What to think or how to think - is symptom reduction in posttraumatic symptomatology associated with change in posttraumatic cognitions or perseverative thinking? A latent change score model approach.

OBJECTIVE: Patients with posttraumatic stress disorder (PTSD) report changes in what they think of the world and themselves, referred to as posttraumatic cognitions, and changes in how they think, reflected in increased perseverative thinking. We investigated whether pre-post therapy changes in the two aspects of thinking were associated with pre-post therapy changes in posttraumatic symptom severity. METHOD: 219 d clinic patients with posttraumatic stress symptoms received trauma-focused psychotherapy with cognitive behavioral and metacognitive elements. The posttraumatic cognitions inventory (PTCI), the perseverative thinking questionnaire (PTQ), and the Davidson trauma scale (DTS) were applied at two occasions, pre- and post-therapy. Using latent change score models, we investigated whether change in PTCI and change in PTQ were associated with change in DTS and its subscales. We then compared the predictive value of PTQ and PTCI in joint models. RESULTS: When jointly modeled, change in overall DTS score was associated with change in both PTCI and PTQ. Concerning DTS subscales, reexperiencing and avoidance were significantly associated with change in PTCI, but not in PTQ. CONCLUSION: Results indicate that both aspects of cognition may be valuable targets of psychotherapy. A focus on posttraumatic cognitions might be called for in patients with severe reexperiencing and avoidance.

Psychiatric and non-psychiatric patients during the midst of Covid-19: Pandemic distress, psychosis and the belief in conspiracy theories.

BACKGROUND: The COVID-19 pandemic was associated with increased levels of psychological distress in the general population, at the same time providing a perfect breeding ground for conspiracy beliefs. Psychiatric patients are considered as a population with an increased vulnerability for stressful events, and conspiracy beliefs show overlaps with paranoid ideations. The aim of the present study was to investigate if psychiatric patients experienced higher levels of pandemic distress than non-psychiatric patients, if they were more prone to conspiracy beliefs and if pandemic distress as well as other mental health variables were associated with believing in conspiracy theories. METHODS: Indicators for mental health (pandemic distress, depressive symptoms, general anxiety symptoms, perceived stress) and indicators for believing in conspiracy theories were assessed within psychiatric (n = 73) and non-psychiatric patients (n = 29) during the midst of the pandemic. RESULTS: Psychiatric patients reported higher levels of pandemic distress than non-psychiatric patients. Conspiracy measurements correlated positively with pandemic distress, but not with anxiety and depression. No differences were found between psychiatric patients with or without psychotic disorder and non-psychiatric patients in regard to conspiracy measurements. CONCLUSION: Our findings suggest a higher susceptibility of psychiatric patients to pandemic distress, but not an increased level of believing in conspiracy theories. The common notion that people suffering from psychosis are more likely to believe in conspiracy theories was not supported. Furthermore, distress caused by a specific event and not anxiety per se seems to be related to the degree of conspiracy beliefs.

Polygenetic risk scores and phenotypic constellations of obsessive-compulsive disorder in clozapine-treated schizophrenia.

