[When does StäB (not) Work? A Qualitative, Multi-Perspective Survey on Factors that can Affect the Outcome of Inpatient-Equivalent Home Treatment (IEHT)]. / Wann funktioniert StäB (nicht)? Eine qualitative, multiperspektivische Erhebung zu Faktoren, die den Erfolg einer stationsäquivalenten Behandlung (StäB) beeinträchtigen können.

OBJECTIVE: There are always cases in which an already started inpatient equivalent home treatment is terminated. Aim of our study was to reach a better understanding of the circumstances leading to a termination of IEHT that has already begun. METHODS: 17 qualitative interviews were conducted with patients, relatives as well as practitioners and therapists. Data analysis was performed by means of qualitative content analysis. RESULTS: Our data shows, that there are further factors, besides the formal exclusion criteria for IEHT, that can complicate or prevent an inpatient equivalent home treatment or lead to its termination. CONCLUSION: IEHT offers many patients the possibility of an intensive treatment in their own home. However, there our various constellations that can lead to a complication or termination of an inpatient equivalent home treatment.

Returning-to-work after mental health-associated sick leave: a qualitative interview study exploring the experiences of general practitioners in Germany.

BACKGROUND AND AIM: Psychiatric disorders are increasing globally. Especially when these disorders affect working people, this places a financial burden on society due to long-term sick leave, the incapacity to work and the inability to earn and pay taxes. General practitioners (GPs) are often the first health professionals to be consulted by those suffering from mental health disorders. This study investigated the experiences of GPs regarding their patients with mental health disorders and identified factors that are important for a successful return to work. METHODS: This qualitative study used semi-structured interviews to explore the opinions of GPs (n = 12) working in Munich, Germany, or its metropolitan area. The interviews were audio-recorded, transcribed, and analyzed using the reflexive thematic analysis method. RESULTS: GPs think of themselves as important players in the rehabilitation process of patients with mental health disorders. In their daily routine, they face many obstacles to ensure the best treatment and outcome for their patients. They also suffer from poor collaboration with other stakeholders, such as psychiatric hospitals, therapists or employers. They indicate that the mental health disorder of each patient is unique, including the barriers to and possibilities of a successful return to work. Additionally, the workplace appears to play a crucial role in the success rate of re-entry into work. It can exacerbate the course of mental health disorders or support recovery. Fear, shame and stigmatization of the patients are personal factors responsible for prolonged sick leave. CONCLUSION: We conclude that GPs believe that they can have a major impact on the rehabilitation of patients with mental health disorders. As such, special focus should be placed on supporting them in this context.

[Does Inpatient Equivalent Home Treatment lead to higher satisfaction? Results on satisfaction of persons involved in treatment within the Multi-center AKtiV Study]. / Stößt die Behandlung zu Hause auf größere Zufriedenheit? Ergebnisse zur Zufriedenheit der an der Behandlung beteiligten Personengruppen im Rahmen der multizentrischen AKtiV-Studie.

This part of the AKtiV Study focuses on treatment satisfaction of patients and their relatives within Inpatient Equivalent Home Treatment (IEHT) and regular treatment. Stress of relatives and job satisfaction and workload of employees in IEHT is also considered. Relevant Parameters were collected via established as well as newly adapted questionnaires at the end of treatment. Patients and relatives in IEHT are significantly more satisfied. The stress experienced by relatives is reduced in both forms of treatment. Employees in IEHT are generally very satisfied, although there is no correlation with the satisfaction of relatives and patients. Known limitations of satisfaction surveys must be taken into account. In general these results encourage the expansion and continuous development of this new form of treatment in Germany.

[IEHT or inpatient treatment? - First results of the multicenter AKtiV study on inpatient-equivalent home treatment regarding the study population and index treatment]. / StäB oder Station? ­ Erste Ergebnisse zur Studienpopulation und zur Behandlung im Rahmen der multizentrischen AKtiV-Studie zur stationsäquivalenten Behandlung.

AIM: The quasi-experimental AKtiV study investigates the effects inpatient-equivalent home treatment (IEHT). This paper describes the study population based on demographic and clinical parameters at baseline and compares the index treatment. METHODS: Over a period of 12 months 200 IEHT users were included in the intervention group (IG) and 200 inpatients were included in the control group (CG). The comparability of the two groups was ensured by propensity score matching (PSM). RESULTS: In addition to the PSM variables, IG and CG did not differ significantly from each other variables at study inclusion. The duration of the index treatment was significantly longer in the IG (M=37.2 days) compared to the CG (M=27.9 days; p<0.001). CONCLUSION: The similarity of the two groups enables comparisons over 12 months, investigating IEHT effects on long-term outcomes.

