Enhancing educational and vocational recovery in adolescents and young adults with early psychosis through Supported Employment and Education (SEEearly): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Psychotic disorders often develop a chronic course with devastating consequences for individuals, families, and societies. Early intervention programs for people in the first 5 years after the initial psychotic episode (early psychosis) can significantly improve the outcome and are therefore strongly recommended in national and international guidelines. However, most early intervention programs still focus on improving symptoms and relapse prevention, rather than targeting educational and vocational recovery. The aim of the present study is to explore the effects of Supported Employment and Education (SEE) following the Individual Placement and Support (IPS) model in people with early psychosis. METHODS: The SEEearly trial compares treatment as usual (TAU) plus SEE to TAU alone in outpatient psychiatric settings. The study is a six-site, two-arm, single-blinded, superiority randomized controlled trial (RCT). Participants are randomly assigned (1:1) to the intervention or control group. Aiming to recruit 184 participants, with an assumed drop-out rate of 22%, we will be able to detect a 24% difference in the main outcome of employment/education with 90% power. We make assessments at baseline and at 6- and 12-month follow-ups. Outcome data on employment/education, medication, and current psychiatric treatment is obtained monthly through phone based short assessments. The primary outcome is steady participation for at least 50% of the 12-month follow-up in competitive employment and/or mainstream education. Secondary employment outcomes capture length of employment/education, time to first employment/education, monthly wages/educational attainment, and social return on investment (SROI). Secondary non-employment outcomes include subjective quality of life, psychopathology, substance use, relapse, hospitalization, and functional impairment. To be eligible, participants must be between 16 and 35 years, fulfill diagnostic criteria for early psychosis, and be interested in competitive employment and/or mainstream education. DISCUSSION: In SEEearly, we hypothesize that participants with psychosis, who receive TAU plus SEE, present with better primary and secondary outcomes than participants, who receive TAU alone. Positive results of this study will justify SEE as an evidence-based strategy for clinical routine treatment in people with early psychosis. TRIAL REGISTRATION: SEEearly was registered nationally and internationally in the German Clinical Trials Register (DRKS; identifier: DRKS00029660) on October 14, 2022.

Effect of standardized post-coercion review on subjective coercion: Results of a randomized-controlled trial.

BACKGROUND: Post-coercion review has been increasingly regarded as a useful intervention in psychiatric inpatient setting. However, little is known about its effect on perceived coercion. METHODS: A multicenter, two-armed, randomized controlled trial was conducted, aiming at analyzing the effect of post-coercion review on perceived coercion. People with severe mental disorders, who experienced at least one coercive measure during inpatient treatment, were randomized using Zelen's design to an intervention group receiving standardized post-coercion review, or a control group treated as usual. The MacArthur admission experience scale (AES) and the coercion ladder (CL) were used to assess perceived coercion during inpatient treatment. The coercion experience scale (CES) measured experienced coercion during the coercive intervention. Analyses of covariance were performed to determine group differences. RESULTS: Of 422 randomized participants, n = 109 consented to participate in the trial. A restricted intention-to-treat analysis of all individuals who consented revealed no significant effect of the intervention on perceived coercion. A significant interaction effect between the factors gender and intervention on the AES scores was found. Sensitivity analysis revealed significant effects of the intervention on both AES and CL scores and an interaction effect between intervention and gender, indicating a higher efficacy in women. No effect of the intervention on CES scores was found. CONCLUSIONS: Standardized post-coercion review sessions did not alleviate the subjective perception of coercion in the total sample. However, post hoc analysis revealed a significant effect of the intervention in women. Results indicate the need to further address gender-specific issues related to coercion.

[Implementation of the principle of supported employment in Germany : Position paper of a task force of the DGPPN]. / Umsetzung der Prinzipien des Supported Employment in Deutschland : Positionspapier einer Task-Force der DGPPN.

The effects of mental diseases on the employment and working situation can be substantial. They are one of the main reasons for inability to work and reduced earning capacity. Against this background the question arises about suitable occupational reintegration measures for people with severe mental illnesses. In recent years, the principle of supported employment has been internationally shown to be increasingly more successful. In this context mentally ill people are primarily placed at a position of the first employment market and supported on-site by a job coach. This concept is inclusive, individual and evidence based. Despite proven effectiveness, it has so far been insufficiently implemented in German-speaking regions. In the future it will be a matter of considering the individual needs for assistance of mentally ill people more intensively than previously and to respond with functional and in a best-case scenario, multiprofessional and flexible offers.

Cognitive and emotional empathy in individuals at clinical high risk of psychosis.

