Predictors and outcomes in primary depression care (POKAL) - a research training group develops an innovative approach to collaborative care.

BACKGROUND: The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care. METHODS: In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges. RESULTS: The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression. CONCLUSION: The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.

[Neuropsychology of psychoeducation in schizophrenia: results of the Munich COGPIP study]. / Neuropsychologie der Psychoedukation bei Schizophrenie: Ergebnisse der Münchner COGPIP-Studie.

BACKGROUND: The aim of the study was to examine whether the efficacy of psychoeducation in patients with schizophrenia is dependent on their cognitive performance and if a preceding cognitive training can enhance the therapeutic effects of psychoeducation. PATIENTS AND METHODS: A total of 116 inpatients were randomly assigned to either a standardized cognitive training (COGPACK) or to routine occupational therapy, followed by a psychoeducational group program of 8 sessions within 4 weeks for all study patients. The effects of cognitive training and psychoeducation were assessed directly afterwards and in a follow-up after 9 months. RESULTS: The patient knowledge and compliance improved. Neurocognition and especially memory acquisition significantly predicted illness knowledge after psychoeducation, whereas psychopathology did not. No differential effects of the COGPACK training were found. After 9 months 75% of the patients showed a very good compliance and the readmission rate was 18%. The results were comparable under both study conditions. CONCLUSION: Besides baseline illness knowledge neurocognition was the only significant predictor for illness knowledge after psychoeducation. Patients with cognitive deficits can profit from psychoeducation in the long run as well. In future it should be examined whether a modified cognitive training program could achieve a faster improvement of the illness knowledge.

Neurocognitive prediction of illness knowledge after psychoeducation in schizophrenia: results from the Munich COGPIP study.

BACKGROUND: Many patients with schizophrenia exhibit neurocognitive impairments, namely, in attentional, mnestic and executive functions. While these deficits limit psychosocial rehabilitation, their effect on psychoeducation is unknown. Within the framework of the longitudinal Munich Cognitive Determinants of Psychoeducation and Information in Schizophrenic Psychoses (COGPIP) study, we examined: (a) whether illness knowledge after psychoeducation could be predicted more precisely from the neurocognitive than from the psychopathological status of the patients; (b) which neurocognitive domains are best predictors. METHOD: A total of 116 in-patients with schizophrenic or schizoaffective disorders were randomized to a neurocognitive training or control condition (2 weeks) followed by a manualized psychoeducational group programme (4 weeks) and then observed over a 9-month follow-up. Repeated measurements included - among others - the Positive and Negative Syndrome Scale and a comprehensive neuropsychological test battery from which normative T scores were used to calculate one global and five domain-specific neurocognitive composite scores. Illness knowledge was measured by a questionnaire (WFB-52) tailored to the psychoeducational programme. RESULTS: Multiple linear regression analyses showed that, apart from baseline illness knowledge, neurocognition significantly predicted knowledge outcome as well as knowledge gain (measured by reliable change indices) after psychoeducation. This was not true for psychopathology. Among the domain-specific neurocognitive composite scores, only memory acquisition was a significant predictor of knowledge outcome and gain. CONCLUSIONS: Neurocognition, not psychopathology, is a significant predictor of illness knowledge after psychoeducation in schizophrenia. This finding should guide efforts to tailor psychoeducational interventions more closely to the patient's needs and resources.

Gender differences in patient and caregiver psychoeducation for schizophrenia.

OBJECTIVE: The aim of this research is to detect gender-related differences in patients and caregivers regarding knowledge about schizophrenia and attitudes towards drugs as well as gender as predictor for changes in these variables during psychoeducation. METHODS: Data sets of one randomised-controlled (study 1) and one naturalistic psychoeducation study (study 2) were reanalysed. Main outcome measures (knowledge about schizophrenia, drug attitude, confidence in medication) were assessed at baseline, post-intervention and 12 months after index discharge. RESULTS: The reanalysed samples consisted in total of 1002 patients and 176 caregivers. In study 2, baseline knowledge was significantly better in male patients and female caregivers. All participants improved significantly their knowledge. The amount of knowledge gain did not differ between genders in either study or either group. Gender was not a major predictor of baseline knowledge or knowledge gain. Only in study 1 did gender significantly impact the knowledge gain from baseline to follow-up. Regarding improvement of drug attitude, females seemed to benefit significantly better from psychoeducation. In both studies, however, changes in drug attitudes respectively confidence in medication were best explained by lower corresponding baseline scores, not gender. Patients' gender did not influence outcomes of their caregivers. CONCLUSION: Our findings suggest that psychoeducational programs might be better adapted to males in order to improve their drug attitude. Concerning knowledge, gender-related changes do not seem to be necessary.

