Efficacy of bifocal diagnosis-independent group psychoeducation in severe psychiatric disorders: results from a randomized controlled trial

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

Objective

The authors sought to identify scalable evidence-based suicide prevention strategies.

Methods

A search of PubMed and Google Scholar identi- fied 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

Results

Training primary care physicians in depression rec- ognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active out- reach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are under-studied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

Conclusions

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physi- cian settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.Reprinted from Am J Psychiatry 2021; 178:611-624, with permission from American Psychiatric Association Publishing. Copyright © 2021.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

OBJECTIVE

The authors sought to identify scalable evidence-based suicide prevention strategies.

METHODS

A search of PubMed and Google Scholar identified 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

RESULTS

Training primary care physicians in depression recognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are understudied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

CONCLUSIONS

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physician settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.

Measurement of unnecessary psychiatric readmissions in the context of care transition interventions: a scoping review

OBJECTIVE

The objective of this study was to examine how published studies of inpatient to outpatient mental healthcare transition processes have approached measuring unnecessary psychiatric readmissions.

DESIGN

Scoping review using Levac et al's enhancement to Arksey and O'Malley's framework for conducting scoping reviews.

DATA SOURCES

Medline (Ovid), Embase (Ovid), PsycINFO, CINAHL, Cochrane and ISI Web of Science article databases were searched from 1 January 2009 through 28 February 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that (1) are about care transition processes associated with unnecessary psychiatric readmissions and (2) specify use of at least one readmission time interval (ie, the time period since previous discharge from inpatient care, within which a hospitalisation can be considered a readmission).

DATA EXTRACTION AND SYNTHESIS

We assessed review findings through tabular and content analyses of the data extracted from included articles.

RESULTS

Our database search yielded 3478 unique articles, 67 of which were included in our scoping review. The included articles varied widely in their reported readmission time intervals used. They provided limited details regarding which readmissions they considered unnecessary and which risks they accounted for in their measurement. There were no perceptible trends in associations between the variation in these findings and the included studies' characteristics (eg, target population, type of care transition intervention).

CONCLUSIONS

The limited specification with which studies report their approach to unnecessary psychiatric readmissions measurement is a noteworthy gap identified by this scoping review, and one that can hinder both the replicability of conducted studies and adaptations of study methods by future investigations. Recommendations stemming from this review include (1) establishing a framework for reporting the measurement approach, (2) devising enhanced guidelines regarding which approaches to use in which circumstances and (3) examining how sensitive research findings are to the choice of the approach.

Scoping review protocol on non-pharmacological interventions for interpersonal and self-directed violence in adults with severe mental illness

INTRODUCTION

Violence committed by people with mental illness has implications for mental health policy and clinical practice. Several strategies to reduce the risk of aggressive and violent behaviour have been proposed, and these include non-pharmacological interventions. There is, however, a need to identify which of these interventions are effective, and as a first step, we will conduct a scoping review to identify non-pharmacological interventions for self-directed or interpersonal violence in adults with severe mental illness across different conditions and settings.

METHODS AND ANALYSIS

This is a scoping review protocol. The review will include any randomised controlled trials (RCTs) and cluster RCTs that assess the efficacy of interventions on self-directed or interpersonal violence with no restrictions on the control treatment in people with severe mental illness in any setting. No restrictions will be applied in terms of language or date of publication. To identify studies, a search will be performed in the following databases: Embase, MEDLINE (via PubMed), PsycINFO, CINAHL, LILACS, SciELO, Cochrane Library, Web of Science, Scopus, ProQuest, Epistemonikos and databases of clinical trials. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement will be followed for reporting the findings, including the use of a PRISMA flow diagram. A standardised form will be used to extract data from studies. The findings will be classified using conceptual categories that will be specified in detail and a descriptive summary of the main results will be created. Moreover, it will be assessed whether the studies identified have been included in systematic reviews or meta-analyses and the results will be used to generate a conceptual map.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. We will prepare a manuscript for publication in a peer-reviewed journal and the results will be presented at mental health conferences.

The challenge of well-being and quality of life: A meta-analysis of psychological interventions in schizophrenia

Well-being is a critical outcome in the recovery from psychosis and the prevention of symptoms. Previous reviews of the effectiveness of psychological interventions have focused on psychotic symptoms and general psychopathology, not recognising well-being as an essential outcome. This study conducted a meta-analysis of the effects of psychological interventions on the well-being and quality of life (QoL) of people with schizophrenia and analysed some critical moderating factors. A systematic literature search was conducted yielding 12986 published reports, 2043 of which were clinical trials. After a detailed review, 36 articles were included in the analyses. Measures of related concepts, well-being and quality of life were included in the present meta-analysis to reflect the current state of the literature and to ensure the representativeness of RCTs that have evaluated the effect of psychological interventions on the extent to which people with schizophrenia experience a good life. Our findings reflect a significant, small, treatment effect on the outcomes of well-being. Subgroup analysis also suggested a significant moderating effect when the primary aim of the intervention was well-being. These findings suggest that symptom or functional improvement does not necessarily lead to an improvement in well-being and would imply the need to focus specifically on those. We recommend psychological interventions that target well-being as a complementary strategy in mental health promotion and treatment. In addition, we stress the need to include well-being outcome measure in RCT as well as to clearly identify the different domains of well-being being measured.

