid), Scopus, Epistemonikos, medRxiv, as well as in study and guideline registers. Concepts on the dynamic updating of guidelines and systematic reviews or dynamically updated guidelines and systematic reviews or their protocols published in English or German were included. RESULTS: The publications included most frequently described the following main processes that must be adapted in dynamic updating processes 1) the establishment of continuously working guideline groups, 2) networking between guidelines, 3) the formulation and application of prioritization criteria, 4) the adaptation of the systematic literature search and 5) the use of software tools for increased efficiency and digitalization of the guidelines. CONCLUSION: The transformation to living guidelines requires a change in the needs for temporal, personnel and structural resources. The digitalization of guidelines and the use of software to increase efficiency are necessary instruments, but alone do not guarantee the realization of living guidelines. A process in which dissemination and implementation must also be integrated is necessary. Standardized best practice recommendations on the updating process are still lacking.

[Expectations of guideline developers on living guidelines]. / Erwartungen der Leitlinienentwickler*innen an "living guidelines".

BACKGROUND: Guidelines are central pillars of high-quality care and care planning. The quality requirements for the development of guidelines and the associated effort are very high. Therefore, more efficient approaches are being forced. OBJECTIVE: The opportunities and challenges in the introduction of a dynamic updating concept within the framework of the digitalization of guidelines were explored from the perspective of guideline developers in the field of psychiatry. This perspective should be included in the implementation. MATERIAL AND METHODS: Between January and May 2022 a cross-sectional survey was conducted among guideline developers (N = 561, response 39%) based on a questionnaire developed and tested in advance. Data were analyzed descriptively. RESULTS: A total of 60% were familiar with the concept of living guidelines. A large proportion endorsed a dynamic updating (83%) and digitalization (88%) of guidelines; however, various challenges are associated with the concept of living guidelines: the risk of inflationary changes (34%), the need for continuity of all actors (53%), involvement of patient and family representatives (37%) and definition of criteria regarding the decision what to change (38%). The vast majority (85%) thought it necessary that guideline development should be followed by implementation projects. CONCLUSION: German guideline developers are very receptive regarding the implementation of living guidelines; however, they named numerous challenges, which need to be addressed in this approach.

[Patient Preferences for Exercise Therapy in People with Severe Mental Illness in Germany]. / Der subjektive Stellenwert von Bewegungs- und Sporttherapie bei Menschen mit schwerer psychischer Erkrankung in Deutschland.

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.

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.

Social Support and Functional Decline in the Oldest Old.

OBJECTIVE: Longitudinal studies investigating the link between social support and functional decline are limited among the oldest old. Thus, the aim of this study was to examine whether changes in social support are associated with functional decline among the oldest old longitudinally using panel regression models. METHODS: Longitudinal data from 3 waves (waves 7, 8, and 9) of a multicenter prospective cohort study covering primary care patients aged ≥85 years were used. In the analytical sample, n equaled 624 individuals. The validated Lawton and Brody Instrumental Activities of Daily Living (IADL) scale and the well-established Barthel Index (ADL) were used to quantify functional status. The psychometrically sound Lubben Social Network Scale was used to measure social support. Several potential confounders such as age, marital status, cognitive decline, or depressive symptoms were included in the fixed effects (FE) regression models. RESULTS: Linear FE regressions showed that a decrease in social support is associated with functional decline (IADL: ß = 0.03, p < 0.05; ADL: ß = 0.27, p < 0.05) in men but not in women. With IADL as outcome measure, the interaction term (sex × social support) achieved statistical significance (p < 0.01). With regard to covariates, functional decline (IADL and ADL) was consistently associated with increasing age, an increase in the number of chronic conditions (except for women [ADL]), and cognitive decline (except for men [ADL]). Furthermore, functional decline (ADL) was associated with an increase in depressive symptoms. DISCUSSION: Our findings highlight the meaning of social support for functional status among the oldest old. Finding ways to sustain social support in highest age may be a promising approach in order to postpone functional decline.