Obsessive-compulsive symptoms (OCS) are frequently observed in individuals with schizophrenia (SCZ) treated with clozapine (CLZ). This study aimed to analyze prevalence of OCS and obsessive-compulsive disorder (OCD) in this subgroup and find possible correlations with different phenotypes. Additionally, this is the first study to examine polygenetic risk scores (PRS) in individuals with SCZ and OCS. A multicenter cohort of 91 individuals with SCZ who were treated with CLZ was recruited and clinically and genetically assessed. Symptom severity was examined using the Positive and Negative Symptom Scale (PANSS), Clinical Global Impression Scale (CGI), the Calgary Depression Scale for Schizophrenia (CDSS), Global Assessment of Functioning Scale (GAF) and Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Participants were divided into subgroups based on phenotypic OCS or OCD using Y-BOCS scores. Genomic-wide data were generated, and PRS analyses were performed to evaluate the association between either phenotypic OCD or OCS severity and genotype-predicted predisposition for OCD, SCZ, cross-disorder, and CLZ/norclozapine (NorCLZ) ratio, CLZ metabolism and NorCLZ metabolism. OCS and OCD were frequent comorbidities in our sample of CLZ-treated SCZ individuals, with a prevalence of 39.6% and 27.5%, respectively. Furthermore, the Y-BOCS total score correlated positively with the duration of CLZ treatment in years (r = 0.28; p = 0.008) and the PANSS general psychopathology subscale score (r = 0.23; p = 0.028). A significant correlation was found between OCD occurrence and PRS for CLZ metabolism. We found no correlation between OCS severity and PRS for CLZ metabolism. We found no correlation for either OCD or OCS and PRS for OCD, cross-disorder, SCZ, CLZ/NorCLZ ratio or NorCLZ metabolism. Our study was able to replicate previous findings on clinical characteristics of CLZ-treated SCZ individuals. OCS is a frequent comorbidity in this cohort and is correlated with CLZ treatment duration in years and PANSS general psychopathology subscale score. We found a correlation between OCD and PRS for CLZ metabolism, which should be interpreted as incidental for now. Future research is necessary to replicate significant findings and to assess possible genetic predisposition of CLZ-treated individuals with SCZ to OCS/OCD. Limitations attributed to the small sample size or the inclusion of subjects on co-medication must be considered. If the association between OCD and PRS for CLZ metabolism can be replicated, it should be further evaluated if CYP1A2 alteration, respectively lower CLZ plasma level, is relevant for OCD development.

Young people at risk for developing bipolar disorder: Two-year findings from the multicenter prospective, naturalistic Early-BipoLife study.

Early identification and intervention of individuals with an increased risk for bipolar disorder (BD) may improve the course of illness and prevent long­term consequences. Early-BipoLife, a multicenter, prospective, naturalistic study, examined risk factors of BD beyond family history in participants aged 15-35 years. At baseline, positively screened help-seeking participants (screenBD at-risk) were recruited at Early Detection Centers and in- and outpatient depression and attention-deficit/hyperactivity disorder (ADHD) settings, references (Ref) drawn from a representative cohort. Participants reported sociodemographics and medical history and were repeatedly examined regarding psychopathology and the course of risk factors. N = 1,083 screenBD at-risk and n = 172 Ref were eligible for baseline assessment. Within the first two years, n = 31 screenBD at-risk (2.9 %) and none of Ref developed a manifest BD. The cumulative transition risk was 0.0028 at the end of multistep assessment, 0.0169 at 12 and 0.0317 at 24 months (p = 0.021). The transition rate with a BD family history was 6.0 %, 4.7 % in the Early Phase Inventory for bipolar disorders (EPIbipolar), 6.6 % in the Bipolar Prodrome Interview and Symptom Scale-Prospective (BPSS-FP) and 3.2 % with extended Bipolar At-Risk - BARS criteria). In comparison to help-seeking young patients from psychosis detection services, transition rates in screenBD at-risk participants were lower. The findings of Early-BipoLife underscore the importance of considering risk factors beyond family history in order to improved early detection and interventions to prevent/ameliorate related impairment in the course of BD. Large long-term cohort studies are crucial to understand the developmental pathways and long-term course of BD, especially in people at- risk.

Leaving the stigma to the patients? Frequency of crisis experiences among mental health professionals in Berlin and Brandenburg and how they cope with it.

BACKGROUND: Although mental health professionals' mental health problems are gaining increased attention, there is little systematic research on this topic. AIMS: This study investigated the frequency of crisis experiences among mental health professionals and examined how they approach these experiences in terms of their personal and social identities. METHODS: An online survey was conducted among mental health professionals in 18 psychiatric hospital departments in the German federal states of Berlin and Brandenburg (N = 215), containing questions about personal crisis experiences, help sought, service use, meaningfulness of lived experiences, causal beliefs of mental illness and psychotherapeutic orientation. Social identification was assessed via semantic differential scales derived from preliminary interview studies. To investigate relationships between the variables, explorative correlation analyses were calculated. RESULTS: Results showed a high frequency rate of crisis experiences, substantial rates of suicidal ideation and incapacity to work and high service use. Most participants regarded their experiences as meaningful for their personal identity. Meaningfulness was positively related to a psychosocial causation model of mental illness, to psychodynamic psychotherapeutic orientation and to a high degree of disidentification with users and crisis experienced colleagues. CONCLUSION: The (paradoxical) disintegration of personal and social identity of may be understood as a strategy to avoid stigmatization. A more challenging coping style among professionals is discussed.

