This research evaluates the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) as add-on therapy to standard care for adults with schizophrenia from an Australian health system perspective.

A Markov model estimated costs in 2021 Australian dollars and Disability-Adjusted Life-Years (DALYs) averted with rTMS added to standard care compared to standard care alone over 12-months for adults aged 25–65 years with hallucinations in schizophrenia refractory to other therapies. rTMS effect size was sourced from a meta-analysis and converted to a relative risk using the Cochrane conversion method. Probabilistic sensitivity analysis evaluated uncertainty in effect size and disability weights. One-way sensitivity analyses varied rTMS session cost and effectiveness, time horizon and inpatient costs.

The base-case average incremental cost-effectiveness ratio (ICER) was $87,310/DALY averted (95% UI: $10,157–$97,877). Reducing rTMS session cost to $100 lowered the ICER to $9,127/DALY (95% UI: Dominant–$50,699). A 4-year time horizon resulted in rTMS being less costly and more effective (Dominant) than standard care. Decreasing the 3-month probability of relapse with rTMS to 4.6% resulted in a 71% probability of rTMS being cost-effective.

Using a threshold of $50,000/ DALY averted, rTMS as add-on therapy to standard care for the treatment of refractory hallucinations in schizophrenia would not be considered a cost-effective treatment option compared to standard care alone. However, given the refractory nature of this condition and the relatively small size of this population, it may be reasonable for decision-makers to adopt a higher ICER threshold.

The salutary effect of window views on greenery for inpatients in hospitals on length of stay and recovery rate has been repeatedly shown, however, not for psychiatric inpatients. The study assessed the association between a window view on green trees or man-made objects and brightness of the room on length of stay in a sample of psychiatric inpatients from one clinic.

Data records of 244 psychiatric inpatients (mean age in years 41.8; SD = 11.8; 59.8% female, length of stay varying between 7 and 100 days) that were admitted between May 2013 and October 2018 with affective disorders were examined. Window view was assessed with images taken from each room and classified into showing man-made objects or green trees. The percentage of green within each image was also calculated as greenness of the view. Brightness was assessed with a luxmeter.

Although no effect was found for the dichotomous measures (man-made objects vs. green trees), a suppression effect emerged for percentage of green and brightness. The results indicate that both greenness of the window view as well as brightness significantly reduce length of stay in psychiatric inpatients with affective disorders.

The suppression effect likely results from the characteristics of the windows; the greenest rooms also being the darkest. Due to the infrastructure of the ward, greenness and brightness came at the expense of each other. The results generally support the importance of a view into greenery and natural sunlight for recovery.

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown.

A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses.

Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538–£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538–£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold.

Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

Despite multiple ethical issues and little evidence of their efficacy, compulsory admission and treatment are still common psychiatric practice. Therefore, we aimed to assess potential differences in treatment and outcome between voluntarily and compulsorily admitted patients.

We extracted clinical data from inpatients treated in an academic hospital in Zurich, Switzerland between January 1, 2013 and December 31, 2019. Observation time started upon the first admission and ended after a one-year follow-up after the last discharge. Several sociodemographic and clinical characteristics, including Health of the Nation Outcome Scales (HoNOS) scores, were retrospectively obtained. We then identified risk factors of compulsory admission using logistic regression in order to perform a widely balanced propensity score matching. Altogether, we compared 4,570 compulsorily and 4,570 voluntarily admitted propensity score-matched patients. Multiple differences between these groups concerning received treatment, coercive measures, clinical parameters, and service use outcomes were detected.

Upon discharge, compulsorily admitted patients reached a similar HoNOS sum score in a significantly shorter duration of treatment. They were more often admitted for crisis interventions, were prescribed less pharmacologic treatment, and received fewer therapies. During the follow-up, voluntarily admitted patients were readmitted more often, while the time to readmission did not differ.

Under narrowly set circumstances, compulsory admissions might be helpful to avert and relieve exacerbations of severe psychiatric disorders.

The aim of this pooled analysis was to evaluate the efficacy and safety of lurasidone in the treatment of an acute exacerbation of schizophrenia in adolescents and young adults.

The six pooled studies in this analysis used similar study designs and outcome measures. Patients (aged 13–25 years) were randomized to 6 weeks of double-blind, placebo-controlled treatment with lurasidone in fixed doses of 40, 80, 120, or 160 mg. The primary efficacy endpoint was Week 6 change in the Positive and Negative Syndrome Scale (PANSS) total score; secondary efficacy endpoints included Week 6 change in the Clinical Global Impression–Severity scale.

The safety population consisted of 537 patients (mean age: 18.1 years); 82.6% of patients completed the studies. Treatment with lurasidone was significantly better than placebo at all doses (p < 0.001) for change in the PANSS total score at Week 6. Placebo-adjusted PANSS scores ranged from −9.4 to −16.1 (effect sizes: 0.53–0.90), with effect sizes increasing at higher doses. For lurasidone (combined doses), three adverse events occurred with a frequency of ≥5% (nausea: 13.5%; somnolence: 12.1%; akathisia: 10.1%). At last observation carried forward (LOCF)-endpoint weight gain of ≥7% was similar for lurasidone versus placebo (3.6 vs. 4.7%). Minimal median changes were observed at endpoint in cholesterol, −2.0 mg/dL; triglycerides, 0.0 mg/dL; and glucose, 0.0 mg/dL.