Premature termination, satisfaction with care, and shared decision-making during home treatment compared to inpatient treatment: A quasi-experimental trial.

BACKGROUND: Inpatient equivalent home treatment (IEHT), implemented in Germany since 2018, is a specific form of home treatment. Between 2021 and 2022, IEHT was compared to inpatient psychiatric treatment in a 12-months follow-up quasi-experimental study with two propensity score matched cohorts in 10 psychiatric centers in Germany. This article reports results on the treatment during the acute episode and focuses on involvement in decision-making, patient satisfaction, and drop-out rates. METHODS: A total of 200 service users receiving IEHT were compared with 200 matched statistical "twins" in standard inpatient treatment. Premature termination of treatment as well as reasons for this was assessed using routine data and a questionnaire. In addition, we measured patient satisfaction with care with a specific scale. For the evaluation of patient involvement in treatment decisions, we used the 9-item Shared Decision Making Questionnaire (SDM-Q-9). RESULTS: Patients were comparable in both groups with regard to sociodemographic and clinical characteristics. Mean length-of-stay was 37 days for IEHT and 28 days for inpatient treatment. In both groups, a similar proportion of participants stopped treatment prematurely. At the end of the acute episode, patient involvement in decision-making (SDM-Q-9) as well as treatment satisfaction scores were significantly higher for IEHT patients compared to inpatients. CONCLUSIONS: Compared to inpatient care, IEHT treatment for acute psychiatric episodes was associated with higher treatment satisfaction and more involvement in clinical decisions.

The cost-utility of a return-to-work intervention in comparison to routine care for patients with mental disorders in Germany: Results from the RETURN project.

BACKGROUND: Only two-thirds of patients admitted to psychiatric wards return to their previous jobs. Return-to-work interventions in Germany are investigated for their effectiveness, but information regarding cost-effectiveness is lacking. This study investigates the cost-utility of a return-to-work intervention for patients with mental disorders compared to treatment as usual (TAU). METHODS: We used data from a cluster-randomised controlled trial including 166 patients from 28 inpatient psychiatric wards providing data at 6- and 12-month follow-ups. Health and social care service use was measured with the Client Sociodemographic and Service Receipt Inventory. Quality of life was measured with the EQ-5D-3L questionnaire. Cost-utility analysis was performed by calculating additional costs per one additional QALY (Quality-Adjusted Life Years) gained by receiving the support of return-to-work experts, in comparison to TAU. RESULTS: No significant cost or QALY difference between the intervention and control groups has been detected. The return-to-work intervention cannot be identified as cost-effective in comparison to TAU. CONCLUSIONS: The employment of return-to-work experts could not reach the threshold of providing good value for money. TAU, therefore, seems to be sufficient support for the target group.

[Return-to-Work - The Transition after Psychiatric Inpatient Treatment]. / Return-to-Work ­ Übergangsprozesse nach Behandlung in einem psychiatrischen Akutkrankenhaus.

OBJECTIVES: Workers on sick-leave due to a mental illness have enormous problems to return to work. The main objective of the present study is to examine, how individuals experience the transition from the mental health system to their workplace. METHODS: A qualitative research design guided by a grounded theory approach was used. Narrative interviews with ten workers on sick leave and four semi-structured interviews with return-to-work-experts were conducted. RESULTS: Relevant for returning to work is the interplay between the involved persons. Essential is the interpretation of the transition and as a result, which calls for action are made to the participants. CONCLUSION: Clinical interventions for returning to work should focus the support on the expectations of the participants and stimulate a common interpretation.

How should patient decision aids for schizophrenia treatment be designed? - A scoping review.

Despite the clear rationale for applying shared decision-making in the context of the preference sensitive decision for or against antipsychotics and the upswing of patient decision aids (pDAs) to support this process, there is still a lack of knowledge regarding which key features are crucial for pDAs in schizophrenia treatment. A scoping review according to the PRISMA-SRc was conducted to inform on crucial key features and quality indicators. The review focussed on the following seven aspects for investigating pDAs: (1) Types of decision aids, (2) Values, (3) Decision Guidance, (4) Output of the decision aid, (5) Target group, (6) Effectiveness according to publication and (7) Decision aid evaluation. Eleven studies which addressed six unique decision aids met the eligibility criteria. There were major differences in the design as well as in the development of the decision aids. Three aspects emerged that should be given special consideration in the design of such tools for antipsychotics: the evidence used by the decision aid, the algorithm for translating evidence into a decision aid and finally the presentation of the evidence. We recommend the use of data with a high level of evidence and to combine it with individualized treatment by taking into account patient preferences and previous experiences as well as comparing them with clinical assessments. Fully computerized decision aids that use complicated algorithms, for example, by merging treatment effects with patient characteristics to suggest an appropriate treatment at the end, tend to be paternalistic and thus not appropriate for SDM, in our view. In addition, possible cognitive deficits need to be considered when presenting the output of decision aids for antipsychotics.

Informing the development of a decision aid: Expectations and wishes from service users and psychiatrists towards a decision aid for antipsychotics in the inpatient setting.

OBJECTIVES: Decision aids (DAs) are promising tools to foster evidence-based shared decision-making between practitioners and service users. Nevertheless, it is still obscure how an evidence-based DA for people with severe mental illness, especially psychosis, should look in an inpatient treatment setting to be useful and feasible. Therefore, we conducted focus groups with psychiatrists and service users to collect and assess their expectations and wishes regarding an evidence-based DA. From these findings, we derived immediate recommendations for the future development of DAs. METHODS: We held two group interviews with service users (n = 8) and three group interviews with psychiatrists (n = 10). We used an open, large-scale topic guide. First, we presented data from a current meta-analysis on antipsychotics to the interviewees and, in a second step, asked for their expectations and wishes towards a DA that integrates these data. RESULTS: Our thematic analysis revealed six key themes addressed by the respondents: (1) general considerations on the importance and usefulness of such a DA, (2) critical comments on psychiatry and psychopharmacotherapy, (3) communicative prerequisites for the use of a DA, (4) form and content of the DA, (5) data input, data processing and output as well as (6) application of the DA and possible obstacles. CONCLUSIONS: Participants identified several important features for the development of DAs for selecting antipsychotics in inpatient psychiatric treatment. The digital format was met with the greatest approval. Especially the adaptability to different needs, users and psychopathologies and the possibility to outsource information dissemination via app seemed to be a decisive convincing argument. Further research is required to test specific features of DAs to be developed in clinical settings.

Supporting return to work after psychiatric hospitalization-A cluster randomized study (RETURN-study).

BACKGROUND: If people with episodic mental-health conditions lose their job due to an episode of their mental illness, they often experience personal negative consequences. Therefore, reintegration after sick leave is critical to avoid unfavorable courses of disease, longer inability to work, long payment of sickness benefits, and unemployment. Existing return-to-work (RTW) programs have mainly focused on "common mental disorders" and often used very elaborate and costly interventions without yielding convincing effects. It was the aim of the RETURN study to evaluate an easy-to-implement RTW intervention specifically addressing persons with mental illnesses being so severe that they require inpatient treatment. METHODS: The RETURN study was a multi-center, cluster-randomized controlled trial in acute psychiatric wards addressing inpatients suffering from a psychiatric disorder. In intervention wards, case managers (RTW experts) were introduced who supported patients in their RTW process, while in control wards treatment, as usual, was continued. RESULTS: A total of 268 patients were recruited for the trial. Patients in the intervention group had more often returned to their workplace at 6 and 12 months, which was also mirrored in more days at work. These group differences were statistically significant at 6 months. However, for the main outcome (days at work at 12 months), differences were no longer statistically significant (p = 0.14). Intervention patients returned to their workplace earlier than patients in the control group (p = 0.040). CONCLUSIONS: The RETURN intervention has shown the potential of case-management interventions when addressing RTW. Further analyses, especially the qualitative ones, may help to better understand limitations and potential areas for improvement.

How do employees currently admitted to acute psychiatric inpatient units rate their psychosocial working conditions with the COPSOQ (Copenhagen Psychosocial Questionnaire).

