[Influence of guideline recommendations, care structures and individual factors on the use of psychosocial therapies in severely mentally ill people]. / Einfluss von Leitlinienempfehlungen, Versorgungsstrukturen und individuellen Faktoren auf die Inanspruchnahme von psychosozialen Therapien bei schwer psychisch kranken Menschen.

OBJECTIVE: The influence of guideline recommendations and other factors on the utilization of psychosocial interventions in people with severe mental illness was examined. METHODS: Data from a cross-sectional study of 397 people with severe mental illness were analysed descriptively. RESULTS: Patients are less likely to receive therapies with a strong recommendation compared to other levels of recommendation. Various other factors are diffusely associated with utilization rates, but no ubiquitous predictors could be identified across all therapies. CONCLUSION: Current practice in the use of psychosocial interventions does not follow guideline recommendation strength. Interventions with strong recommendations are probably not available across services. Consequently, routine practice is not able to follow guideline recommendations according to their strength. Other consistent predictors could not be identified.

Moderators and mediators of effects of interventions to reduce stress in hospital employees: A systematic review.

This systematic review examines moderators and mediators tested in evaluations of stress management interventions for hospital employees to determine their significance for intervention outcomes. To be included, studies had to comprise a moderator or mediator analysis and a quantitative assessment of stress or mental well-being, and to be published in English or German language. Five databases (APA PsycInfo, APA PsycArticles, Embase, Medline, and Web of Science) were searched. Moderators and mediators were categorised thematically and examined using effect direction plots. Study quality was assessed using RoB 2 and ROBINS-I. In fifteen included studies, 22 moderators and ten mediators were identified. Moderators and mediators were categorised into individual psychological factors (14), socio-economic status (6), work situation (5), intervention (3), and duration of employment (3). Two moderators (perceived stressfulness of residency, job control) had a positive, two a negative impact (spirituality, socially desirable responding). One moderator (years of professional experience) had a positive and negative impact. Three moderators measured on categorical scales (gender, profession, and shiftwork) also had effects, favouring women, physicians and night-shift employees. Five mediators (adherence to intervention, mindfulness, non-reactivity to inner experience, total observing, and self-compassion) had a positive impact, while three (isolation, over-identification, psychological inflexibility) had a negative impact. In conclusion, effects of interventions were predominantly driven by individual psychological factors, while the role of other variables seems to be limited. Interventions focussing on primary or tertiary prevention were rare. Also processes through which organisational-level interventions can be most effective have been hardly investigated. Larger and methodologically robust studies are needed to better understand causal pathways and optimise matching of interventions to target groups.

Does the peer-led Honest, Open, Proud program reduce stigma's impact for everyone? An individual participant data meta-regression analysis.

PURPOSE: Many people with mental illness experience self-stigma and stigma-related stress and struggle with decisions whether to disclose their condition to others. The peer-led Honest, Open, Proud (HOP) group program supports them in their disclosure decisions. In randomized controlled trials, HOP has shown positive effects on self-stigma and stigma stress on average. This study examined individual predictors of HOP outcomes and tested the hypothesis that stigma stress reduction at the end of HOP mediates positive HOP effects at follow-up. METHODS: Six RCTs were included with data at baseline, post (after the HOP program) and at 3- or 4-week follow-up. Baseline variables were entered in meta-regression models to predict change in self-stigma, stigma stress, depressive symptoms and quality of life among HOP participants. Mediation models examined change in stigma stress (post) as a mediator of HOP effects on self-stigma, depressive symptoms, and quality of life at follow-up. RESULTS: More shame at baseline, and for some outcomes reduced empowerment, predicted reduced HOP effects on stigma stress, self-stigma, depressive symptoms, and quality of life. Younger age was related to greater improvements in stigma stress after the HOP program. Stigma stress reductions at the end of HOP mediated positive effects on self-stigma, depressive symptoms and quality of life at follow-up. CONCLUSION: Participants who are initially less burdened by shame may benefit more from HOP. Stigma stress reduction could be a key mechanism of change that mediates effects on more distal outcomes. Implications for the further development of HOP are discussed.

[Patient Preferences for Exercise Therapy in People with Severe Mental Illness in Germany]. / Der subjektive Stellenwert von Bewegungs- und Sporttherapie bei Menschen mit schwerer psychischer Erkrankung in Deutschland.