Leipzig - Individual Placement and Support for people with mental illnesses (LIPSY): study protocol of a randomized controlled trial.

BACKGROUND: Individuals receiving means-tested benefits are at a higher risk of being diagnosed with a psychiatric illness compared to those who are employed, and the rate of those working in the first labor market is low. The intervention (Individual Placement and Support, IPS) aims at maintaining or regaining working ability and at facilitating reintegration into the (first) labor market following a "first place, then train"-approach. The objective of the study is to conduct the first RCT in Germany that addresses a broad group of long-term unemployed individuals with severe mental illnesses that receive means-tested benefits, and to test the effectiveness of the IPS intervention. METHODS: In this randomized controlled trial, about 120 eligible participants aged between 18 years and local retirement age will be randomly allocated to an intervention group (IG) or to an active control group (CG) using a parallel arm design. The IG will receive IPS + high quality treatment as usual (TAU), the active CG will receive TAU + a booklet on integration measures. A block-randomization algorithm with a targeted assignment ratio of 1:1 for participants in IG and active CG will be used, stratified by sex and three age groups. Assessments will take place before the intervention at baseline (t0), and 6 (t1), 12 (t2), and 18 (t3) months later. Primary outcome will be the proportion of participants having worked at least 1 day in competitive employment since baseline, as assessed at t3. Secondary outcomes will be related to employment/ vocation and mental health. In addition, there will be a process evaluation. Treatment effects on outcomes will be tested using appropriate panel-data regression models, and acceptability, uptake and adherence will be evaluated using descriptive statistics and appropriate inference testing. DISCUSSION: The results of this trial are expected to generate a better understanding of the efficiency, feasibility, acceptance, and relevance of the IPS intervention in a German setting. They could be a first step towards the implementation of the method and towards improving the situation of long-term unemployed individuals with severe mental health problems. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00023245 ), registered on 22.02.2021.

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).

Valuing end-of-life care: translation and content validation of the ICECAP-SCM measure.

BACKGROUND: The evaluation of care strategies at the end of life is particularly important due to the globally increasing proportion of very old people in need of care. The ICECAP-Supportive Care Measure is a self-complete questionnaire developed in the UK to evaluate palliative and supportive care by measuring patient's wellbeing in terms of 'capability'. It is a new measure with high potential for broad and international use. The aims of this study were the translation of the ICECAP-Supportive Care Measure from English into German and the content validation of this version. METHODS: A multi-step and team-based translation process based on the TRAPD model was performed. An expert survey was carried out to assess content validity. The expert panel (n = 20) consisted of four expert groups: representative seniors aged 65+, patients aged 65+ living in residential care, patients aged 65+ receiving end-of-life care, and professionals in end-of-life care. RESULTS: The German version of the ICECAP-Supportive Care Measure showed an excellent content validity on both item- and scale-level. In addition, a high agreement regarding the length of the single items and the total length of the questionnaire as well as the number of answer categories was reached. CONCLUSIONS: The German ICECAP-SCM is a valid tool to assess the quality of life at the end of life that is suitable for use in different settings. The questionnaire may be utilized in multinational clinical and economic evaluations of end-of-life care.

[DNVF-Discussion paper - Specificities, Challenges and Aims of Mental Health Service Research in Germany]. / DNVF-Diskussionspapier ­ Besonderheiten, Herausforderungen und Ziele der Versorgungsforschung im Feld der seelischen Gesundheit.

Research in mental health services in Germany is of increasing relevance. To this end, the recently founded "Mental Health Working Group" as part of the German Network of Health Services Research (DNVF) has written a discussion paper presenting key specifics, challenges, and goals of health service research in the field of mental health. Some research-relevant specifics in the area of mental health care, pragmatic challenges of research organization, ethical problems, and particular research topics in this field are presented and discussed critically.

[Peer Support: Utilization and Benefit in Severe Mental Illness - Results from an Observational, Cross-Sectional Study]. / Genesungsbegleitung: Inanspruchnahme und Nutzenbewertung aus Betroffenenperspektive ­ Ergebnisse einer Beobachtungsstudie.