Prediction of estimated risk for bipolar disorder using machine learning and structural MRI features.

BACKGROUND: Individuals with bipolar disorder are commonly correctly diagnosed a decade after symptom onset. Machine learning techniques may aid in early recognition and reduce the disease burden. As both individuals at risk and those with a manifest disease display structural brain markers, structural magnetic resonance imaging may provide relevant classification features. METHODS: Following a pre-registered protocol, we trained linear support vector machine (SVM) to classify individuals according to their estimated risk for bipolar disorder using regional cortical thickness of help-seeking individuals from seven study sites (N = 276). We estimated the risk using three state-of-the-art assessment instruments (BPSS-P, BARS, EPIbipolar). RESULTS: For BPSS-P, SVM achieved a fair performance of Cohen's κ of 0.235 (95% CI 0.11-0.361) and a balanced accuracy of 63.1% (95% CI 55.9-70.3) in the 10-fold cross-validation. In the leave-one-site-out cross-validation, the model performed with a Cohen's κ of 0.128 (95% CI -0.069 to 0.325) and a balanced accuracy of 56.2% (95% CI 44.6-67.8). BARS and EPIbipolar could not be predicted. In post hoc analyses, regional surface area, subcortical volumes as well as hyperparameter optimization did not improve the performance. CONCLUSIONS: Individuals at risk for bipolar disorder, as assessed by BPSS-P, display brain structural alterations that can be detected using machine learning. The achieved performance is comparable to previous studies which attempted to classify patients with manifest disease and healthy controls. Unlike previous studies of bipolar risk, our multicenter design permitted a leave-one-site-out cross-validation. Whole-brain cortical thickness seems to be superior to other structural brain features.

The mediating role of attachment and anger: exploring the impact of maternal early-life maltreatment on child abuse potential.

Background: Maternal early-life maltreatment (ELM) increases the risk of subsequent child maltreatment, but the underlying mechanisms of these intergenerational effects remain largely unknown. Identifying these mechanisms is crucial for developing preventive interventions that can break the cycle of abuse. Notably, previous research has shown that ELM often results in attachment insecurity and altered anger characteristics. Therefore, this study determines whether these characteristics mediate the relationship between maternal history of ELM and child abuse potential. Methods: The study sample included 254 mothers, of whom 149 had experienced ELM to at least a moderate degree. Maternal ELM was assessed using the Childhood Experience of Care and Abuse (CECA) interview. Attachment insecurity, trait anger and anger expression, and maternal abuse potential were assessed using the Vulnerable Attachment Questionnaire (VASQ), State-Trait Anger Expression Inventory (STAXI), and Child Abuse Potential Inventory (CAPI), respectively. Results: The severity of maternal ELM predicted higher child abuse potential, with attachment insecurity and anger suppression mediating this effect. Specifically, higher levels of maternal ELM were associated with greater attachment insecurity and increased anger suppression, resulting in a higher child abuse potential. Although higher levels of trait anger were directly associated with higher child abuse potential, this parameter did not mediate the relationship with ELM. In addition, no significant associations were observed between outwardly expressed anger and ELM or child abuse potential. All analyses were adjusted for maternal mental disorders, years of education, and relationship status. Discussion: Attachment insecurity and anger suppression may serve as pathways linking the maternal history of ELM to the risk of child abuse, even when considering maternal psychopathology. Overall, our findings indicate that interventions aimed at strengthening attachment and improving anger suppression may be beneficial for all mothers with ELM history and high child abuse potential, not just those who suffer from mental illness.

Increase in presentations with new-onset psychiatric disorders in a psychiatric emergency department in Berlin, Germany during the second wave of the COVID-19 pandemic - a retrospective cross-sectional study.