PURPOSE: Assessing the experience with and the attitudes towards exercise therapy in persons with severe mental illness (SMI). Furthermore, potential variables of high preference towards exercise therapy are investigated. METHODS: Cross-sectional observational study of SMI patients aged between 18 and 65 years (n=385). Patients were interviewed by trained staff using standardised instruments. Potential variables were analysed using a hierarchic binary logistic regression model. RESULTS: 84,4% of SMI patients had a high preference for exercise therapy; of these, 44,1% exercised regularly. Among patients with severe mental illness especially a higher value in the GAF-assessment (p=0,041) and living in a metropolitan area (p=0,011) predict a high preference for exercise therapy. CONCLUSION: Most of the patients with severe mental illness interviewed in this study place a surprisingly high value on sports and exercise therapy. Due to the increasing evidence with regard to positive effects of these therapies, it may be an excellent starting point to expand sports and exercise therapy as part of a comprehensive treatment plan. At the same time, strategies for everyday transfer need to be implemented more rigorously.

Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey.

Importance: The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear. Objective: To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey. Design, Setting, and Participants: This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group. Interventions: The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees. Main Outcomes and Measures: The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021. Results: Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone. Conclusions and Relevance: This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.

The role of migration in mental healthcare: treatment satisfaction and utilization.

Migration rates increase globally and require an adaption of national mental health services to the needs of persons with migration background. Therefore, we aimed to identify differences between persons with and without migratory background regarding (1) treatment satisfaction, (2) needed and received mental healthcare and (3) utilization of mental healthcare.In the context of a cross-sectional multicenter study, inpatients and day hospital patients of psychiatric settings in Southern Germany with severe affective and non-affective psychoses were included. Patients' satisfaction with and their use of mental healthcare services were assessed by VSSS-54 and CSSRI-EU; patients' needs were measured via CAN-EU.In total, 387 participants (migratory background: n = 72; 19%) provided sufficient responses for analyses. Migrant patients were more satisfied with the overall treatment in the past year compared to non-migrant patients. No differences between both groups were identified in met and unmet treatment needs and use of supply services (psychiatric, psychotherapeutic, and psychosocial treatment).Despite a comparable degree of met and unmet treatment needs and mental health service use among migrants and non-migrants, patients with migration background showed higher overall treatment satisfaction compared to non-migrants. The role of sociocultural and migrant-related factors may explain our findings.

Predictors of competitive employment in individuals with severe mental illness: results from an observational, cross-sectional study in Germany.

BACKGROUND: Employment is of great importance as it is associated with various positive effects. Individuals with severe mental illness (SMI) are often excluded from competitive employment. Current data on employment of individuals with mental illness are rare, and influencing factors are under-researched. The present study examines possible predictors of competitive employment among individuals with SMI. METHODS: This was a cross-sectional and multicentered study of 300 individuals with SMI aged 18 to 65 years. The following inclusion criteria were used: (I) diagnosis of schizophrenia, schizotypal and delusional disorders (ICD-10 F2x), or affective disorders (ICD-10 F3x), (II) duration of psychiatric illness ≥ 2 years, and (III) substantial impact of illness on social functioning. Participants were interviewed by trained staff using standardised instruments. The relationship between potential predictors (age, sex, education, marital status, living situation, migration background, psychosocial functioning, age at first mental problem, physical illness, work ability) and employment was analysed using a hierarchic binary logistic regression model. RESULTS: Only one-third (34%) of participants were competitively employed. Almost one-third were unemployed (30%), and 28% reported early retirement due to mental illness. Psychosocial functioning was positively associated with competitive employment (OR = 1.09, 95% CI: 1.05 - 1.13, p < 0.001); concurrent chronic physical illness was negatively associated with competitive employment (OR = 0.38, 95% CI: 0.21 - 0.71, p = 0.002). CONCLUSIONS: Findings confirm a high risk of exclusion from competitive employment among individuals with SMI. Nonetheless, a substantial proportion of individuals are employed. Findings call for efforts to maintain or enhance workforce participation among individuals with SMI. A special focus should be placed on improving physical health and strengthening psychosocial functioning. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register (DRKS) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

[Peer Support: Utilization and Benefit in Severe Mental Illness - Results from an Observational, Cross-Sectional Study]. / Genesungsbegleitung: Inanspruchnahme und Nutzenbewertung aus Betroffenenperspektive ­ Ergebnisse einer Beobachtungsstudie.