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.

Which Factors Contribute to Frailty among the Oldest Old? Results of the Multicentre Prospective AgeCoDe and AgeQualiDe Study.

INTRODUCTION: There is a lack of studies investigating the link between time-varying factors associated with changes in frailty scores in very old age longitudinally. This is important because the level of frailty is associated with subsequent morbidity and mortality. OBJECTIVE: To examine time-dependent predictors of frailty among the oldest old using a longitudinal approach. METHODS: Longitudinal data were drawn from the multicentre prospective cohort study "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe), covering primary care patients aged 85 years and over. Three waves were used (from follow-up, FU, wave 7 to FU wave 9 [with 10 months between each wave]; 1,301 observations in the analytical sample). Frailty was assessed using the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS). As explanatory variables, we included sociodemographic factors (marital status and age), social isolation as well as health-related variables (depression, dementia, and chronic diseases) in a regression analysis. RESULTS: In total, 18.9% of the individuals were mildly frail, 12.4% of the individuals were moderately frail, and 0.4% of the individuals were severely frail at FU wave 7. Fixed effects regressions revealed that increases in frailty were associated with increases in age (ß = 0.23, p < 0.001), and dementia (ß = 0.84, p < 0.01), as well as increases in chronic conditions (ß = 0.03, p = 0.058). CONCLUSION: The study findings particularly emphasize the importance of changes in age, probably chronic conditions as well as dementia for frailty. Future research is required to elucidate the underlying mechanisms. Furthermore, future longitudinal studies based on panel regression models are required to confirm our findings.

[Evidence-Based Treatment of Severely Mentally Ill People with Psychosocial Therapies - First Update of the DGPPN S3 Guideline]. / Evidenzbasierte Behandlung von schwer psychisch kranken Menschen mit psychosozialen Therapien ­ Erstes Update der DGPPN-S3-Leitlinie erscheint Ende 2018.

INTRODUCTION: Severe mental illness (SMI) is associated with a large burden for affected individuals and their relatives. Psychosocial therapies are a central pillar of the treatment in SMI. MATERIAL & METHODS: Recommendations on psychosocial treatment on the basis of current scientific evidence and structured consensus-finding procedure are provided in the update of the S3 guideline "Psychosocial therapies for severe mental illness". RESULTS: The update of the guideline includes 33 recommendations and 12 statements in the areas of system-level and individual-level interventions (e. g., to work, housing and psychoeducation) as well as on approaches to self-help (e. g. to self-management and peer services) and on general strategies and orientations (e. g., recovery). A so-called Matrix Chapter meets the specifics of the German healthcare system. DISCUSSION: There is a large body of international scientific evidence on various psychosocial interventions, outlining chances of improved social and work participation of people with severe mental illness (SMI). Further developments in the areas of implementation and quality assurance are urgently needed.

[Importance of Work and Employment in the Treatment of People with Mental Illness - Results of a Qualitative Study]. / Der Stellenwert von Arbeit und beruflicher Beschäftigung in der Behandlung psychisch kranker Menschen.

Exclusion of individuals with mental disorders is common, especially exclusion from the work force. This paper investigates the role of work and the reintegration into the workforce of patients with mental illness from the mental health professional's perspective. Within a qualitative study design, 44 mental health professionals from different settings and regions in Germany were interviewed. The material was transcribed verbatim and a content analysis was conducted. It can be shown that work and inclusion in the workforce is an important topic and that occupational status is discussed early in the treatment process. However, the roles of mental health professionals in different settings vary considerably. Within treatment settings, specific concepts and structured cooperation facilitating the reintegration of patients with mental illness into the workforce are largely lacking.

[Psychosocial Therapies in Severe Mental Illness: Outlook on the Update of the DGPPN-S3-Guideline]. / Psychosoziale Therapien bei schweren psychischen Erkrankungen: Ausblick auf das Update der S3-Leitlinie der DGPPN.

