[Who Benefits from the App? Internet- and Mobile-Based Interventions (IMIs) and the Tension between Autonomy and Patient Well-Being]. / Wem nützt die App? Internet- und mobilgestützte Interventionen (IMIs) im Spannungsfeld von Autonomie und Patientenwohl.

OBJECTIVE: The use of internet- and mobile-based interventions (IMIs) is often considered as empowerment of patients and improvement of accessibility of mental health services. Risks for specific patient groups are seldom discussed. Aim of the study is to identify patient groups that do not benefit from IMIs given the tension between autonomy and patient well-being. METHODS: The ethical analysis is based on available empirical evidence (randomized control trials - RCTs, reviews) as well as ethical papers. Methodological background is the tension between patient autonomy and patient well-being, which is crucial to the therapeutic alliance. On this foundation, patient groups are identified that do not benefit from IMIs in terms of empowerment or accessibility. RESULTS: The evidence-based ethical analysis shows that patients with certain disorders or high symptom severity, patients with low level of education or a lack of technical skills, and patients with a migrant background do often not benefit from IMIs. Risks of IMIs are a lack of individualization of interventions given individual treatment needs, symptom deterioration, higher dropout-rate, and insufficient identification of emergency situations. DISCUSSION: Overemphasizing autonomy may compromize patient well-being in certain patient groups. This may lead to a situation where those patient groups whose inclusion into mental health service should be facilitated by IMIs might not be reached. These access barriers should be considered when designing IMIs, so that multimorbid marginalized groups are not forgotten in the necessary digitalization of the health market. CONCLUSION: The application of IMIs depends on the individual resources of the patient. Should IMIs be further implemented within the German mental healthcare system, it is imperative that the patient well-being of those patient groups that do not benefit from IMIs is guaranteed. In addition, an early focus on marginalized groups may and the implementation of low-level access to counselling and treatment may provide chances for said groups.

Evaluation of a new person-centered integrated care model in psychiatry.

The present study evaluated a new integrated treatment concept offering inpatient care, acute psychiatric day hospital and outpatient treatment by the same therapeutic team. 178 patients participated in this randomized controlled trial. Data on psychopathology, global and social functioning, patient satisfaction, continuity of care and administrative data was gathered on admission, throughout the course of treatment, upon discharge and at 1-year follow-up. In addition, the physicians in charge rated the therapeutic relationship. The data analysis consists of group-wise comparisons and regression analyses (cross-tabulations and χ(2) test statistics for categorical data and Mann-Whitney U tests for continuous data). Differences between groups over time were analyzed with a series of generalized linear mixed model. The integrated care group showed a significant reduction in psychopathological impairment (20.7%) and an improvement of psychosocial functioning (36.8%). The mean number of days before re-admission was higher in the control group when compared to the integrated care group (156.8 vs. 91.5). There was no difference in the number of re-admissions and days spent in psychiatric institutions. This new approach offers a treatment model, which facilitates continuity of care. Beside it improves psychopathological outcome measures and psychosocial functioning in patients with mental illness.

High-Order Language Processing Difficulties in Patients With Schizophrenia: Cross-linguistic and Cross-cultural Results From the Hindi Version of a Newly Developed Language Test.