OBJECTIVE: Peer support is playing an increasing role in the treatment of severely mentally ill people. International findings are available on its effectiveness. However, little is known about knowledge, use and benefit assessment in Germany. This paper addresses this question and presents results from an observational study with 10 participating clinics in southern Germany. METHODS: As part of the observational cross-sectional study with people with severe mental illness (IMPPETUS, N=359), sociodemographic and illness- and treatment-associated data were collected by trained study staff between March 2019 and September 2019. Binary logistic regression was used to analyse a possible association with peer support use. RESULTS: 38% (N=138) of respondents reported knowledge about the possibility of peer support; 15% (N=55) affirmed its use. Use of peer support varied across sites (between 6.5 and 37.5%) and was associated with household income. Significantly less frequent use of peer support was among those with high versus low household income (OR=0.20 [95% CI: 0.06-0.68], p=0.01). Of respondents with peer support use (N=55), 78% reported perceiving peer support to be helpful or highly helpful. DISCUSSION: Peer support not only proves to be effective under study conditions with regard to various outcomes, but is also assessed as beneficial under routine conditions in a defined care region by the majority of users. However, only a few respondents knew and used the possibility of peer support. CONCLUSION: In order to implement peer support more strongly, information about this kind of service should be provided more effectively and a dialogue about successful implementation experiences should be initiated on a regional level.

Employment status and desire for work in severe mental illness: results from an observational, cross-sectional study.

PURPOSE: People with a severe mental illness (SMI) are at particular risk of occupational exclusion. Among the approaches to occupational rehabilitation, supported employment (SE) has been proven to be the most effective. A requirement to enter SE-programs is that individuals must want to seek competitive employment. The aim of this work is to investigate the relationship between serious mental illness and the desire to work including potential predictors. METHODS: This is a cross-sectional observational study of patients with SMI aged 18-65 years (n = 397). Patients were interviewed by trained staff using standardised instruments. The relationship between potential predictors and a strong preference for employment were analysed using a hierarchic binary logistic regression model. RESULTS: Only about one-quarter (27.9%) of SMI patients is in competitive employment. Another quarter is unemployed (25.9%). Results show that the desire for competitive employment is strong among more than half of the SMI patients. Among the unemployed, two-thirds express a strong desire for work. These individuals are an ideal target group for SE interventions. Comorbid chronic physical illness, diagnosis, and the subjectively judged ability to work are associated with the desire for work. CONCLUSION: Our data confirm a substantial exclusion of individuals with SMI from the workforce. In general, care needs for workplace interventions are not being met and leave much room for improvement. In addition to employment status, the desire for work should be routinely assessed. STUDY REGISTRATION: The study was registered in the German Clinical Trials Register (DRKS) ( https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015801 ) and under the WHO-Platform "International Clinical Trials Registry Platform" (ICTRP) ( https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00015801 ) under the registration number DRKS00015801 before the start of recruitment (Registration date: 21.02.2019).

Honest, Open, Proud to support disclosure decisions and to decrease stigma's impact among people with mental illness: conceptual review and meta-analysis of program efficacy.

PURPOSE: Honest, Open, Proud (HOP; formerly "Coming Out Proud"/COP) is a peer-led group program to support people with mental illness in their disclosure decisions and in their coping with stigma. The aims of this study were to provide (i) a conceptual review of HOP, including versions for different target groups and issues related to outcome measurement and implementation; and (ii) a meta-analysis of program efficacy. METHODS: Conceptual and empirical literature on disclosure and the HOP program was reviewed. Controlled trials of HOP/COP were searched in literature databases. A meta-analysis of HOP efficacy in terms of key outcomes was conducted. RESULTS: HOP program adaptations for different target groups (e.g. parents of children with mental illness; veterans or active soldiers with mental illness) exist and await evaluation. Recruitment for trials and program implementation may be challenging. A meta-analysis of five HOP RCTs for adults or adolescents with mental illness or adult survivors of suicide attempts found significant positive effects on stigma stress (smd = - 0.50) as well as smaller, statistically non-significant effects on self-stigma (smd = - 0.17) and depression (smd = - 0.11) at the end of the HOP program. At 3- to 4-week follow-up, there was a modest, not statistically significant effect on stigma stress (smd = - 0.40, 95%-CI -0.83 to 0.04), while effects for self-stigma were small and significant (smd = - 0.24). Long-term effects of the HOP program are unknown. CONCLUSION: There is initial evidence that HOP effectively supports people with mental illness in their disclosure decisions and in their coping with stigma. Implementation issues, future developments and public health implications are discussed.