The Psychiatry Enquête turned 40 years old last year. The S3 guideline "Psychosocial therapies for severe mental illness" is considered to be the last milestone of the reform to date. This paper highlights new impulses resulting from the S3 guideline for psychiatric care and provides an outlook on the update, expected in 2017. Many of the interventions reported in the S3 guideline are now supported by a broader evidence base.

S3 guideline on psychosocial therapies in severe mental illness: evidence and recommendations.

The burden of severe and persistent mental illness is high. Beside somatic treatment and psychotherapeutic interventions, treatment options for patients with severe mental illness also include psychosocial interventions. This paper summarizes the results of a number of systematic literature searches on psychosocial interventions for people with severe mental illness. Based on this evidence appraisal, recommendations for the treatment of people with severe mental illness were formulated and published in the evidence-based guideline series of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) as an evidence-based consensus guideline ("S3 guideline"). Recommendations were strongly based on study results, but used consensus processes to consider external validity and transferability of the recommended practices to the German mental healthcare system. A distinction is made between system-level interventions (multidisciplinary team-based psychiatric community care, case management, vocational rehabilitation and participation in work life and residential care interventions) and single psychosocial interventions (psychoeducation, social skills training, arts therapies, occupational therapy and exercise therapy). There is good evidence for the efficacy of the majority of psychosocial interventions in the target group. The best available evidence exists for multidisciplinary team-based psychiatric community care, family psychoeducation, social skills training and supported employment. The present guideline offers an important opportunity to further improve health services for people with severe mental illness in Germany. Moreover, the guideline highlights areas for further research.

[Work Life Participation of Mentally Ill Individuals--Implications for Research and Best Practice]. / Teilhabe psychisch Kranker am Arbeitsleben--Forschungs- und Handlungsbedarf?

Participation in working life improves the health outcome of mentally ill individuals. The paper reviews the current situation of mentally ill individuals and barriers to enter the open labour market. Barriers are discussed and the contribution of mental health professionals is outlined. Implications for research and best practice are considered.

[Outpatient Medical Rehabilitation Services: A New Socio-Law Perspective In Psychiatric Care]. / Ambulante Leistungen der medizinischen Rehabilitation: Eine neue sozialrechtliche Perspektive in der psychiatrischen Versorgung.

The equality of mentally ill people with somatically ill people and the provision of community care were central topics of the Psychiatry-Enquête. With regard to medical rehabilitation services, this goal has not been implemented to date. The amendments to the Ninth Book of the Social Code (SGB IX) made by the Federal Participation Act (BTHG) again open up the possibility of making outreach medical rehabilitation services accessible to people with severe mental illnesses.

[How Successful is the Participation of People with Mental Illness and Family Members in the Development of Evidence- and Consensus-Based Clinical Practice Guidelines? Results of a Survey in Psychiatry]. / Wie gelingt die Einbindung von Betroffenen- und Angehörigenvertreter:innen in die Entwicklung von evidenz- und konsensbasierten Behandlungsleitlinien? Ergebnisse einer Umfrage im Fachbereich Psychiatrie.

OBJECTIVE: The study examines how successful the participation of people with mental illness and family members is currently in the development of psychiatric guidelines. METHODS: Survey results of N=561 (Response 37%) guideline developers are analyzed. RESULTS: Involvement of affected individuals succeeds more often than that of family members (61% vs. 55%). 68% felt that this participation was central to successful guideline development. 51% perceived discrepancies between empirical evidence and experience perspective. 33-36% perceived a lack of appreciation of experience expertise, 37% an insufficient representation and 46% an inequality in consensus building. 45% did not see barriers effectively removed. CONCLUSION: There remain challenges in the participation of people with mental illness and family members. There is an increasing awareness that their participation is central.

[Influence of guideline recommendations, care structures and individual factors on the use of psychosocial therapies in severely mentally ill people]. / Einfluss von Leitlinienempfehlungen, Versorgungsstrukturen und individuellen Faktoren auf die Inanspruchnahme von psychosozialen Therapien bei schwer psychisch kranken Menschen.

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.