BACKGROUND: Impairments of social cognition are considered core features of schizophrenia and are established predictors of social functioning. However, affective aspects of social cognition including empathy have far less been studied than its cognitive dimensions. The role of empathy in the development of schizophrenia remains largely elusive. METHODS: Emotional and cognitive empathy were investigated in large sample of 120 individuals at Clinical High Risk of Psychosis (CHR-P) and compared with 50 patients with schizophrenia and 50 healthy controls. A behavioral empathy assessment, the Multifaceted Empathy Test, was implemented, and associations of empathy with cognition, social functioning, and symptoms were determined. RESULTS: Our findings demonstrated significant reductions of emotional empathy in individuals at CHR-P, while cognitive empathy appeared intact. Only individuals with schizophrenia showed significantly reduced scores of cognitive empathy compared to healthy controls and individuals at CHR-P. Individuals at CHR-P were characterized by significantly lower scores of emotional empathy and unspecific arousal for both positive and negative affective valences compared to matched healthy controls and patients with schizophrenia. Results also indicated a correlation of lower scores of emotional empathy and arousal with higher scores of prodromal symptoms. CONCLUSION: Findings suggest that the tendency to 'feel with' an interaction partner is reduced in individuals at CHR-P. Altered emotional reactivity may represent an additional, early vulnerability marker, even if cognitive mentalizing is grossly unimpaired in the prodromal stage. Different mechanisms might contribute to reductions of cognitive and emotional empathy in different stages of non-affective psychotic disorders and should be further explored.

Clinical high risk for psychosis: the association between momentary stress, affective and psychotic symptoms.

OBJECTIVE: The aim of this study was to assess associations between momentary stress and both affective and psychotic symptoms in everyday life of individuals at clinical high risk (CHR), compared to chronic psychotic patients and healthy controls, in search for evidence of early stress sensitization. It also assessed whether psychotic experiences were experienced as stressful. METHOD: The experience sampling method was used to measure affective and psychotic reactivity to everyday stressful activities, events and social situations in 22 CHR patients, 24 patients with a psychotic disorder and 26 healthy controls. RESULTS: Multilevel models showed significantly larger associations between negative affect (NA) and activity-related stress for CHR patients than for psychotic patients (P = 0.008) and for CHR compared to controls (P < 0.001). Similarly, the association between activity-related stress and psychotic symptoms was larger in CHR than in patients (P = 0.02). Finally, the association between NA and symptoms (P < 0.001) was larger in CHR than in patients. CONCLUSION: Stress sensitization seems to play a role particularly in the early phase of psychosis development as results suggest that CHR patients are more sensitive to daily life stressors than psychotic patients. In this early phase, psychotic experiences also contributed to the experience of stress.

A systematic review and meta-analysis of prospective transition from major depression to bipolar disorder.

OBJECTIVE: Some people with major depressive disorder (MDD) may be at a pre-onset stage for bipolar disorder (BD), where early identification or prevention efforts may be feasible. We aimed to identify rates and characteristics predictive of transition to BD in prospective follow-up studies of people with MDD. METHODS: Using a systematic search strategy, we identified studies with a diagnostic ascertainment of MDD and BD of an adequate standard, and where the minimum length of follow-up was 6 months. We examined the incidence and point prevalence of BD and the pooled odds ratios (OR) for baseline predictors. RESULTS: From 5554 unique publications, 56 were included. Nearly a quarter of adults (22.5%) and adolescents with MDD followed up for a mean length of 12-18 years developed BD, with the greatest risk of transition being in the first 5 years. The meta-analysis identified that transition from MDD to BD was predicted by family history of BD (OR = 2.89, 95% CI: 2.01-4.14, N = 7), earlier age of onset of depression (g = -0.33, SE = 0.05, N = 6) and presence of psychotic symptoms (OR = 4.76, 95% CI: 1.79-12.66, N = 5). CONCLUSIONS: Participants with the identified risk factors merit closer observation and may benefit from prevention efforts, especially if outcomes broader than BD are considered.

Evaluation of the 'Jumping to conclusions' bias in different subgroups of the at-risk mental state: from cognitive basic symptoms to UHR criteria.