Introduction: While numerous studies have identified an increase in symptoms of depression as well as anxiety and distress due to the COVID-19 pandemic, relatively few studies have investigated the new-onset of psychiatric diseases during the pandemic. Methods: This study focuses on the number of psychiatric new-onset diagnoses in a psychiatric emergency department (pED) in Berlin, Germany during the second wave of the pandemic (i.e. from 09/15/2020 to 03/01/2021 = COVID-19-period) compared to pre-pandemic times (09/15/2019 to 03/01/2020 = control period). We focused on diagnostic subgroups and performed logistic regression analysis to investigate potential risk groups based on covariables such as age, gender, homelessness, attending in police custody and familial relationship. Results: Overall, there was a 59.7% increase in new-onset psychiatric diagnoses during the COVID-19-period. Increases in the following diagnoses were observed: new-onset of substance-related and addictive disorders (+192.5%), depressive disorders (+115.8%), schizophrenia spectrum and psychotic disorders (+113.3%) and anxiety disorders (+63.6%). These diagnostic subgroups, together with attending in police custody, were found to predict pED presentations with new-onset during the COVID-19-period. Interestingly, in the group of new-onset psychiatric diseases in the COVID-19-period, higher amounts of job loss and living alone as well as a relative decrease in familial relationships were observed. Discussion: COVID-19 infections and post-COVID-19 syndrome are unlikely to have played a substantial role in the increase of new-onset diseases in this study. Conclusion: Our findings underline the role of indirect factors in new-onset of psychiatric diseases during the pandemic and should be a caveat for future pandemic control policies.

Relationship between perceived coercion and perceived justification of coercive measures - secondary analysis of a randomized-controlled trial.

BACKGROUND: Subjective perception of coercion has gained attention as an important outcome. However, little is known about its relation to patients' appraisal of the justification of coercive measures. The present study aims to analyze the relationship between patients' appraisal of the justification of coercive measures and their level of perceived coercion. METHODS: This study presents a secondary analysis of the results of a multi-center RCT conducted to evaluate the effects of post-coercion review. Patients who experienced at least one coercive measure during their hospital stay were included in the trial. Participants' appraisal of the justification of coercive measures was categorized into patient-related and staff-related justifications. Subjective coercion was assessed using the Coercion Experience Scale (CES) and used as dependent variable in a multivariate regression model. RESULTS: 97 participants who completed the CES were included in the analysis. CES scores were significantly associated with the perception of the coercive measure as justified by staff-related factors (B = 0,540, p < 0,001), as well as with higher level of negative symptoms (B = 0,265, p = 0,011), and with mechanical restraint compared to seclusion (B=-0,343, p = 0,017). CONCLUSIONS: Patients' perceptions of coercive measures as justified by staff-related factors such as arbitrariness or incompetence of staff are related to higher levels of perceived coercion. Multiprofessional efforts must be made to restrict the use of coercive measures and to ensure a transparent and sustainable decision-making process, particularly with patients showing high levels of negative symptoms. Such key elements should be part of all coercion reduction programs.

Patient characteristics, validity of clinical diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D): design, procedures and outcomes.

BACKGROUND: Suicidality, ranging from passive suicidal thoughts to suicide attempt, is common in major depressive disorder (MDD). However, relatively little is known about patient, illness and treatment characteristics in those with co-occurring MDD and suicidality, including the timing of and factors associated with the offset, continuation or reemergence of suicidality. Here, we present the background, rationale, design and hypotheses of the Patient Characteristics, Validity of Clinical Diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D) study, an investigator-initiated, observational study, funded by Janssen-Cilag GmbH. METHODS/RESULTS: OASIS-D is an eight-site, six-month, cohort study of patients aged 18-75 hospitalized with MDD. Divided into three sub-studies and patient populations (PPs), OASIS-D will (i) systematically characterize approximately 4500 consecutively hospitalized patients with any form of unipolar depressive episode (PP1), (ii) evaluate the validity of the clinical diagnosis of moderate or severe unipolar depressive episode with the Mini-International Neuropsychiatric Interview (M.I.N.I.) and present suicidality (at least passive suicidal thoughts) present ≥ 48 h after admission with the Sheehan-Suicide Tracking Scale (S-STS), assessing also predictors of the diagnostic concordance/discordance of MDD in around 500 inpatients (PP2), and (iii) characterize and prospectively follow for 6 months 315 inpatients with a research-verified moderate or severe unipolar depressive episode and at least passive suicidal thoughts ≥ 48 h after admission, evaluating treatment and illness/response patterns at baseline, hospital discharge, 3 and 6 months. Exploratory objectives will describe the association between the number of days with suicidality and utilization of outpatient and inpatient care services, and structured assessments of factors influencing the risk of self-injurious behavior without suicidal intent, and of continuous, intermittent or remitted suicidality during the 6-month observation period. CONCLUSION: Despite their frequency and clinical relevance, relatively little is known about patient and treatment characteristics of individuals with MDD and suicidality, including factors moderating and mediating the outcome of both MDD and suicidality. Results of the OASIS-D study are hoped to improve the understanding of the frequency, correlates and 6-month naturalistic treatment and outcome trajectories of different levels of suicidality in hospitalized adults with MDD and suicidality. TRIAL REGISTRATION: NCT04404309 [ClinicalTrials.gov].