Parkinson's disease psychosis: therapy tips and the importance of communication between neurologists and psychiatrists

Parkinson's disease (PD) is a chronic and complex neurodegenerative disorder resulting in a mixture of motor and nonmotor symptoms. Psychosis develops in around 60% of PD patients during and can be one of the most challenging nonmotor symptoms. PD psychosis is considered the single greatest precipitant for nursing home placement. PD psychosis is an independent predictor of increased mortality, and there is no 'ideal' or universal treatment strategy. The treatment approach to PD psychosis should be tailored and individualized for each patient. In this review, we will discuss PD psychosis and provide practical treatment considerations for neurologists, psychiatrists and other healthcare professionals. We stress the importance of real-time communication between members of the healthcare team.

Frequency and relevance of psychoeducation in psychiatric diagnoses: results of two surveys five years apart in German-speaking European countries

BACKGROUND

Psychoeducation has been shown to reduce relapse rates in several psychiatric disorders. Studies investigating for which psychiatric diagnoses psychoeducation is offered and assessing its perceived relevance compared to other interventions are lacking.

METHODS

A two-part questionnaire addressing these questions was sent to the heads of all psychiatric hospitals in Germany, Austria and Switzerland. Results were compared with those from a similar survey 5 years earlier.

RESULTS

289 of 500 (58%) institutions responded. Significantly (p = 0,02) more institutions (93%) offer any type of psychoeducation as compared to 5 years before (86%). Psychoeducation is mainly offered for schizophrenia (86%) and depression (67%) and less frequently for anxiety disorders (18%) and substance abuse (17%). For the following specific diagnoses it is offered by less than 10% of the institutions: Personality disorder, bipolar disorder, posttraumatic stress disorder, dementia, obsessive compulsive disorder, sleeping disorders, eating disorders, schizophrenia plus substance abuse, pain, attention deficit hyperactivity disorder and early psychosis. 25% offer diagnosis-unspecific psychoeducation. 'Pharmacotherapy' (99%), 'basic occupational therapy' (95%) and 'psychoeducation for patients' (93%) were the therapies being most often, 'light therapy' (24%) and 'sleep deprivation' (16%) the therapies being least often perceived as relevant by the respondents when asked about the value of different interventions offered in their hospitals. Art therapy (61%) and psychoanalytically oriented psychotherapy (59%), two therapies with a smaller evidence base than light therapy or sleep deprivation, were perceived as relevant by more than the half of the respondents.

CONCLUSION

Psychoeducation for patients is considered relevant and offered frequently in German-speaking countries, however, mostly only for schizophrenia and depression. The ranking of the perceived relevance of different treatment options suggests that the evidence base is not considered crucial for determining their relevance.

Psychoeducation for schizophrenia

BACKGROUND

Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' knowledge of, and insight into, their illness and its treatment. It is supposed that this increased knowledge and insight will enable people with schizophrenia to cope in a more effective way with their illness, thereby improving prognosis.

OBJECTIVES

To assess the effects of psychoeducational interventions compared with standard levels of knowledge provision.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (February 2010).

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducation for schizophrenia and/or related serious mental illnesses involving individuals or groups. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. We used a fixed-effects model for heterogeneous dichotomous data. Where possible we also calculated the numbers needed to treat (NNT), as well as weighted means for continuous data.

MAIN RESULTS

This review includes a total of 5142 participants (mostly inpatients) from 44 trials conducted between 1988 and 2009 (median study duration ˜ 12 weeks, risk of bias - moderate). We found that incidences of non-compliance were lower in the psychoeducation group in the short term (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16). This finding holds for the medium and long term. Relapse appeared to be lower in psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14) and this also applied to readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Scale-derived data also suggested that psychoeducation promotes better social and global functioning. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. Evidence suggests that participants receiving psychoeducation are more likely to be satisfied with mental health services (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8) and have improved quality of life.

AUTHORS' CONCLUSIONS

Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach.

Psychoeducation for schizophrenia

BACKGROUND

Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' knowledge of, and insight into, their illness and its treatment. It is supposed that this increased knowledge and insight will enable people with schizophrenia to cope in a more effective way with their illness, thereby improving prognosis.

OBJECTIVES

To assess the effects of psychoeducational interventions compared with standard levels of knowledge provision.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (February 2010).

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducation for schizophrenia and/or related serious mental illnesses involving individuals or groups. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. We used a fixed-effects model for heterogeneous dichotomous data. Where possible we also calculated the numbers needed to treat (NNT), as well as weighted means for continuous data.

MAIN RESULTS

This review includes a total of 5142 participants (mostly inpatients) from 44 trials conducted between 1988 and 2009 (median study duration ˜ 12 weeks, risk of bias - moderate). We found that incidences of non-compliance were lower in the psychoeducation group in the short term (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16). This finding holds for the medium and long term. Relapse appeared to be lower in psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14) and this also applied to readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Scale-derived data also suggested that psychoeducation promotes better social and global functioning. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. Evidence suggests that participants receiving psychoeducation are more likely to be satisfied with mental health services (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8) and have improved quality of life.

AUTHORS' CONCLUSIONS

Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach.