Filicides lead to questions about motives and missed opportunities for prevention. The development of preventive strategies is difficult due to heterogeneous perpetrator-victim dynamics. Eighteen child killings by parents over a period of 10 consecutive years in the catchment area of Dusseldorf’s Institute of Legal Medicine were identified, and the autopsy reports and prosecution files were analysed. With regard to motives and psychodynamics, a heterogeneous group of perpetrators were identified; the perpetrators were responsible for 8 accidental filicides, 3 killings of unwanted children, 1 killing during perpetrator psychosis, 1 spousal revenge killing and 5 homicide-suicides. Except for the homicide-suicides, overburdening seemed to be the main risk factor for the killings. Preventive measures are difficult to establish. They should focus on awareness campaigns and increasing or establishing multi-professional support for affected families.

Quality indicators (QI) are becoming increasingly important in mental healthcare in Germany. QI can be used for various purposes, such as for creating transparency as well as for benchmarking between hospitals. QI themselves are subject to high quality standards. The aim of this report is to describe the development and implementation of QI in a group of psychiatric hospitals. Since 2015, the LVR hospital group has developed and gradually implemented QI for the purposes of quality measurement, quality assurance and internal benchmarking in its nine psychiatric hospitals in a comprehensive, multidisciplinary, scientifically accompanied process. The full LVR-QI set, consisting of eight structure-, twelve process- and four outcome indicators as well as one patient satisfaction questionnaire, was implemented by 2019. In order to create high documentation quality and acceptance by clinicians, various implementation and dissemination strategies were used, such as written documentation manuals, staff training as well as regular face-to-face communication between the LVR hospitals, the LVR Institute for Health Services Research as the central coordinating body and the headquarters of the LVR hospital group. The QI led to a quality-oriented dialogue within and between the LVR hospitals.

BACKGROUND:There is limited knowledge of whether cognitive-behavioral therapy (CBT) or second-generation antipsychotics (SGAs) should be recommended as the first-line treatment in individuals at clinical high risk for psychosis (CHRp). HYPOTHESIS:To examine whether individual treatment arms are superior to placebo and whether CBT is non-inferior to SGAs in preventing psychosis over 12 months of treatment. STUDY DESIGN:PREVENT was a blinded, 3-armed, randomized controlled trial comparing CBT to clinical management plus aripiprazole (CM + ARI) or plus placebo (CM + PLC) at 11 CHRp services. The primary outcome was transition to psychosis at 12 months. Analyses were by intention-to-treat. STUDY RESULTS:Two hundred eighty CHRp individuals were randomized: 129 in CBT, 96 in CM + ARI, and 55 in CM + PLC. In week 52, 21 patients in CBT, 19 in CM + ARI, and 7 in CM + PLC had transitioned to psychosis, with no significant differences between treatment arms (P = .342). Psychopathology and psychosocial functioning levels improved in all treatment arms, with no significant differences. CONCLUSIONS:The analysis of the primary outcome transition to psychosis at 12 months and secondary outcomes symptoms and functioning did not demonstrate significant advantages of the active treatments over placebo. The conclusion is that within this trial, neither low-dose aripiprazole nor CBT offered additional benefits over clinical management and placebo.

Background. The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.Methods. We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.Results. We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.Conclusions. Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

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

Dry eye disease (DED) is a multifactorial disease of the ocular surface that leads to symptoms of discomfort and reduces quality of life. Several studies have shown an association with depression. We investigated the prevalence of depressive symptoms and their severity in DED patients and examined whether depressive symptoms correlate with signs, symptoms, or subtypes of DED or with psychological factors (resilience, premorbid personality, and subjective well-being).

The objective of the study was to evaluate an operational integrated care model (IC) aiming at optimized treatment of depression. It consisted of cooperation between a company and an external clinic with respect to early recognition of the disorder, early access to treatment and support for return to work. Method: A retrospective group comparison of patients with depression receiving IC in a psychiatric outpatient clinic (N=64) and a control group with standard care in the same clinic (N=64) was performed. Primary outcome was return to work. Results: Patients of the IC group returned to work significantly more often (Odds Ratio 11.9; p<0.001) and 91.2 days earlier (p=0.010) than those of the group that received standard care. Conclusion: Specific measures of an IC program might accelerate the process of return to work.