Psychiatric Adverse Events of Acetylcholinesterase Inhibitors in Alzheimer's Disease and Parkinson's Dementia: Systematic Review and Meta-Analysis.

BACKGROUND: The acetylcholinesterase inhibitors (AChEIs) donepezil, galantamine, and rivastigmine are commonly used in the management of various forms of dementia. OBJECTIVES: While these drugs are known to induce classic cholinergic adverse events such as diarrhea, their potential to cause psychiatric adverse events has yet to be thoroughly examined. METHODS: We sought to determine the risk of psychiatric adverse events associated with the use of AChEIs through a systematic review and meta-analysis of double-blind randomized controlled trials involving patients with Alzheimer's dementia and Parkinson's dementia. RESULTS: A total of 48 trials encompassing 22,845 patients were included in our analysis. Anorexia was the most commonly reported psychiatric adverse event, followed by agitation, insomnia, and depression. Individuals exposed to AChEIs had a greater risk of experiencing appetite disorders, insomnia, or depression compared with those who received placebo (anorexia: odds ratio [OR] 2.93, 95% confidence interval [CI] 2.29-3.75; p < 0.00001; decreased appetite: OR 1.93, 95% CI 1.33-2.82; p = 0.0006; insomnia: OR 1.55, 95% CI 1.25-1.93; p < 0.0001; and depression: OR 1.59, 95% CI 1.23-2.06, p = 0.0004). Appetite disorders were also more frequent with high-dose versus low-dose therapy. A subgroup analysis revealed that the risk of insomnia was higher for donepezil than for galantamine. CONCLUSIONS: Our findings suggest that AChEI therapy may negatively impact psychological health, and careful monitoring of new psychiatric symptoms is warranted. Lowering the dose may resolve some psychiatric adverse events, as may switching to galantamine in the case of insomnia. CLINICAL TRIAL REGISTRATION: The study was pre-registered on PROSPERO (CRD42021258376).

Affect Recognition, Theory of Mind, and Empathy in Preschool Children with Externalizing Behavior Problems-A Group Comparison and Developmental Psychological Consideration.

Preschool mental disorders are often associated with significant interpersonal problems, related to impaired affect recognition, theory of mind (ToM), and empathy. To date, these skills have not been studied together in preschoolers with externalizing behavior problems (EBPs). The aim of the present study was to investigate whether and to what extent preschool children with EBPs show impairments in affect recognition, ToM, and empathy. Preschoolers with EBPs, defined by current psychiatric treatment and T-scores ≥ 60 on the externalizing problem scale of the Child Behavior Checklist (CBCL/1½-5 or 6-18R) were compared to non-clinical controls (HCs), defined by no past and no current psychiatric treatment and T-scores < 60 on all CBCL broad-band scales. Groups were compared on affect recognition (NEuroPSYchological Assessment-II), affective ToM (Test of Emotion Comprehension), cognitive ToM (Extended Theory-of-Mind Scale), parent-reported emotional contagion, attention to others' feelings, and prosocial action (Empathy Questionnaire), IQ and language (Wechsler Preschool and Primary Scale of Intelligence-III Matrices, Active and Passive Vocabulary test), controlling for age, sex, and language abilities. Compared to 28 HCs, 22 preschoolers with EBPs (total sample meanage = 5.5 years +/- 0.8 years, range= 4.2-6.9 years, males 66%) had significantly greater impairments in cognitive ToM (p = 0.0012, η2 = 0.266), attention to others' feelings (p = 0.0049, η2 = 0.222), and prosocial action (p = 0.0070, η2 = 0.210), each representing strong effect sizes. EBPs were significantly related to cognitive domains, like prosocial action (r = -0.501), cognitive ToM (r = -0.425), and attention to others' feelings (r = -0.332), but not to affective domains of social cognition. Social cognitive development may be impaired as early as preschool age and should be promoted before the child starts school.