BACKGROUND: Patients with psychosis display the so-called 'Jumping to Conclusions' bias (JTC) - a tendency for hasty decision-making in probabilistic reasoning tasks. So far, only a few studies have evaluated the JTC bias in 'at-risk mental state' (ARMS) patients, specifically in ARMS samples fulfilling 'ultra-high risk' (UHR) criteria, thus not allowing for comparisons between different ARMS subgroups. METHOD: In the framework of the PREVENT (secondary prevention of schizophrenia) study, a JTC task was applied to 188 patients either fulfilling UHR criteria or presenting with cognitive basic symptoms (BS). Similar data were available for 30 healthy control participants matched for age, gender, education and premorbid verbal intelligence. ARMS patients were identified by the Structured Interview for Prodromal Symptoms (SIPS) and the Schizophrenia Proneness Instrument - Adult Version (SPI-A). RESULTS: The mean number of draws to decision (DTD) significantly differed between ARM -subgroups: UHR patients made significantly less draws to make a decision than ARMS patients with only cognitive BS. Furthermore, UHR patients tended to fulfil behavioural criteria for JTC more often than BS patients. In a secondary analysis, ARMS patients were much hastier in their decision-making than controls. In patients, DTD was moderately associated with positive and negative symptoms as well as disorganization and excitement. CONCLUSIONS: Our data indicate an enhanced JTC bias in the UHR group compared to ARMS patients with only cognitive BS. This underscores the importance of reasoning deficits within cognitive theories of the developing psychosis. Interactions with the liability to psychotic transitions and therapeutic interventions should be unravelled in longitudinal studies.

[Early Detection of Bipolar Disorders: Current State of the Art and Research Approaches]. / Früherkennung von bipolaren Störungen: Stand und Forschungsstrategien.

Bipolar affective disorders (BD) are severe, recurrent and disabling disorders with devastating consequences for individuals, families and the society. Although this personal burden and costs for the health system provide a compelling rationale for development of early detection and early intervention strategies in BD, the development of at-risk criteria for BD is still in an early stage of research. In this paper we review the literature of clinical data that investigate at-risk criteria. Moreover, we will discuss methodological problems associated with the definition of being at high-risk for developing bipolar disorders and show the different research approaches that deal with the investigation of at-risk criteria and appropriate intervention for BD. If prospective studies confirm the at-risk criteria for BD, then there is potential to develop preventive measures in BD with opportunities to ameliorate the severity of or even prevent BD.

[Cognitive Behavioral Therapy and Assertive Community Treatment Reduces Days in Hospital and Delays Hospital Admission in Severe Psychotic Disorders]. / Kognitive Verhaltenstherapie und Assertive Community Treatment reduzieren die Anzahl stationärer Tage und verlängern die Zeit bis zu einer stationären Aufnahme bei schweren psychotischen Störungen.

The primary aim of this study was to assess the effectiveness of integrated home treatment (IV, i. e. intensive cognitive behavioral therapy and pharmacotherapy provided within a framework of assertive community treatment) in individuals with severe mental disorders (n = 13) within the German healthcare system. A treatment-as-usual group (TAU, n = 13) was identified by propensity score matching. Symptoms (CGI), functioning (GAF) and service engagement (SES) were assessed. Quality of life (MSLQ-R) was rated by the IV patients. A reduction of days spent in hospital [IV: 2.3 (6.1); TAU: 33.6 (53.6); Z = 45; p = 0.044], time to admission (IV: 384 days 95% CI 309 - 459.1; TAU: 234.9 days 95% CI 127.2 - 342.5; log rank: Chi-square = 4.31, p < 0.05), severity of the illness (p < 0.01), positive symptoms (p < 0.001), and cognitive symptoms (p < 0.05), as well as functioning (p < 0.05) and service engagement (p < 0.05) was observed in IV patients. Despite differences on a descriptive level, differences in total admissions (IV: 15.3%; TAU: 53.8%; odds ratio = 0.155, 95% CI 0.0243 - 1.00) were not significant. A methodological limitation is that symptom ratings were not performed by independent and blinded raters.

[Services for the early recognition of psychoses and bipolar disorders in Germany: inventory survey study]. / Angebote zur Früherkennung von Psychosen und bipolaren Störungen in Deutschland: Bestandsaufnahme.