BACKGROUND: In recent years it could be shown that psychosocial working conditions and mental health of employees are closely correlated. One well-established instrument to measure psychosocial stress at work is the COPSOQ (Copenhagen Psychosocial Questionnaire, German Standard Version). It is an 84 item self-rating instrument addressing several domains of psychosocial working conditions and is generally used for risk assessments in companies. AIMS: To examine associations between COPSOQ ratings with clinical features and symptoms of employees who currently suffer from an episode of a mental illness requiring inpatient treatment. METHOD: For 265 inpatients with mental disorders who participated in a cluster randomized trial (RETURN-study) COPSOQ-data were available as part of the baseline data acquisition. These data were compared with the German COPSOQ validation sample of the Freiburg research center for occupational sciences (FFAW; approximately 250,000 participants). For subdomains of the COPSOQ that showed major and significant differences between the two samples regression analyses were done to predict COPSOQ scores within the RETURN-sample. RESULTS: Psychiatric inpatients did not assess their working conditions significantly different compared to the population based FFAW sample. However, with regard to the effects of working conditions (general health, burnout, presenteeism, and intention to leave the job) there were major differences between the two samples with the clinical sample expressing more negative views. In the RETURN sample these were predicted by a greater expression of depressive symptoms. CONCLUSIONS: The linkage between work and mental wellbeing is complex. Mental illness is not necessarily a result of poor working conditions, while good working conditions may not in every case prevent symptoms of bad health, even if such associations exist.

[Development of a Return-to-work Intervention for Psychiatric Inpatients]. / Entwicklung einer Intervention zur Unterstützung von stationär-psychiatrisch behandelten Patienten bei der Rückkehr an den Arbeitsplatz im Rahmen der RETURN-Studie.

OBJECTIVE: Patients with mental illnesses often face difficulties when returning to workplace after an episode of inpatient treatment. Available resources intended to support the return-to-work process are often not used. It was the aim of the present study to develop an intervention that facilitates the implementation of patient support at the interface of in- and outpatient care. METHODS: We used a structured development process for the establishment of a return-to-work intervention for psychiatric inpatients. RESULTS: The intervention consisted of the use of return-to-work experts who worked on the basis of a manual. In clearly defined modules, patients were given information on social law basics and details of the return process. Difficult situations (e. g., dealing with the disclosure of the diagnosis, return interview) were discussed and rehearsed. After discharge, further care took place, above all with regard to experiences on the first working day, accompaniment to discussions with the employer and support with any other upcoming difficulties. CONCLUSION: The results of the ongoing study will show whether the chosen approach actually yields the expected results, namely an improvement of the return-to-work process.

Return-to-work interventions for persons/employees with mental illnesses.

PURPOSE OF REVIEW: Mental illnesses are among the most common diseases worldwide. Cases of inability to work caused by mental illness are frequent and the related economic burden is immense. A successful reintegration into their work environment of those patients who were on sick leave due to a mental illness is an important prognostic factor for the further course of the disease and helps reducing financial consequences. It was the aim of the present review to give an overview of the status quo of return-to-work interventions in the international literature. RECENT FINDINGS: Main themes of interventions addressing return to work of persons with mental illnesses are the provision of psychotherapeutic support with or without combining these approaches with work directed interventions. Personal contact of employees, mental healthcare staff and supervisors may be helpful with regard to facilitating return to work. SUMMARY: Current return to work interventions are mostly elaborate, extensive and expensive without convincing results regarding work related outcome parameters. A variety of reasons might be responsible for this finding, including heterogeneity of outcomes, a poor definition of return-to-work-interventions and the complexity of the issue (involving multiple stakeholders).

Evidence-based Shared-Decision-Making Assistant (SDM-assistant) for choosing antipsychotics: protocol of a cluster-randomized trial in hospitalized patients with schizophrenia.

BACKGROUND: Choosing an antipsychotic medication is an important medical decision in the treatment of schizophrenia. This decision requires risk-benefit assessments of antipsychotics, and thus, shared-decision making between physician and patients is strongly encouraged. Although the efficacy and side-effect profiles of antipsychotics are well-established, there is no clear framework for the communication of the evidence between physicians and patients. For this reason, we developed an evidence-based shared-decision making assistant (SDM-assistant) that presents high-quality evidence from network meta-analysis on the efficacy and side-effect profile of antipsychotics and can be used as a basis for shared-decision making between physicians and patients when selecting antipsychotic medications. METHODS: The planned matched-pair cluster-randomised trial will be conducted in acute psychiatric wards (n = 14 wards planned) and will include adult inpatients with schizophrenia or schizophrenia-like disorders (N = 252 participants planned). On the intervention wards, patients and their treating physicians will use the SDM-assistant, whenever a decision on choosing an antipsychotic is warranted. On the control wards, antipsychotics will be chosen according to treatment-as-usual. The primary outcome will be patients' perceived involvement in the decision-making during the inpatient stay as measured with the SDM-Q-9. We will also assess therapeutic alliance, symptom severity, side-effects, treatment satisfaction, adherence, quality of life, functioning and rehospitalizations as secondary outcomes. Outcomes could be analysed at discharge and at follow-up after three months from discharge. The analysis will be conducted per-protocol using mixed-effects linear regression models for continuous outcomes and logistic regression models using generalised estimating equations for dichotomous outcomes. Barriers and facilitators in the implementation of the intervention will also be examined using a qualitative content analysis. DISCUSSION: This is the first trial to examine a decision assistant specifically designed to facilitate shared-decision making for choosing antipsychotic medications, i.e., SDM-assistant, in acutely ill inpatients with schizophrenia. If the intervention can be successfully implemented, SDM-assistant could advance evidence-based medicine in schizophrenia by putting medical evidence on antipsychotics into the context of patient preferences and values. This could subsequently lead to a higher involvement of the patients in decision-making and better therapy decisions. TRIAL REGISTRATION: German Clinical Trials Register (ID: DRKS00027316 , registration date 26.01.2022).