Validation of natural language processing methods capturing semantic incoherence in the speech of patients with non-affective psychosis.

Background: Impairments in speech production are a core symptom of non-affective psychosis (NAP). While traditional clinical ratings of patients' speech involve a subjective human factor, modern methods of natural language processing (NLP) promise an automatic and objective way of analyzing patients' speech. This study aimed to validate NLP methods for analyzing speech production in NAP patients. Methods: Speech samples from patients with a diagnosis of schizophrenia or schizoaffective disorder were obtained at two measurement points, 6 months apart. Out of N = 71 patients at T1, speech samples were also available for N = 54 patients at T2. Global and local models of semantic coherence as well as different word embeddings (word2vec vs. GloVe) were applied to the transcribed speech samples. They were tested and compared regarding their correlation with clinical ratings and external criteria from cross-sectional and longitudinal measurements. Results: Results did not show differences for global vs. local coherence models and found more significant correlations between word2vec models and clinically relevant outcome variables than for GloVe models. Exploratory analysis of longitudinal data did not yield significant correlation with coherence scores. Conclusion: These results indicate that natural language processing methods need to be critically validated in more studies and carefully selected before clinical application.

Coercive measures in psychiatry - When do they occur and who is at risk?

Coercive measures (CM) in psychiatry adversely affect patients and efforts to minimize CM are steadily increasing. One area that has not been a strong focus of preventative efforts to date is the time of use of CM during hospitalization although previous research indicates that the admission situation and early hospitalization are times of increased risk for CM. This study therefore aims to contribute to the body of research in this field by analyzing in detail the times of use of CM and identifying patient characteristics serving as predictors for CM during early hospitalization. Using a large sample (N = 1556) of all cases admitted in 2019 via the emergency room at the Charité Department of Psychiatry at St. Hedwig Hospital in Berlin, this study supports previous research showing that the risk of CM is highest within the first 24 h h of hospitalization. Of 261 cases who experienced CM, 71.6% (n = 187) experienced a CM within the first 24 h of hospitalization and 54.4% (n = 142) of cases only experienced CM within the first 24 h of hospitalization and did not receive any CM after. Furthermore, this study identified significant predictors for the early use of CM during hospitalization including acute intoxication (p < .01), aggression (p < .01), male gender (p < .001) and limited communication ability (p < .001). The results highlight the importance of directing preventative efforts to minimize the use of CM not only to psychiatric units but also to mental health crisis response and to develop interventions specifically tailored to this time and patient groups at highest risk.

Machine Learning Prediction of Estimated Risk for Bipolar Disorders Using Hippocampal Subfield and Amygdala Nuclei Volumes.

The pathophysiology of bipolar disorder (BD) remains mostly unclear. Yet, a valid biomarker is necessary to improve upon the early detection of this serious disorder. Patients with manifest BD display reduced volumes of the hippocampal subfields and amygdala nuclei. In this pre-registered analysis, we used structural MRI (n = 271, 7 sites) to compare volumes of hippocampus, amygdala and their subfields/nuclei between help-seeking subjects divided into risk groups for BD as estimated by BPSS-P, BARS and EPIbipolar. We performed between-group comparisons using linear mixed effects models for all three risk assessment tools. Additionally, we aimed to differentiate the risk groups using a linear support vector machine. We found no significant volume differences between the risk groups for all limbic structures during the main analysis. However, the SVM could still classify subjects at risk according to BPSS-P criteria with a balanced accuracy of 66.90% (95% CI 59.2-74.6) for 10-fold cross-validation and 61.9% (95% CI 52.0-71.9) for leave-one-site-out. Structural alterations of the hippocampus and amygdala may not be as pronounced in young people at risk; nonetheless, machine learning can predict the estimated risk for BD above chance. This suggests that neural changes may not merely be a consequence of BD and may have prognostic clinical value.