Objective: To detect subtle linguistic performance deficits in patients with schizophrenia, a test battery was developed in Hindi vernacular language. Method: It was a replication study of observational, analytical, and case-control design. Total of 86 participants, namely 43 patients with schizophrenia and 43 controls, were recruited into the study. The patients were evaluated by using PANSS (positive and negative symptoms scale for schizophrenia) for recruitment into the study. Participants from the general population were evaluated with GHQ-12 (General Health Questionnaire-12) to be found to fit as healthy controls. Subsequently, the linguistic performance of patients (on HLFT: Hindi linguistic function test) was compared with that of controls. The HLFT battery was designed, containing 3 blocks by using antonyms, synonyms, homonyms, hyperonyms, hyponyms, distractors, and adages. Result: Patients scored significantly less than that of controls in identifying antonyms, distractors, and hyponyms while in identifying homonyms they scored significantly more than that of controls. At block I (antonyms) score of 15.5; at homonym score of 5.5; at hyponym (as in hyponym plus distractor combination) score of 2.5, the sensitivity and specificity for using them as a cutoff to screen for schizophrenia are 60.5% and 67.4%; 86% and 41.9%; 81.4% and 46.5%, respectively. Conclusion: Ambiguity processing of taxonomic representation such as antonymia, homonymia, hypo-/hyperonymia, synonymia, and also understanding of adages might be significantly impaired in patients with schizophrenia. The HLFT battery could be used as a quick and sensitive instrument to detect and quantify the linguistic difficulties of patients with schizophrenia.

Informal coercion in acute inpatient setting--knowledge and attitudes held by mental health professionals.

This pilot study aimed at investigating how mental health professionals on acute psychiatric wards recognize different levels of formal and informal coercions and treatment pressures as well as their attitude towards these interventions. An explorative cross-sectional survey among mental health professionals (N=39) was conducted using a questionnaire that consisted of 15 vignettes describing typical clinical situations on five different stages of the continuum of coercion. Low levels of coercion are recognized adequately while higher levels are grossly underestimated. The degree of coercion inherent to interventions comprising persuasion and leverage was underestimated by professionals with a positive attitude and overestimated by those with a negative attitude towards the respective interventions. No associations of the ability to recognize different levels of coercion with ward or staff related variables were found. Higher knowledge on ambiguous variations of coercive interventions seems to foster more balanced reflections about their ethical implications. Advanced understanding of influencing factors of professionals׳ attitudes towards coercion could lead to improved training of professionals in utilizing interventions to enhance treatment adherence in an informed and ethical way.

The processing of lexical ambiguity in healthy ageing and Parkinson׳s disease: role of cortico-subcortical networks.

Previous neuroimaging studies showed that correct resolution of lexical ambiguity relies on the integrity of prefrontal and inferior parietal cortices. Whereas prefrontal brain areas were associated with executive control over semantic selection, inferior parietal areas were linked with access to modality-independent representations of semantic memory. Yet insufficiently understood is the contribution of subcortical structures in ambiguity processing. Patients with disturbed basal ganglia function such as Parkinson׳s disease (PD) showed development of discourse comprehension deficits evoked by lexical ambiguity. To further investigate the engagement of cortico-subcortical networks functional Magnetic Resonance Imaging (fMRI) was monitored during ambiguity resolution in eight early PD patients without dementia and 14 age- and education-matched controls. Participants were required to relate meanings to a lexically ambiguous target (homonym). Each stimulus consisted of two words arranged on top of a screen, which had to be attributed to a homonym at the bottom. Brain activity was found in bilateral inferior parietal (BA 39), right middle temporal (BA 21/22), left middle frontal (BA 10) and bilateral inferior frontal areas (BA 45/46). Extent and amplitude of activity in the angular gyrus changed depending on semantic association strength that varied between conditions. Less activity in the left caudate was associated with semantic integration deficits in PD. The results of the present study suggest a relationship between subtle language deficits and early stages of basal ganglia dysfunction. Uncovering impairments in ambiguity resolution may be of future use in the neuropsychological assessment of non-motor deficits in PD.

High order linguistic features such as ambiguity processing as relevant diagnostic markers for schizophrenia.

Due to the deficits of schizophrenic patients regarding the understanding of vague meanings (D. Ketteler and S. Ketteler (2010)) we develop a special test battery called HOLF (high order linguistic function test), which should be able to detect subtle linguistic performance deficits in schizophrenic patients. HOLF was presented to 40 schizophrenic patients and controls, focussing on linguistic features such as ambiguity, synonymy, hypero-/hyponymy, antinomy, and adages. Using the HOLF test battery we found that schizophrenic patients showed significant difficulties in discriminating ambiguities, hypero- and hyponymy, or synonymy compared to healthy controls. Antonyms and adages showed less significant results in comparing both groups. The more difficult a linguistic task was, the more confusion was measured in the schizophrenic group while healthy controls did not show significant problems in processing high order language tasks.