A German psychiatric care program aiming to improve patients’ compliance – Patients’ view

Noncompliance is a worldwide problem in medical care, leading to prolonged recovery times and rehospitalizations. Especially in the field of psychiatry, consistent therapy compliance is crucial. Hence the Munich Integrated Care program for patients suffering from psychiatric disorders aims at improving patients’ compliance. To bring to light participants' personal experiences with the program, we conducted group interviews that we evaluated using qualitative methods. We shed light on what aspects make a psychiatric health care program so valuable in the eyes of its participants that it can develop its effect as a relapse-preventive agent. We found that in this program, patients experienced safety, stability, support, hope, motivation and understanding.

Concept of the Munich/Augsburg Consortium Precision in Mental Health for the German Center of Mental Health.

The Federal Ministry of Education and Research (BMBF) issued a call for a new nationwide research network on mental disorders, the German Center of Mental Health (DZPG). The Munich/Augsburg consortium was selected to participate as one of six partner sites with its concept "Precision in Mental Health (PriMe): Understanding, predicting, and preventing chronicity." PriMe bundles interdisciplinary research from the Ludwig-Maximilians-University (LMU), Technical University of Munich (TUM), University of Augsburg (UniA), Helmholtz Center Munich (HMGU), and Max Planck Institute of Psychiatry (MPIP) and has a focus on schizophrenia (SZ), bipolar disorder (BPD), and major depressive disorder (MDD). PriMe takes a longitudinal perspective on these three disorders from the at-risk stage to the first-episode, relapsing, and chronic stages. These disorders pose a major health burden because in up to 50% of patients they cause untreatable residual symptoms, which lead to early social and vocational disability, comorbidities, and excess mortality. PriMe aims at reducing mortality on different levels, e.g., reducing death by psychiatric and somatic comorbidities, and will approach this goal by addressing interdisciplinary and cross-sector approaches across the lifespan. PriMe aims to add a precision medicine framework to the DZPG that will propel deeper understanding, more accurate prediction, and personalized prevention to prevent disease chronicity and mortality across mental illnesses. This framework is structured along the translational chain and will be used by PriMe to innovate the preventive and therapeutic management of SZ, BPD, and MDD from rural to urban areas and from patients in early disease stages to patients with long-term disease courses. Research will build on platforms that include one on model systems, one on the identification and validation of predictive markers, one on the development of novel multimodal treatments, one on the regulation and strengthening of the uptake and dissemination of personalized treatments, and finally one on testing of the clinical effectiveness, utility, and scalability of such personalized treatments. In accordance with the translational chain, PriMe's expertise includes the ability to integrate understanding of bio-behavioral processes based on innovative models, to translate this knowledge into clinical practice and to promote user participation in mental health research and care.

[Inpatient equivalent home-treatment: an overview]. / Stationsäquivalente Behandlung: Ein Überblick zum Status quo.

Inpatient equivalent home-treatment (IEHT) was implemented in Germany in 2018. Persons with a mental disorder can be admitted to acute multiprofessional IEHT to avoid or shorten inpatient hospital treatment. Exclusion criteria are amongst others lack of consent of cohabitants or endangerment of self and others. Advantages of IEHT include normalization and reduction of stigma. Nevertheless, administrative requirements are high. While there is international evidence for home treatment and crisis resolution teams, there is still a lack of evidence for the concept of IEHT, although specific studies are currently being carried out (e.g. AktiV study financed by the Innovation Fund). Overall, IEHT is important for mental health services and should be further developed.