Daring to Feel: Emotion-Focused Psychotherapy Increases Amygdala Activation and Connectivity in Euthymic Bipolar Disorder-A Randomized Controlled Trial.

BACKGROUND: In bipolar disorder (BD), the alternation of extreme mood states indicates deficits in emotion processing, accompanied by aberrant neural function of the emotion network. The present study investigated the effects of an emotion-centered psychotherapeutic intervention on amygdala responsivity and connectivity during emotional face processing in BD. METHODS: In a randomized controlled trial within the multicentric BipoLife project, euthymic patients with BD received one of two interventions over 6 months: an unstructured, emotion-focused intervention (FEST), where patients were guided to adequately perceive and label their emotions (n = 28), or a specific, structured, cognitive behavioral intervention (SEKT) (n = 31). Before and after interventions, functional magnetic resonance imaging was conducted while patients completed an emotional face-matching paradigm (final functional magnetic resonance imaging sample of patients completing both measurements: SEKT, n = 17; FEST, n = 17). Healthy control subjects (n = 32) were scanned twice after the same interval without receiving any intervention. Given the focus of FEST on emotion processing, we expected FEST to strengthen amygdala activation and connectivity. RESULTS: Clinically, both interventions stabilized patients' euthymic states in terms of affective symptoms. At the neural level, FEST versus SEKT increased amygdala activation and amygdala-insula connectivity at postintervention relative to preintervention time point. In FEST, the increase in amygdala activation was associated with fewer depressive symptoms (r = 0.72) 6 months after intervention. CONCLUSIONS: Enhanced activation and functional connectivity of the amygdala after FEST versus SEKT may represent a neural marker of improved emotion processing, supporting the FEST intervention as an effective tool in relapse prevention in patients with BD.

Predicting psychotic relapse following randomised discontinuation of paliperidone in individuals with schizophrenia or schizoaffective disorder: an individual participant data analysis.

BACKGROUND: Predicting relapse for individuals with psychotic disorders is not well established, especially after discontinuation of antipsychotic treatment. We aimed to identify general prognostic factors of relapse for all participants (irrespective of treatment continuation or discontinuation) and specific predictors of relapse for treatment discontinuation, using machine learning. METHODS: For this individual participant data analysis, we searched the Yale University Open Data Access Project's database for placebo-controlled, randomised antipsychotic discontinuation trials with participants with schizophrenia or schizoaffective disorder (aged ≥18 years). We included studies in which participants were treated with any antipsychotic study drug and randomly assigned to continue the same antipsychotic drug or to discontinue it and receive placebo. We assessed 36 prespecified baseline variables at randomisation to predict time to relapse, using univariate and multivariate proportional hazard regression models (including multivariate treatment group by variable interactions) with machine learning to categorise the variables as general prognostic factors of relapse, specific predictors of relapse, or both. FINDINGS: We identified 414 trials, of which five trials with 700 participants (304 [43%] women and 396 [57%] men) were eligible for the continuation group and 692 participants (292 [42%] women and 400 [58%] men) were eligible for the discontinuation group (median age 37 [IQR 28-47] years for continuation group and 38 [28-47] years for discontinuation group). Out of the 36 baseline variables, general prognostic factors of increased risk of relapse for all participants were drug-positive urine; paranoid, disorganised, and undifferentiated types of schizophrenia (lower risk for schizoaffective disorder); psychiatric and neurological adverse events; higher severity of akathisia (ie, difficulty or inability to sit still); antipsychotic discontinuation; lower social performance; younger age; lower glomerular filtration rate; benzodiazepine comedication (lower risk for anti-epileptic comedication). Out of the 36 baseline variables, predictors of increased risk specifically after antipsychotic discontinuation were increased prolactin concentration, higher number of hospitalisations, and smoking. Both prognostic factors and predictors with increased risk after discontinuation were oral antipsychotic treatment (lower risk for long-acting injectables), higher last dosage of the antipsychotic study drug, shorter duration of antipsychotic treatment, and higher score on the Clinical Global Impression (CGI) severity scale The predictive performance (concordance index) for participants who were not used to train the model was 0·707 (chance level is 0·5). INTERPRETATION: Routinely available general prognostic factors of psychotic relapse and predictors specific for treatment discontinuation could be used to support personalised treatment. Abrupt discontinuation of higher dosages of oral antipsychotics, especially for individuals with recurring hospitalisations, higher scores on the CGI severity scale, and increased prolactin concentrations, should be avoided to reduce the risk of relapse. FUNDING: German Research Foundation and Berlin Institute of Health.