BACKGROUND: In order to successfully implement early recognition and intervention services in psychiatry, it is crucial to improve the attention to and recognition of severe mental disorders and to establish low threshold services that are available at short notice for diagnostic and treatment procedures. MATERIAL AND METHODS: For this inventory survey study, questionnaires regarding the presence and type of early recognition services for psychoses and bipolar disorders were sent separately to German psychiatric hospitals by mail in September and October 2012. Additionally, an internet search and telephone inquiries as well as an alignment of responses from the two surveys and with network lists from published and ongoing early recognition studies were performed. RESULTS: Response rates in the psychosis and bipolar disorder surveys were 21 % (51/246) and 36 % (91/255), respectively. Three quarters of participating institutions reported at least an interest in creating an early recognition service for psychoses and one half for bipolar disorders. Overall, 26 institutions were identified that already offer early recognition of psychoses and 18 of bipolar disorders. Of these 16 are low threshold early recognition centres with direct access at short notice for first-episode patients and person from at-risk groups and separate specific public relations work. Of these early recognition centres five have a separate and easy to find homepage available; in an additional 15 institutions the specific websites are part of the institutions homepage. CONCLUSION: Despite widespread interest and the increasingly recognized importance of early recognition and intervention services in psychiatry, there is currently no nationwide coverage with early recognition services for severe mental disorders in Germany. Public relations and information activities are not (yet) sufficiently provided to reach affected persons and their environment. Common standards are (still) missing and interdisciplinary models are sparse. To correct these shortcomings, amongst other factors, acquisition of sufficient funding for such services is required.

[The relationship between therapist's competence and adherence to outcome in cognitive-behavioural therapy - results of a metaanalysis]. / Der Zusammenhang der Therapeutenkompetenz und Adhärenz zum Therapieerfolg in der Kognitiven Verhaltenstherapie - metaanalytische Ergebnisse.

By now psychotherapy research has provided sufficient evidence in favour of the efficacy of psychotherapy, especially of the cognitive behaviour therapy (CBT). Hence one can argue that psychotherapy truly "works". Nevertheless, the rationale for the efficacy and the underlying mechanisms have not yet been explored. Resolving this ambiguity by focusing on the active ingredients in CBT is the aim of our review. More precisely we have explored whether the therapist's competence or his/her adherence to the CBT protocol is responsible for the therapeutic improvement that many patients sustain subsequent to psychotherapy. By means of a broad literature search we identified a total of n = 13 studies, whereby n = 7 referred to the impact of therapist's competence and n = 7 to the impact of adherence on post-treatment outcome, respectively, and one of these studies referred to both. The meta-analytical evaluation yielded a small significant total effect (r = 0.24) for the therapist's competence on therapeutic improvement of patients with diverse disorders and a moderate total effect (r = 0.38) regarding patients with major depression. In contrast, for the case of an influence of adherence to protocol on post-treatment outcome we did not achieve significant results. Therefore a competent performance of cognitive-behaviour techniques on the part of the therapist seems to contribute thoroughly to the therapeutic improvement subsequent to treatment. However, solely a manual-guided implementation of CBT seems not to have a significant impact on patients impromvement. Furthermore, our results indicate that the therapeutic change constitutes an extensive process that has consequently to be understood in future process-outcome research. Finally the implications of our results as well as potentials for future research are discussed.

Obsessive-compulsive symptoms in at-risk mental states for psychosis: associations with clinical impairment and cognitive function.

OBJECTIVE: Obsessive-compulsive symptoms (OCS) constitute a major comorbidity in schizophrenia. Prevalence estimations of OCS for patients with at-risk mental states (ARMS) for psychosis vary largely. It is unclear how ARMS patients with or without comorbid OCS differ regarding general psychosocial functioning, psychotic and affective symptoms and neurocognitive abilities. METHOD: At-risk mental states patients (n = 233) from the interventional trial PREVENT (Secondary Prevention of Schizophrenia) were stratified according to the presence or absence of comorbid OCS and compared on several clinical variables. RESULTS: Patients, who fulfilled the criteria for obsessive-compulsive disorder (OCD) or presented with subclinical OCS (ARMSposOCS sample), did not significantly differ from patients without OCS (ARMSnegOCS) with regard to gender, age, premorbid verbal intelligence and levels of education. Furthermore, similar severity of depressive syndromes, basic cognitive, attenuated psychotic and brief limited intermittent psychotic symptoms were found. However, ARMSposOCS patients showed more impairment of psychosocial functioning and higher general psychopathology. In contrast, they scored higher in cognitive tasks measuring working memory and immediate verbal memory. CONCLUSION: Findings extend upon previous results due to the multidimensional assessment. Subsequent longitudinal studies might elucidate how comorbid OCS influence differential treatment response, especially to cognitive behavioural interventions and the transition rates to psychosis.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 1: Häufigkeit, Störungspersistenz, Belastungsfaktoren, Service-Inanspruchnahme und Behandlungsverzögerung mit Konsequenzen.

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 2: Krankheitslast, Defizite des deutschen Versorgungssystems, Effektivität und Effizienz von "Early Intervention Services"

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

[Interventions in people at risk of developing first episode psychosis: a survey of current randomised controlled studies]. / Interventionen bei Personen mit erhöhtem Psychoserisiko: Eine aktuelle Übersicht über randomisiert kontrollierte Studien.