ZusammenfassungZiel der Arbeit war die Evaluation eines betriebsnahen integrierten Versorgungsmodells (IGV) zur Optimierung der Behandlung depressiver Störungen. Es handelte sich um eine Kooperation zwischen einem Betrieb und einer externen Versorgungseinrichtung mit dem Ziel der Früherkennung, einem frühen Behandlungszugang sowie der Unterstützung bei der Rückkehr zur Arbeit. Methode: IGV-Patienten mit Depressionen (N=64) wurden mit einer parallelisierten Kontrollgruppe der Regelversorgung (N=64) retrospektiv verglichen. Die Evaluation erfolgte primär anhand der Messung der Rückkehr zur Arbeit. Ergebnisse: Patienten der IGV kehrten häufiger (Odds Ratio 11.9; p<0,001) und 91,2 Tage früher (p=0,010) an den Arbeitsplatz zurück als Patienten aus der Regelversorgung. Schlussfolgerung: Betriebsnahe IGV-Maßnahmen könnten die Zeit bis zur Wiederaufnahme der Arbeit verkürzen.

AIM:Psychological interventions, such as cognitive behavioural therapy (CBT) and supportive counselling (SC), are used to treat people with schizophrenia and people at clinical high risk (CHR) of psychosis. However, little information is available on predictors of treatment response. This study aims to identify such predictors of psychological interventions in CHR.METHODS:A total of 128 help-seeking CHR outpatients were randomized into two groups-integrated psychological intervention (IPI), including CBT, and SC-for 12 months. Multiple regression analysis was used to identify demographic, symptomatic and functional variables that predict improvement in positive (PANSS Positive), negative (PANSS Negative) and basic symptoms (Basic symptom total score) and improvement in functioning (GAF) at 1-year follow up.RESULTS:In the merged group (IPI + SC), people who lived independently, were younger and presented with higher baseline functioning showed more improvement in symptomatic outcomes at follow up. Negative symptoms at baseline predicted less improvement in positive and basic symptoms. Being married or cohabiting and living in the primary family were found to correlate with good functioning at 1-year follow up.CONCLUSIONS:Younger CHR individuals and those who are functioning well may particularly benefit from early intervention. Treatment might need to be modified for low-functioning CHR and those who already display higher scores of negative symptoms. Registration number: NCT00204087.

Für die Messung der Behandlungsqualität psychisch Kranker in Deutschland wurden bereits verschiedene Qualitätsindikatoren-Sets vorgeschlagen und in vereinzelten psychiatrischen Einrichtungen pilotiert. Die Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN) befasst sich in einer „Task Force Qualitätsindikatoren (QI)“ mit der Weiterentwicklung und praktischen Umsetzung von Qualitätsindikatoren für Schizophrenie.

Background: Although there are encouraging results from clinical trials focusing on second generation antipsychotics, omega-3-fatty acids or psychotherapy for the prevention of psychosis, their empirical evidence remains uncertain and it is unknown whether these interventions are comparable in reducing the risk of conversion to psychosis in persons at clinical high risk (CHR). Therefore, the present multicenter, prospective, randomized, blinded trial with three parallel groups (PREVENT) was designed to explore the differential preventive efficacy of two approaches 1. cognitive behavioral therapy (CBT) and 2. Aripiprazole (ARI) + clinical management (CM) to 3. placebo (PL) + CM. Methods: Individuals aged 18–49 identified as CHR by Ultra-High-Risk and/or basic symptoms COGDIS criteria were assessed at baseline, 28 and 52 weeks. The primary outcome was progression to psychosis including transition to psychosis or conversion from early initial prodromal state (defined by COGDIS or decline of functioning in combination with family risk factors or schizotypal disorder) to late initial prodromal state (defined by the presence of attenuated positive symptoms or brief limited intermittent psychotic symptoms). Secondary outcome was transition to psychosis. Results: Of 611 eligible individuals 280 were randomized. The Full analysis set comprised 216 individuals [mean age 24.4 (5.1) years; about 66 % male]. In terms of the primary outcome, there was a clinical relevant difference between the three treatment arms (CBT: 19.2 %; AR+CM: 26.8 %; PL+CM: 30.0 %), but no statistical difference (P > .05). Pairwise comparisons showed a statistical trend in favor of CBT compared with CM + PL. With respect to the secondary outcome, there was a reduction in favor of CBT compared to CM + ARI also on a statistical trend level. Drop-out rates differed between the arms over time (P < .05), with indications for more premature terminations in ARI + CM and PL + CM compared to CBT. Conclusion: Pairwise comparisons showed a clinically relevant reduction regarding the primary (about 30%) and secondary outcome (about 40%) in favor of CBT. Lower drop-out rates in CBT could be interpreted as higher adherence and acceptance of psychotherapy within this trial.

