[How human rights can guide german psychiatry]. / Wie Menschenrechte der Psychiatrie in Deutschland den Weg weisen.

The concerns and recommendations of the UN "Final Remarks" on the first German State Report are substantiated by up-to-date health reporting data. Their "recommendations" are substantiated by evidence-based care models and supplemented by additional content from the Special Rapporteur's report of 2017 as visions for German psychiatric care, thus demonstrating the path of psychiatry determined by respect for human rights and social inclusion. The avoidance of coercion through traumainformed treatment and the development of complex outpatient treatment structures through the models of open dialogue and the recovery approach are seen as the focus of a paradigm shift. The awareness that in today's psychiatry, especially through deficient structures, human rights violations are committed that could be avoided, should contribute to the determination for the necessary changes.

Open Dialogue services around the world: a scoping survey exploring organizational characteristics in the implementation of the Open Dialogue approach in mental health services.

Objective: This cross-sectional study investigates the characteristics and practices of mental health care services implementing Open Dialogue (OD) globally. Methods: A structured questionnaire including a self-assessment scale to measure teams' adherence to Open Dialogue principles was developed. Data were collected from OD teams in various countries. Confirmatory Composite Analysis was employed to assess the validity and reliability of the OD self-assessment measurement. Partial Least Square multiple regression analysis was used to explore characteristics and practices which represent facilitating and hindering factors in OD implementation. Results: The survey revealed steady growth in the number of OD services worldwide, with 142 teams across 24 countries by 2022, primarily located in Europe. Referrals predominantly came from general practitioners, hospitals, and self-referrals. A wide range of diagnostic profiles was treated with OD, with psychotic disorders being the most common. OD teams comprised professionals from diverse backgrounds with varying levels of OD training. Factors positively associated with OD self-assessment included a high percentage of staff with OD training, periodic supervisions, research capacity, multi-professional teams, self-referrals, outpatient services, younger client groups, and the involvement of experts by experience in periodic supervision. Conclusion: The findings provide valuable insights into the characteristics and practices of OD teams globally, highlighting the need for increased training opportunities, supervision, and research engagement. Future research should follow the development of OD implementation over time, complement self-assessment with rigorous observations and external evaluations, focus on involving different stakeholders in the OD-self-assessment and investigate the long-term outcomes of OD in different contexts.

Dissociative symptoms in patients with schizophrenia: relationships with childhood trauma and psychotic symptoms.

OBJECTIVE: This study sought to examine the stability of dissociative symptoms in patients with schizophrenia spectrum disorders as well as relationships between psychotic symptoms, childhood trauma, and dissociation. METHOD: One hundred forty-five patients with schizophrenia spectrum disorders (72% schizophrenia, 67% men) were examined at admission to inpatient treatment and 3 weeks later using the Positive and Negative Syndrome Scale, the Childhood Trauma Questionnaire, and the Dissociative Experiences Scale. RESULTS: Dissociative symptoms significantly decreased over time (mean, 19.2 vs 14.1; P < .001). The best predictor of dissociative symptoms at admission was the Positive and Negative Syndrome Scale positive subscale (F(inc)(3,64) = 3.66, P = .017), whereas childhood sexual abuse best predicted dissociation when patients were stabilized (F(inc)(10,80) = 2.00, P = .044). CONCLUSION: Dissociative symptoms in patients with schizophrenia spectrum disorders are related to childhood trauma. Dissociation seems to be state dependent in this diagnostic group. Moreover, diagnostic interviews, in addition to the Dissociative Experiences Scale, should be considered to avoid measurement artifacts.

Implementation of open dialogue in Germany: Efforts, challenges, and obstacles.

Purpose: The Open Dialogue (OD) approach has been implemented in different countries worldwide. OD not only depends on therapeutic principles but also requires a distinct set of structural changes that may impede its full implementation. In Germany, OD is currently practiced in different mental health care settings across the country. Yet, full implementation of OD principles is limited due to the extreme structural and financial fragmentation of the German mental health care system. With this as a background, the aim of this study was to investigate the efforts, challenges and obstacles of OD implementation in Germany. Methods: This article presents the German results from the international HOPEnDIALOGUE survey, supplemented with expert interview data. Thirty eight teams currently providing OD took part in the survey. Sixteen expert interviews were carried out with stakeholders from various care settings. Survey data were analyzed descriptively and the qualitative data were evaluated using a thematic analysis approach. Results: While having to adapt to the fragmented German health care system, OD has been mainly implemented from outpatient service providers and stand-alone services. About half of the teams implemented OD under the conditions of cross-sectoral model contracts and, thus, are considerably limited when it comes to OD implementation. Altogether, OD is not implemented to its full extent in each of the institutions surveyed. Similarly, the expert interviews revealed various challenges that mainly relate to the realization of OD's structural principles, whereas the implementation of its therapeutic benefits remains less affected. However, these challenges have managed to lead to great commitment by single teams and a certain level of implementation of OD-related concepts. Conclusion: OD in Germany can currently only be fully implemented under the cross-sectoral care model contract system that is often temporary, thus significantly hindering its continuous development. Any evaluation of OD's effectiveness in Germany thus needs to take into account the fragmented nature of the country's health care system and control for the multiple barriers that impede implementation. Reforms of the German health care system are also urgently needed to create more favorable conditions for the implementation of OD.

Dialogue as a Response to the Psychiatrization of Society? Potentials of the Open Dialogue Approach.