[Evaluation of the German version of the STAR scale]. / "Scale to Assess Therapeutic Relationships, STAR": Evaluation der deutschen Skalenversion zur Beurteilung der therapeutischen Beziehung.

OBJECTIVE: The assessment of the therapeutic relationship has become increasingly important due to evidence suggesting that it has a direct therapeutic effect and may improve outcome indirectly. In Great Britain and Sweden the STAR (Scale To Assess Therapeutic Relationship) was developed for pan-theoretical assessment of therapeutic relationships from both clinicians' and patients' points of view. We translated the English version of the instrument into German and made an analysis of its feasibility and reliability. METHODS: The German translation (STAR-D) was generated in a consensus procedure. The STAR-D was then administered to 100 patients admitted to the Psychiatric University Hospital Zurich (STAR-P) and their clinicians in charge (STAR-C). The psychometric qualities of feasibility and reliability were assessed. RESULTS: The overall results for the scales in terms of feasibility and reliability were satisfactory. We did, however, find shortcomings concerning the subscales. They could not be extracted in the principal component analysis and showed high inter-correlation coefficients. CONCLUSIONS: STAR can serve as an important tool in research concerning the therapeutic relationship. We suggest conducting further analyses concerning the validity of the subscales in the German version.

Functional magnetic resonance imaging of tics and tic suppression in Gilles de la Tourette syndrome.

Tics are defined as involuntary, quick, sudden, and stereotypical movements or phonic productions. Despite the fact that tic suppression plays an important role for the patient's ability to cope with tic disorders, investigations of the underlying neural correlates using functional imaging focused on tic generation rather than tic suppression. We examined a patient with Gilles de la Tourette syndrome with regard to neural mechanisms of tic generation and tic suppression using fMRI. Three different conditions were compared: "tics", "tics suppressed", and "tics imitated". The comparisons of "tics" to tics suppressed" and of "tics" to "tics imitated" showed similar activation in the anterior cingulate cortex. This leads to distinct suggestions concerning the neural network involved in tic suppression. Similar mechanisms may be involved in tic suppression via mental efforts or active movements.

The subcortical role of language processing. High level linguistic features such as ambiguity-resolution and the human brain; an fMRI study.

In the present study, we were interested in the neurofunctional representations of ambiguity processing by using functional magnetic resonance imaging (fMRI). Twelve right-handed, healthy adults aged between 21 and 29 years (6 male, 6 female) underwent an ambiguity resolution task with 4 different conditions (dominant vs. non-dominant; dominant vs. distractor; non-dominant vs. distractor; distractor vs. distractor). After subtraction of the corresponding control task (distractor vs. distractor) we found significant activation especially in the thalamus and some parts of the basal ganglia (caudate nucleus, putamen). Our findings implicate a participation of the thalamus and other basal ganglia circuits in high level linguistic functions and match with theoretical considerations on this highly controversial topic. Subcortical neural circuits probably become activated when the language processing system cannot rely entirely on automatic mechanisms but has to recruit controlled processes as well. Furthermore, we found broad activation in the inferior parietal lobule, the prefrontal gyrus, pre-SMA and SMA and the cingulate cortex. This might reflect a strategic semantic search mechanism which probably can be illustrated with connectionist models of language processing. According to this, we hypothesize a neuroregulatory role for the thalamus and basal ganglia in regulating and monitoring the release of preformulated language segments for motor programming and semantic verification. According to our findings there is strong evidence, that especially the thalamus, the caudate nucleus, the cingulate cortex, the inferior parietal lobule and the prefrontal cortex are responsible for an accurate ambiguity resolution in the human brain.