Honest, Open, Proud for adolescents with mental illness: pilot randomized controlled trial.

BACKGROUND: Due to public stigma or self-stigma and shame, many adolescents with mental illness (MI) struggle with the decision whether to disclose their MI to others. Both disclosure and nondisclosure are associated with risks and benefits. Honest, Open, Proud (HOP) is a peer-led group program that supports participants with disclosure decisions in order to reduce stigma's impact. Previously, HOP had only been evaluated among adults with MI. METHODS: This two-arm pilot randomized controlled trial included 98 adolescents with MI. Participants were randomly assigned to HOP and treatment as usual (TAU) or to TAU alone. Outcomes were assessed pre (T0/baseline), post (T1/after the HOP program), and at 3-week follow-up (T2/6 weeks after T0). Primary endpoints were stigma stress at T1 and quality of life at T2. Secondary outcomes included self-stigma, disclosure-related distress, empowerment, help-seeking intentions, recovery, and depressive symptoms. The trial is registered on ClinicalTrials (NCT02751229; http://www.clinicaltrials.gov). RESULTS: Compared to TAU, adolescents in the HOP program showed significantly reduced stigma stress at T1 (d = .92, p < .001) and increased quality of life at T2 (d = .60, p = .004). In a longitudinal mediation model, the latter effect was fully mediated by stigma stress reduction at T1. HOP further showed significant positive effects on self-stigma, disclosure-related distress, secrecy, help-seeking intentions, attitudes to disclosure, recovery, and depressive symptoms. Effects at T1 remained stable or improved further at follow-up. In a limited economic evaluation HOP was cost-efficient in relation to gains in quality of life. CONCLUSIONS: As HOP is a compact three-session program and showed positive effects on stigma and disclosure variables as well as on symptoms and quality of life, it could help to reduce stigma's negative impact among adolescents with MI.

[Nonsuicidal self-injury in adolescence]. / Selbstverletzendes Verhalten im Jugendalter.

Nonsuicidal self-injury (NSSI) usually starts in adolescence. International studies report prevalence rates between 3 and 37% (for Germany between 15 and 26%) in adolescents. From a neurobiological perspective, there is evidence that primarily the serotonergic system is involved in the origin and maintenance of this behaviour. NSSI is often used by adolescents to influence aversive affective states, but sometimes serves other functions as well, such as self-punishment or anti-dissociation. To date there are many assessment instruments, some of which are available in a German translation. Regarding psychotherapeutic interventions there is evidence for a good efficacy of dialectical behavioral therapy for adolescents (DBT-A). There is little evidence for psychopharmacological interventions in childhood and adolescence; thus treatment should focus on psychotherapeutic interventions.

[Psychopharmacological treatments in childhood and adolescence]. / Psychopharmaka im Kindes- und Jugendalter.

Compared to adults, the use of psychopharmacological substances in childhood and adolescence is significantly more controversial. Often sensation-seeking media reports on the negative effects of psychopharmacological treatments of children and adolescents intensify this controversy on a regular basis. In addition, even pharmacologically trained experts--though frequently without expertise in Child and Adolescent Psychiatry--question the seriousness and thus the demands for treatment of psychiatric disorders in childhood and adolescence. Considering this background evidence based treatment decisions in pediatric psychopharmacology are of utmost importance. Effective psychopharmacotherapy needs to be distinguished from ineffective treatments. The pros and cons of such evidence based treatment approaches ought to be weighted out carefully together with the patients and their families. The aim of this article is to provide a rational and concise foundation for the use of psychopharmacotherapy for clinicians treating children and adolescents as well as to point out the currently best evidence for psychopharmacological treatments of selected disorders in child and adolescent psychiatry.

[Introduction of the module "Evidence-based Medicine" in Child and Adolescent Psychiatry into the psychiatry block practicum at the University of Ulm]. / Einführung eines Moduls "Evidenz-basierte Medizin in der Kinder- und Jugendpsychiatrie" in das Blockpraktikum Psychiatrie an der Universität Ulm.

OBJECTIVE: The essential need for the timely availability of additional relevant information has resulted in a focus on "Evidence-based Medicine" (EBM) in medical practice. In Child and Adolescent Psychiatry (CAP) training it is essential to impart knowledge of how to effectively use the available literature, since the evidence for many therapies is still poor. METHOD: We modified the "Duke Model" for teaching EBM in CAP to better attune it to the educational needs of a German university. We describe the introduction of the teaching module "Evidence-based Medicine in CAP" in practical clinical training. RESULTS: Integrating EBM into mandatory practical training enables the students to deal with problems that directly pertain to patient treatment, thus motivating them to access and read relevant scientific literature. An initial evaluation of this pilot project shows the successful linkage of research with clinical routine and also the conveyance of improved decision making abilities as well as an attitude of life-long learning. CONCLUSIONS: Modifying the EBM-module for practical clinical training is an innovative approach to integrating EBM into medical curricula. In the course of a curricular reform, "EBM cross sectional training" for all medical students was introduced into the new curriculum of the Medical School at the University of Ulm.