Systematic evaluation of the 'efficacy-effectiveness gap' in the treatment of depression with venlafaxine and duloxetine.

OBJECTIVE: Evidence of larger drug effects in highly standardized studies (efficacy) compared to clinical routine (effectiveness) is discussed as efficacy-effectiveness gap. This study aimed to quantify effect size differences of RCTs and non-RCTs in the treatment of depression with venlafaxine and duloxetine and to identify effect modifying predictors. METHODS: A comprehensive systematic review and meta-analysis was conducted, including all prospective trials, which evaluated the treatment effects of duloxetine or venlafaxine in patients with depression. The primary outcome was the pre-post effect size after acute therapy, which were compared between RCTs and non-RCTs. Moreover, an exploratory analysis of predictors in a mixed meta-regression model within an information-theoretic approach was performed. RESULTS: 171 RCTs and 74 non-RCTs were included. The pre-post effect size differed significantly between RCTs and non-RCTs (-3.04 vs. -2.62, Δ = 0.41, p = 0.012, high heterogeneity). Study characteristics were very similar between RCTs and non-RCTs. Most important variables to predict effect sizes were 'depression severity', 'dose' and 'number of participants'. CONCLUSION: Despite differences in effect sizes between RCTs and non-RCTs, study design is not clearly an important predictor for the effect sizes. Our results question the common assumption that non-RCTs are generally better suited to describe a drug's effectiveness in clinical practice than RCTs. Future studies and their reporting should put more emphasis on the description of external validity, in order to allow better assessments of clinical relevance.

Multifactorial barriers in the implementation of schizophrenia and psychosocial therapies guidelines: A quantitative study across different professions.

BACKGROUND: Clinical guidelines can facilitate the transfer of scientific evidence into clinical practice, yet their implementation still faces difficulties. The aim of this study was to examine the implementation status of the current German evidence- and consensus-based guidelines for schizophrenia (2019) and psychosocial therapies (2019) and to identify barriers as well as facilitators in guideline adherence. METHODS: We used a quantitative approach by developing an online questionnaire, focusing on the current implementation status as well as barriers and facilitators in guideline adherence. The questionnaire was sent to 100 hospitals for psychiatry and psychosomatics and 52 professional associations in mental healthcare in Germany (investigation period: 10/2019-01/2020). RESULTS: In total, 657 mental healthcare professionals (MHCP, e.g. medical doctors, psychologists, psychosocial therapists, caregivers) provided sufficient responses for analyses. Less than half (47%) of our participants were aware of the existence of the guideline for psychosocial therapies, while 74% exhibited awareness of the schizophrenia guideline. A minority reported to adhere to the current guidelines for schizophrenia (41%) and psychosocial interventions (18%). Profession-related differences in the implementation-status were detected. Specifically, medical doctors exhibited higher awareness rates than psychosocial therapists and caregivers and additionally higher adherence rates than psychologists and caregivers. Medical doctors were less exposed to knowledge-related barriers (e.g. lack of guideline familiarity), while no differences across professions were found in external/behavior-related barriers (e.g. long versions). DISCUSSION AND CONCLUSION: Our findings indicate that the implementation of guidelines as well as related barriers vary between professions. To prevent a growing gap in guideline adherence between MHCP, target-specific implementation strategies should be considered.

Development and implementation of guidelines for the management of depression: a systematic review.

OBJECTIVE: To evaluate the development and implementation of clinical practice guidelines for the management of depression globally. METHODS: We conducted a systematic review of existing guidelines for the management of depression in adults with major depressive or bipolar disorder. For each identified guideline, we assessed compliance with measures of guideline development quality (such as transparency in guideline development processes and funding, multidisciplinary author group composition, systematic review of comparative efficacy research) and implementation (such as quality indicators). We compared guidelines from low- and middle-income countries with those from high-income countries. FINDINGS: We identified 82 national and 13 international clinical practice guidelines from 83 countries in 27 languages. Guideline development processes and funding sources were explicitly specified in a smaller proportion of guidelines from low- and middle-income countries (8/29; 28%) relative to high-income countries (35/58; 60%). Fewer guidelines (2/29; 7%) from low- and middle-income countries, relative to high-income countries (22/58; 38%), were authored by a multidisciplinary development group. A systematic review of comparative effectiveness was conducted in 31% (9/29) of low- and middle-income country guidelines versus 71% (41/58) of high-income country guidelines. Only 10% (3/29) of low- and middle-income country and 19% (11/58) of high-income country guidelines described plans to assess quality indicators or recommendation adherence. CONCLUSION: Globally, guideline implementation is inadequately planned, reported and measured. Narrowing disparities in the development and implementation of guidelines in low- and middle-income countries is a priority. Future guidelines should present strategies to implement recommendations and measure feasibility, cost-effectiveness and impact on health outcomes.