Early and valid detection of the psychosis risk syndrome, and indicated prevention aim at preventing, delaying or ameliorating frank psychosis, improving current symptoms as well as emerging psychosocial disability. In a systematic literature search we identified seven completed randomised controlled trials of interventions for individuals at high risk of developing first episode psychosis. These studies evaluated antipsychotics, neuroprotective agents, cognitive behavioural and integrated treatment approaches. All trials reported advantages for specific interventions as compared to the respective control conditions (although not significant in each of the studies), which proved to be significant in the first meta-analysis of the studies. However, the current results do not allow recommendations for any specific treatment. Therefore, interventions should be thoroughly reviewed based on their risk/benefit ratio. The level of individual clinical risk, assumed benefits and side effects of interventions are critical determinants for these considerations. Future research is needed with sufficiently powered, methodologically sound replication studies, which are designed to explore differential efficacy of the interventions.

Rationale and first results of developing at-risk (prodromal) criteria for bipolar disorder.

Bipolar affective disorder (BD) is a severe, recurrent and disabling disorder with devastating consequences for individuals, families and society. Although these hazards and costs provide a compelling rationale for development of early detection and early intervention strategies in BD, the development of at-risk criteria for first episode mania is still in an early stage of development. In this paper we review the literature with respect to the clinical, neuroantomical and neuropsychological data, which support this goal. We also describe our recently developed bipolar at-risk criteria (BAR). This criteria comprises the peak age range of the first onset of bipolar disorder, genetic risk, presenting with sub-threshold mania, cyclothymic features or depressive symptoms. An initial pilot evaluation of the BAR criteria in 22 subjects indicated conversion rates to proxies of first-episode mania of 23% within 265 days on average, and high specificity and sensitivity of the criteria. If prospective studies confirm the validity of the BAR criteria, then the criteria would have the potential to open up new avenues of research for indicated prevention in BD and might therefore offer opportunities to ameliorate the severity of, or even prevent BD.

[State-dependent motivational interviewing for people with schizophrenia and substance use: results of a randomised controlled trial]. / Motivationsbehandlung für Patienten mit der Doppeldiagnose Psychose und Sucht : Ergebnisse einer randomisierten Studie.

BACKGROUND: Comorbid substance use disorder in patients with schizophrenia is associated with poor clinical and social outcome and low compliance with integrated outpatient treatment programs. For the first time the present trial compares the efficacy of four sessions of motivational interviewing (MI) and four sessions of supportive therapy (ST). The primary outcome was compliance with integrated outpatient treatment post-intervention. Secondary outcomes were substance use, psychopathology, compliance with medication and stage of change in psychotherapy. METHODS: Sixty inpatients with schizophrenia and substance use disorder were randomised to receive either four sessions of MI or four sessions of ST. Masked assessments took place at baseline, post-treatment and 3- and 6-month follow-ups. RESULTS: The integrated outpatient program was attended by 70.0% of the MI (n=30) and 40.0% of the ST patients (n=30; p=0.020). There were no differences regarding secondary outcome between MI and ST groups. CONCLUSION: The study design allows one for the first time to attribute the findings to the specific effects of MI and thereby emphasizes the effectiveness of this particular treatment approach. In summary, these findings show that the integration of short-term MI for people with both psychosis and substance abuse could significantly improve their chances of attending appropriate outpatient settings and thereby improve their well-being.

Preventing progression to first-episode psychosis in early initial prodromal states.

BACKGROUND: Young people with self-experienced cognitive thought and perception deficits (basic symptoms) may present with an early initial prodromal state (EIPS) of psychosis in which most of the disability and neurobiological deficits of schizophrenia have not yet occurred. AIMS: To investigate the effects of an integrated psychological intervention (IPI), combining individual cognitive-behavioural therapy, group skills training, cognitive remediation and multifamily psychoeducation, on the prevention of psychosis in the EIPS. METHOD: A randomised controlled, multicentre, parallel group trial of 12 months of IPI v. supportive counselling (trial registration number: NCT00204087). Primary outcome was progression to psychosis at 12- and 24-month follow-up. RESULTS: A total of 128 help-seeking out-patients in an EIPS were randomised. Integrated psychological intervention was superior to supportive counselling in preventing progression to psychosis at 12-month follow-up (3.2% v. 16.9%; P = 0.008) and at 24-month follow-up (6.3% v. 20.0%; P = 0.019). CONCLUSIONS: Integrated psychological intervention appears effective in delaying the onset of psychosis over a 24-month time period in people in an EIPS.