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

BackgroundThe objective of this study is to test the conflicting theories concerning the association of negative self and other schemata and paranoid ideation.MethodsA risk‐based approach, including risk stratification, is used to gain insight into the association of the negative self and other schemata that may be shared by individuals or differentiate between individuals at clinical high risk (CHR) for a first‐episode psychosis and those with full‐blown psychosis. The dataset includes a sample of individuals at CHR (n = 137) and a sample of individuals with persisting positive symptoms (PPS, n = 211). The CHR sample was subdivided according to a prognostic index yielding 4 CHR sub‐classes with increasing risk for transition to psychosis.ResultsNegative beliefs about the self were associated with paranoid ideation in CHR and a lower risk state. In the highest risk state and full‐blown psychosis, there is an association with negative beliefs about others.ConclusionThese findings are in line with theories suggesting a switch from a predominantly activated negative self‐schema to a malevolent others‐schema in association with paranoid ideation along the risk‐continuum. However, due to methodological limitations these results should be replicated by future studies.

In Germany, several quality indicators have been proposed for the measurement of quality of mental healthcare. Some of these quality indicators have been tested in feasibility studies. The German Association for Psychiatry and Psychotherapy (DGPPN) established the "Task Force Quality Indicators (QI)" that, based on previous experience in the development and pilot testing of indicators, considered the further development and practical realization of QI for schizophrenia. The aim was to select a set of QI for schizophrenia that can also be applied to other diagnoses or used in generic measurements. Another goal was to focus on high feasibility of indicators. In a multistage selection process, the DGPPN Task Force selected QI that focus on essential quality aspects from an inventory of 161 existing QI developed by national and international research groups. Indicators were adapted in consultation with the "trialogic forum" of the DGPPN. The DGPPN proposes the following ten indicators for quality measurement in mental healthcare for schizophrenia: QI1 Long-term treatment/Monitoring of side effects, QI2 Seclusion and restraint, QI3 Number of suicides, QI4 Psychoeducational-oriented intervention for significant others, QI5 Timely beginning of outpatient treatment after discharge from inpatient treatment, QI6 Aggression management - inpatient treatment, QI7 Diagnostic procedures/Physical examination, QI8 Antipsychotic polypharmacy, QI9 Rehabilitation/Vocational rehabilitation, QI10 Diagnostic procedures/Psychosocial functioning. Most of our proposed QI have to be measured by means of additional data documentation. Based on prior experience in the pilot testing of QI, the DGPPN estimates that the additional efforts in data documentation would be manageable, but have to be refinanced. The indicators will be tested in feasibility studies in different mental healthcare hospitals in Germany.

Metabolic Syndrome (MetS) is one of the most common factors underlying the high rate of mortality observed in patients with schizophrenia. Recent research on this topic revealed that many of the patients studied were, in fact, in a medicated state. As such, it is unclear whether MetS is causally associated with the disorder itself or the medication used to treat it. In this study, patients with a clinically high risk of expressing first episode psychosis (CHR) were examined regarding the prevalence of MetS. N=144 unmedicated and antipsychotic-naïve CHR patients, aged between 18 and 42years and suffering from unmanifested prodromal symptoms, were compared with a cohort of N=3995 individuals from the "German Metabolic and Cardiovascular Risk Study" (GEMCAS). A slightly higher prevalence of individual MetS criteria was observed in the CHR group compared to the GEMCAS sample; specifically, the following were noted: a higher blood pressure (35.0% vs. 28.0%), increased waist circumference (17.6% vs. 15.1%), and increased fasting blood glucose (9.4% vs. 4.0%) in CHR patients. Additionally, the rate of reduced HDL cholesterol concentrations was lower in the control group (20.2% vs. 13.3%).

psychotherapeutische Diagnostik, Behandlung und Versorgung ein relativ neues Verfahren dar. Grundlage des Benchmarking-Ansatzes ist es, relevante Dimensionen des Behandlungsprozesses und der Ergebnisbewertung mittels Kennzahlen oder Indikatorenzuerfassenunddamiteinerstatistischen Auswertung und Analyse zuganglich zu machen. Die Indikatoren bilden eine Grundlage fur den Vergleich unterschiedlicher Einrichtungen mit dem Ziel, „gute Praxis“ zu identifizieren und einem Erfahrungstransfer zuganglich zu machen.