Implementation of the patient version of the evidence-based (S3) guideline for psychosocial interventions for patients with severe mental illness (IMPPETUS): study protocol for a cluster randomised controlled trial.

BACKGROUND: The German guideline on psychosocial interventions for people with severe mental disorders recommends a broad spectrum of evidence-based treatments. Structured implementation of the associated patient version of the guideline is missing to date. The study aims to assess whether structured implementation of a patient guideline improves the empowerment of patients with severe mental disorders, as well as knowledge, attitudes and experiences regarding psychosocial interventions, service use, treatment satisfaction, treatment needs, quality of life and burden of care. METHODS: The study is a multicentre, cluster-randomised, controlled study with two parallel groups. Inpatients and day hospital patients (all sexes; 18-65 years) with severe mental disorders will be included. Additionally, relatives of patients with mental disorders (all sexes; ≥ 18 years) will be included. In the experimental group, the patient guideline will be implemented using a multimodal strategy. Participants in the control group will receive treatment as usual but will be made aware of the patient guideline. The primary outcome is the change of empowerment, assessed by using the 'empowerment in the process of psychiatric treatment of patients with affective and schizophrenia disorders' (EPAS) scale. In addition, knowledge, attitudes and experiences regarding psychosocial interventions will be assessed as secondary outcomes, as well as service use, satisfaction with care, patient need and quality of life and participation and social inclusion. For relatives, the perceived burden of care also will be recorded. Results will be analysed using hierarchical linear models. For the health economic evaluation, the incremental cost-utility ratios will be computed using the differences in total costs of illness and the differences in quality-adjusted life years (QALY) between study groups. DISCUSSION: The study will be the first to assess the effects of a structured implementation of the patient version of a psychiatric treatment guideline. The study has some limitations regarding the transferability of the results to other patients and other regions. Furthermore, problems with the recruitment of patients and relatives and with the implementation of intervention could occur during the study. TRIAL REGISTRATION: The study is registered in the German Clinical Trials Register (DRKS) and the WHO International Clinical Trials Registry Platform (ICTRP) under registration number DRKS00017577 (Date of registration: 23 October 2019.

Parental military deployment as risk factor for children's mental health: a meta-analytical review.

There is evidence that military service increases the risk of psychosocial burden for not only service members but also their spouses and children. This meta-analysis aimed to systematically assess the association between military deployment of (at least one) parent and impact on children's mental health. For this meta-analytic review, publications were systematically searched and assessed for eligibility based on predefined inclusion criteria (studies between 2001 until 2017 involving children with at least one parent working in military services). Measurements were determined by total problem scores of the children as well as symptoms of anxiety/depression, hyperactivity/inattention, and aggressive behavior. Meta-analyses aggregated the effect sizes in random-effect models and were calculated separately for the relation between parental deployment and civilian/normative data and for the relation between parental deployment and non-deployment. Age of the children was used as moderator variable to explore any potential source of heterogeneity between studies. Parental military deployment was associated with problems in children and adolescents compared to civilian/normative samples. Significant effect sizes reached from small to moderate values; the largest effect sizes were found for overall problems and specifically for anxious/depressive symptoms and aggressive behavior. Within the military group, children of deployed parents showed more problem behavior than children of non-deployed parents, but effect sizes were small. Age of the children had no moderating effect. The results emphasize that children of military members, especially with a deployed parent, should be assessed for emotional and behavioral problems.

Effectiveness of interventions to promote help-seeking for mental health problems: systematic review and meta-analysis.