The effect of family interventions on relapse and rehospitalization in schizophrenia--a meta-analysis.

Twenty-five intervention studies were meta-analytically examined regarding the effect of including relatives in schizophrenia treatment. The studies investigated family intervention programs to educate relatives and help them cope better with the patient's illness. The patient's relapse rate, measured by either a significant worsening of symptoms or rehospitalization in the first years after hospitalization, served as the main study criterion. The main result of the meta-analysis was that the relapse rate can be reduced by 20 percent if relatives of schizophrenia patients are included in the treatment. If family interventions continued for longer than 3 months, the effect was particularly marked. Furthermore, different types of comprehensive family interventions have similar results. The bifocal approach, which offers psychosocial support to relatives and schizophrenia patients in addition to medical treatment, was clearly superior to the medication-only standard treatment. The effects of family interventions and comprehensive patient interventions were comparable, but the combination did not yield significantly better results than did a treatment approach, which focused on either the patient or the family. This meta-analysis indicates that psychoeducational interventions are essential to schizophrenia treatment.

[Psychoeducational intervention for schizophrenic patients and subsequent long-term ambulatory care. A four-year follow-up] . / Psychoedukative Gruppen bei schizophrenen Patienten und anschliessende ambulante Langzeitbehandlung. Eine 4-Jahres-Katamnese und Literaturübersicht.

A subset of schizophrenic inpatients and families participated in an eight-sessions bifocal psychoeducational intervention, followed by treatment in a corresponding outpatient department. These patients were a part of the multicenter and randomized Münchner Psychosis-Information-Project (PIP). The course of illness in 88 patients treated in the outpatient department of the Technical University of Munich has been recorded in a 4-year follow-up study. 60% of the patients continued outpatient treatment while 40% lost contact with the outpatient department. Predictors for patient drop-out were assessed and the course of illness of both groups was compared. There was no significant difference between the relapse rate of the patients who dropped out (66%) and those who continued the long-term treatment (53%). However, within the 4-year period the drop-out patients had more than twice as many hospital days compared to the patients who maintained the outpatient treatment. The improved social adjustment and quality of life of these patients, along with the 50% reduction of readmission days demonstrates the impact of the long-term treatment in this study.

Efficacy and extrapyramidal side-effects of the new antipsychotics olanzapine, quetiapine, risperidone, and sertindole compared to conventional antipsychotics and placebo. A meta-analysis of randomized controlled trials.

The objective of this meta-analysis is to summarize the efficacy and tolerability of the new antipsychotics risperidone, olanzapine, sertindole and quetiapine in schizophrenia compared to placebo and conventional antipsychotics. The main results are: (1) All of the 4 new drugs are more effective than placebo, but the magnitude of the effect is only moderate [mean effect size, r, of all antipsychotics vs. placebo = 0.25, with a 95% confidence interval (CI) = 0.22-0.28, n = 2477]. (2) According to the studies published to date, sertindole and quetiapine are as effective as haloperidol, and risperidone and olanzapine are slightly more effective than haloperidol in the treatment of global schizophrenic symptomatology. (3) With respect to negative symptoms, all new antipsychotics are more effective than placebo. However, contrary to widespread opinion, so is the 'conventional' antipsychotic haloperidol. Risperidone and olanzapine are slightly superior, sertindole is as effective and--according to the only study fully published to date--quetiapine is even slightly less effective than haloperidol in this regard. (4) All new antipsychotics are associated with less frequent use of antiparkinson medication than haloperidol, with risperidone appearing to have a slightly less favourable EPS-profile than the other new antipsychotics. The methodological limitations of this review, the generalizability of the results and expectations from future research are discussed.