Preventing, reducing, and attenuating restraint: A prospective controlled trial of the implementation of peer support in acute psychiatry.

Introduction: The use of restraint as a means of managing patients is considered a critical factor that interferes with recovery. Strategies to create a less restrictive environment within psychiatric facilities are therefore eagerly sought. Peer support workers (PSWs) are increasingly employed in mental health settings. The prevailing theory is that PSWs have the potential to contribute to conflict and restraint prevention efforts in acute psychiatric wards. However, to date, research in support of this claim remains limited. Objective: The present study aimed at assessing the effectiveness of employing peer support workers with regard to reducing the use of restraint. Methods: This prospective controlled pre-post study sought to evaluate the implementation of peer support in one locked ward compared to treatment as usual (TAU) with no implementation of peer support in a second locked ward of a psychiatry department in Berlin, Germany. The pre-post comparison was planned to consist of two assessment periods of 3 months each, taking place directly before and after peer support implementation or TAU. Both assessments were extended to a period of 6 months, before and after the initially planned 12-month implementation process, in order to balance the effects of disruptions and of the COVID-19 pandemic. Using routine data, the proportion, frequency, and duration of mechanical restraint, forced medication as well as mechanical restraint in combination with forced medication, were evaluated. Results: In the control group, an increase in the proportion of patients subjected to measures of restraint was found between pre- and post-assessment, which was accompanied by a further increase in the mean number of events of restraint per patient within this group. In the intervention group, no significant change in the application of restraint was observed during the study period. Discussion: There is some indication that peer support may be protective with regard to restraint in acute wards. However, our study faced major challenges during the implementation process and the post-assessment period, such as COVID-19 and staff reorganization. This may have led to peer support not reaching its full potential. The relationship between the implementation of peer support and the use of restraint therefore merits further investigation.

The Affect Intolerance Scale (AIS), German version: A validation study in a student and clinical sample of patients with trauma-related disorders.

BACKGROUND AND OBJECTIVES: The Affect Intolerance Scale (AIS) assesses two core concepts of emotion regulation: appraisals of negative emotions as threatening and proneness to emotional avoidance. Maladaptive emotion regulation is associated with various psychopathologies. We translated and validated the AIS in a German student and clinical sample of patients with trauma-related disorders. METHODS: 340 patients, 161 with post-traumatic stress disorder and 179 with adjustment disorder, and 322 students were enrolled. We employed exploratory and confirmatory factor analyses in a cross-validation design to investigate construct validity, convergent and discriminant validity, and reliability. RESULTS: We replicated the originally described two-factor structure in both samples. Cronbach's α was 0.947 in the student and 0.950 in the clinical sample. AIS subscales showed moderate to high correlations with convergent and low correlations with discriminant measures. AIS total scores were significantly larger in the clinical sample, controlled for gender and age. LIMITATIONS: This study provides a unified cross-validation model in a clinical and a student sample at the cost of reduced sample sizes. CONCLUSIONS: The AIS is a valid measure of affect intolerance with the discriminative ability to distinguish between patients with trauma-related disorders and students. Test redundancy within both sub-constructs of the AIS might lead to biased estimates but allows for increased test precision, rendering the AIS a tool suitable for individual treatment monitoring.