Help-seeking is important to access appropriate care and improve mental health. However, individuals often delay or avoid seeking help for mental health problems. Interventions to improve help-seeking have been developed, but their effectiveness is unclear. A systematic review and meta-analysis were therefore conducted to examine the effectiveness of mental health related help-seeking interventions. Nine databases in English, German and Chinese were searched for randomised and non-randomised controlled trials. Effect sizes were calculated for attitudes, intentions and behaviours to seek formal, informal and self-help. Ninety-eight studies with 69 208 participants were included. Interventions yielded significant short-term benefits in terms of formal help-seeking, self-help, as well as mental health literacy and personal stigma. There were also positive long-term effects on formal help-seeking behaviours. The most common intervention types were strategies to increase mental health literacy, destigmatisation (both had positive short-term effects on formal help-seeking behaviours) as well as motivational enhancement (with positive long-term effects on formal help-seeking behaviours). Interventions improved formal help-seeking behaviours if delivered to people with or at risk of mental health problems, but not among children, adolescents or the general public. There was no evidence that interventions increased the use of informal help. Few studies were conducted in low- and middle-income countries (LMICs). This study provides evidence for the effectiveness of help-seeking interventions in terms of improving attitudes, intentions and behaviours to seek formal help for mental health problems among adults. Future research should develop effective interventions to improve informal help-seeking, for specific target groups and in LMICs settings.

Challenging mental health related stigma in China: Systematic review and meta-analysis. II. Interventions among people with mental illness.

People with mental illness often face different types of mental illness stigma that may affect their lives, including perceived stigma, self-stigma, harmful coping strategies and poor quality of life. Although anti-stigma interventions for people with mental illness from Western countries have been identified by recent systematic reviews, their efficacy in China is unknown. This review evaluates the efficacy of anti-stigma interventions among people with mental illness in Mainland China, Hong Kong, Taiwan and Macau. A systematic search of 8 electronic databases in English and Chinese yielded 17 randomized and non-randomized controlled trials. Standardized mean differences (SMDs) were calculated wherever possible. Psychoeducation was the most commonly used intervention. SMDs were large and significant for perceived/experienced/anticipated stigma, self-prejudice and coping with stigma, as well as for depression and anxiety symptoms and quality of life. Both Cognitive Behavioral Therapy and psychoeducation had positive effects on perceived/experienced/anticipated stigma. The quality of studies was modest and heterogeneity across studies was high. Anti-stigma interventions demonstrated promise to reduce stigma's negative impact on people with mental illness in China, but more high-quality intervention research is needed.

Challenging mental health related stigma in China: Systematic review and meta-analysis. I. Interventions among the general public.

Mental illness stigma is widely endorsed by the general public in China. Evidence-based anti-stigma interventions to reduce public stigma are needed. However, most studies on the efficacy of anti-stigma interventions took place in Western countries and existing Chinese studies were often not included in recent systematic reviews. This review evaluates the efficacy of anti-stigma interventions among the general population in Mainland China, Hong Kong, Taiwan and Macau. Eight databases in English and Chinese were searched for randomized and non-randomized controlled trials. Subgroup analyses compared interventions with and without consumer contact. Standardized mean differences were calculated from eligible studies where possible. We included 9 trials involving 2041 participants. Interventions yielded a small effect on stereotypes reduction and a similar effect on improving mental health literacy. No study assessed discrimination outcomes. Interventions with consumer contact were not superior to those without. There were insufficient data on medium and long term effects. Heterogeneity across studies was moderate. Quality of studies was modest. Further research using rigorous methods is required.

[Quality Indicators for Integrated Care in Patients with Schizophrenia - Results from a Feasibility Study]. / Qualitätsindikatoren für die Behandlung von Menschen mit Schizophrenie ­ Ergebnisse einer Anwendungsstudie.

Objective The study aimed to evaluate the applicability of a set of quality indicators to assess models of integrated care for patients with a diagnosis of schizophrenia. We report first values for these indicators in routine care in Germany. Methods The study is based on a cohort of adult patients with schizophrenia insured by one large German statutory health insurance company, which were assessed two times and gave consent to evaluate their routine claims data. The study tried to use 12 basic and 22 quality indicators from claims data. Results It was possible to estimate most structural indicators using available data, but only half of the quality indicators. This means that while assessment of quality indicators is feasible in general, routine claims data needs to be supplemented by additional (primary) data. Four of the calculated quality indicators had clear targets or red-flag values, which were not met in our cohort in all four indicators. None of the patients had an outpatient mental health related contact within one week (target > 90 %). The readmission rate within 30 days (21 %) was twice as high as the proposed red-flag value of 10 %. Similar figures were seen for antipsychotic polypharmacy (25 %, red-flag value > 10 %) and the proportion of patients with compulsory treatment (15 %) exceeded the red-flag value by 5 %. Conclusion The study shows that it is possible to measure quality indicators, but also demonstrates considerable limitations. There is a need to validate indicators in routine care.