In recent decades, the use of psychosocial and psychiatric care systems has increased worldwide. A recent article proposed the concept of psychiatrization as an explanatory framework, describing multiple processes responsible for the spread of psychiatric concepts and forms of treatment. This article aims to explore the potentials of the Open Dialogue (OD) approach for engaging in less psychiatrizing forms of psychosocial support. While OD may not be an all-encompassing solution to de-psychiatrization, this paper refers to previous research showing that OD has the potential to 1) limit the use of neuroleptics, 2), reduce the incidences of mental health problems and 3) decrease the use of psychiatric services. It substantiates these potentials to de-psychiatrize psychosocial support by exploring the OD's internal logic, its use of language, its processes of meaning-making, its notion of professionalism, its promotion of dialogue and how OD is set up structurally. The conclusion touches upon the dangers of co-optation, formalization and universalization of the OD approach and stresses the need for more societal, layperson competencies in dealing with psychosocial crises.

Open Dialogue as a Human Rights-Aligned Approach.

Throughout the last 20 years, the human rights perspective has increasingly developed into a paradigm against which to appraise and evaluate mental health care. This article investigates to what extent the Finnish open dialogue (OD) approach both aligns with human rights and may be qualified to strengthen compliance with human rights perspectives in global mental health care. Being a conceptual paper, the structural and therapeutic principles of OD are theoretically discussed against the background of human rights, as framed by the Universal Declaration of Human Rights, the UN Convention on the Rights of People with Disabilities, and the two recent annual reports of the Human Rights Council. It is shown that OD aligns well with discourses on human rights, being a largely non-institutional and non-medicalizing approach that both depends on and fosters local and context-bound forms of knowledge and practice. Its fundamental network perspective facilitates a contextual and relational understanding of mental well-being, as postulated by contemporary human rights approaches. OD opens the space for anyone to speak (out), for mutual respect and equality, for autonomy, and to address power differentials, making it well suited to preventing coercion and other forms of human rights violation. It is concluded that OD can be understood as a human rights-aligned approach.

Sexual and physical abuse during childhood and adulthood as predictors of hallucinations, delusions and thought disorder.

In light of recent studies indicating a relationship between child abuse and the positive symptoms of schizophrenia, this study investigated the hypotheses that childhood sexual and physical abuse are related to hallucinations, delusions, and thought disorder in adults, and that those relationships are greater in those who have suffered abuse during adulthood as well as childhood. In 200 community mental-health-centre clients, the clinically evaluated symptomatology of the 92 clients whose files documented sexual or physical abuse at some point in their lives was compared with that of the 108 for whom no abuse was documented. In the 60 patients for whom child abuse was documented, hallucinations (including all six subtypes), but not delusions, thought disorder or negative symptoms, were significantly more common than in the non-abused group. Adult sexual assault was related to hallucinations, delusions, and thought disorder. In linear regression analysis, a combination of child abuse and adult abuse predicted hallucinations, delusions, and thought disorder. However, child abuse was a significant predictor of auditory and tactile hallucinations, even in the absence of adult abuse. Possible psychological and neurobiological pathways from abuse to symptoms are discussed, along with research and clinical implications.

Influence of antipsychotics on mortality in schizophrenia: systematic review.

BACKGROUND: Antipsychotic medication is the cornerstone of schizophrenia treatment. The impact of long-term exposure to antipsychotics on life-expectancy has recently received some attention, partly because awareness is increasing of the differential mortality of people with schizophrenia and the general population. METHODS: A systematic review of studies assessing the association between antipsychotic exposure and mortality in persons with schizophrenia was undertaken. RESULTS: In total, 12 studies met the inclusion criteria. Three out of five studies examining antipsychotic dosage and higher mortality showed a significant association for one or more antipsychotics. Two out of four found negative effects of antipsychotic polypharmacy on life-expectancy. Some studies found a lower cardiovascular mortality risk with higher treatment intensity or when comparing current versus past or non-use of antipsychotics. Others established a stable correlation between antipsychotic exposure and an increase in cardiovascular mortality. Evidence for differential effects on mortality in favor of second generation (SGA) compared to first generation antipsychotics was inconsistent. No study of SGA drugs had a sufficient follow-up time. A major confounding factor may be a higher risk factor load for somatic disorders in the most severely mentally ill. CONCLUSION: There is some evidence that long-term exposure to antipsychotics increases mortality in schizophrenia. More rigorously designed, prospective studies are urgently needed.

Childhood trauma and dissociation in female patients with schizophrenia spectrum disorders: an exploratory study.

The few studies that have investigated the relationship between trauma and dissociative symptoms in patients with schizophrenia have not assessed the role of the severity of psychotic symptoms. The current study examined correlations among five domains of childhood trauma and dissociative symptoms in 30 female patients with schizophrenia spectrum disorders, using the Dissociative Experiences Scale and the Childhood Trauma Questionnaire. Psychotic symptoms were measured by the Positive and Negative Syndrome Scale. Consistent with previous studies, high levels of childhood traumatic experiences were found (Childhood Trauma Questionnaire total score M = 48.5, SD = 18.3). Physical neglect and emotional abuse showed significant correlations with dissociative symptoms at admission. When patients were stabilized, about a month after admission, emotional abuse still showed a significant correlation with dissociative symptoms. However, in contrast to previous findings, Dissociative Experiences Scale findings were not stable over time. Our results confirm the relevance of childhood trauma in schizophrenic patients but also demonstrate the need to develop appropriate methodologies for measuring dissociation in this population.