[Docs'n Drugs--an E-learning program for medical students; feasibility and evaluation of the acceptance in student training in child and adolescent psychiatry at the University Hospital in Ulm]. / E-learning mit Docs'n Drugs--Anwendung und Akzeptanz in der Kinder- und Jugendpsychiatrie der Universität Ulm.

OBJECTIVE: Increasingly widespread is the use of modern media such as E-learning in medical education. The Medical Faculty of the University of Ulm, being the Competence Center of E-learning, and the Competence Network in Medical Education in Baden-Württemberg have been developing a web based multimedia educational program since 1998. METHODS: In 2004 a grant for modular teaching projects sponsored by the Medical School was obtained in order to incorporate cases from Child and Adolescent Psychiatry into the Docs'n Drugs E-learning Module. The objective was to explore the feasibility of adding psychiatric cases to an educational system that was primarily oriented towards somatic diseases and to then evaluate the acceptance of these child and adolescent psychiatric cases. RESULTS: Once cases had been developed, this module was integrated into Docs'n Drugs as a one-and-a-half hour web-based seminar as part of a block practicum in child and adolescent psychiatry and subsequently evaluated. The evaluation included data from 69 participants between summer 2004 and spring 2006. Of the participating students, 80.8% had never used the E-learning platform together with a monitor in a seminar before. 44.9%, respectively 41%, of the students responded that psychiatric cases could be dealt with in a good or partially satisfying way with that system. This gives an overall positive acceptance of 86%. CONCLUSIONS: Our evaluated feasibility trial with a child psychiatric module within an E-learning based teaching platform showed that knowledge not only of somatic cases but also of psychiatric cases can be imparted via E-learning. The integration into an existing curriculum is advisable in any case.

Are amygdalar volume alterations in children with Tourette syndrome due to ADHD comorbidity?

Recent studies have shown that changes in the basal ganglia circuitry and limbic loops may play an important role both in Tourette syndrome (TS) and attention-deficit-hyperactivity disorder (ADHD). This study aimed to investigate in vivo possible morphological alterations of the amygdala as a key component of the limbic system. Amygdalar and total brain volumes were measured in three-dimensional magnetic resonance imaging data sets of 17 male patients with TS (mean age 11 y 8 mo [SD 2 y]; range 9-16 y) and 17 age-matched comparison children (mean age 12 y 6 mo (SD 2 y 1 mo); range 9-17 y) by volume-of-interest-based volumetry. Eight members of the TS group also fulfilled the diagnostic criteria for ADHD. A significant decrease in the left-hemispheric amygdalar volumes and in the proportions of amygdalar to total brain volumes was observed in members of the TS group compared with the comparison group. Amygdalar volumes did not correlate with tic severity, but with behavioural impairment and especially with symptoms of ADHD. The amygdalar volume reduction might be the pathoanatomical correlate of an impaired input of the amygdala to the striatum and frontal cortex. Future studies should investigate if the involvement of the amygdala is due to TS or rather caused by the genetically-linked most frequent comorbidity ADHD.

Grey-matter abnormalities in boys with Tourette syndrome: magnetic resonance imaging study using optimised voxel-based morphometry.

The genesis of Tourette syndrome is still unknown, but a core role for the pathways of cortico-striatal-thalamic-cortical circuitry (CSTC) is supposed. Volume-rendering magnetic resonance imaging data-sets were analysed in 14 boys with Tourette syndrome and 15 age-matched controls using optimised voxel-based morphometry. Locally increased grey-matter volumes (corrected P < 0.001) were found bilaterally in the ventral putamen. Regional decreases in grey matter were observed in the left hippocampal gyrus. This unbiased analysis confirmed an association between striatal abnormalities and Tourette syndrome, and the hippocampal volume alterations indicate an involvement of temporolimbic pathways of the CSTC in the syndrome.

[Chemical restraint: management of aggressive behaviours in inpatient treatment--theory and clinical practice]. / Chemical restraint: "Pharmakologische Ruhigstellung" zum Management aggressiven Verhaltens im stationären Bereich in Theorie und Praxis.

"Chemical restraint" (CR) is an important intervention for the management of aggressive behaviour in children and adolescents. The use of CR during in-patient treatment should be based on standardized intervention strategies. The principles of such an approach include transparent agreement with all participants on fast save and staff-independent reduction of aggressive behaviour without inducing retraumatisation. In clinical practice medication that is effective both for tranquilization and prevention of aggressive escalation is recommended. Current data suggest first line treatment using neuroleptics and benzodiazepines. Due to their potential use both for rapid sedation and prevention atypical neuroleptics are of particular importance. Further controlled studies are needed to evaluate pharmacological treatment of aggressive states with potential (self) harming behaviour in children and adolescents.