In adolescents and young adults with schizophrenia, treatment with lurasidone in doses of 40–160 mg/d was a safe, well-tolerated, and effective treatment. Short-term treatment with lurasidone was associated with minimal effects on weight and metabolic parameters.

People suffering from schizophrenia cannot easily access employment in European countries. Different types of vocational programs coexist in France: supported employment, sheltered employment (ShE), and hybrid vocational programs. It is now acknowledged that the frequent cognitive impairments constitute a major obstacle to employment for people with schizophrenia. However, cognitive remediation (CR) is an evidence-based nonpharmacological treatment for these neurocognitive deficits.

RemedRehab was a multicentric randomized comparative open trial in parallel groups conducted in eight centers in France between 2013 and 2018. Participants were recruited into ShE firms before their insertion in employment (preparation phase). They were randomly assigned to cognitive training Cognitive Remediation for Schizophrenia (RECOS) or Treatment As Usual (TAU). The aim of the study was to compare with the benefits of the RECOS program on access to employment and work attendance for people with schizophrenia, measured by the ratio: number of hours worked on number of hours stipulated in the contract.

Seventy-nine patients were included in the study between October 2018 and September 2019. Fifty-three patients completed the study. Hours worked / planned hours equal to 1 or greater than 1 were significantly higher in the RECOS group than in the TAU group.

Participants benefited from a RECOS individualized CR program allows a better rate of work attendance in ShE, compared to the ones benefited from TAU. Traditional vocational rehabilitation enhanced with individualized CR in a population of patients with schizophrenia is efficient on work attendance during the first months of work integration.

Many interventions to reduce the use of seclusion and restraint have been suggested in the last decades. Evidence-based interventions in old age psychiatry are different from those in general psychiatry. A common database for psychiatric hospitals introduced in 2004 allowed to examine the use of seclusion and restraint over 16 years under routine conditions.

A registry for coercive measures in the Federal State of Baden-Wuerttemberg has been available since 2015, and comprises all 32 hospitals licensed to admit involuntary patients. A study group had collected data prospectively since 2004 from a subsample of these hospitals. We analyzed the mean percentage of patients subjected to coercive measures and the mean cumulative duration of these interventions in ICD-10 diagnostic groups in psychiatric hospitals from 2004 to 2019 among a total of 1,038,239 admissions.

The proportion of cases affected by coercive measures dropped significantly from 28.4 to 10.5% in patients with ICD-10 F0 disorders, while rates in patients with other diagnoses decreased insignificantly from 7.0 to 5.4%. The cumulated duration of coercive measures per affected case also dropped significantly among patients with F0 disorders, while changes in patients with other diagnoses remained insiginficant.

The use of coercive measures in patients with organic disorders could be reduced by about 50% in a State of 11 million inhabitants within 15 years, while in contrast no substantial reduction occurred among all other diagnostic groups. Specific interventions to reduce coercive interventions seem to be particularly successful for this patient group.

People living with serious mental illness (SMI) experience debilitating symptoms that worsen their physical health and quality of life. Regular physical activity (PA) may bring symptomatic improvements and enhance wellbeing. When undertaken in community-based group settings, PA may yield additional benefits such as reduced isolation. Initiating PA can be difficult for people with SMI, so PA engagement is commonly low. Designing acceptable and effective PA programs requires a better understanding of the lived experiences of PA initiation among people with SMI.

This systematic review of qualitative studies used the meta-ethnography approach by Noblit and Hare (1988). Electronic databases were searched from inception to November 2017. Eligible studies used qualitative methodology; involved adults (≥18 years) with schizophrenia, bipolar affective disorder, major depressive disorder, or psychosis; reported community-based group PA; and captured the experience of PA initiation, including key features of social support. Study selection and quality assessment were performed by four reviewers.

Sixteen studies were included in the review. We identified a “journey” that depicted a long sequence of phases involved in initiating PA. The journey demonstrated the thought processes, expectations, barriers, and support needs of people with SMI. In particular, social support from a trusted source played an important role in getting people to the activity, both physically and emotionally.

The journey illustrated that initiation of PA for people with SMI is a long complex transition. This complex process needs to be understood before ongoing participation in PA can be addressed. Registration—The review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) on 22/03/2017 (registration number CRD42017059948).

In line with previous findings, in a recent randomized controlled trial (RCT), we found that home treatment (HT) for acute mental health care can reduce (substitute) hospital use among severely ill patients in crises. This study examined whether the findings of the RCT generalize to HT services provided under routine care conditions.

We compared patients who received HT during the RCT study phase with patients who received the same HT service after it had become part of routine mental health services in the same catchment area. Sociodemographic and clinical characteristics as well as service use (HT and hospital bed days) were compared between the RCT and the subsequent routine care study period.

Compared to patients who received HT during the RCT, routine care HT patients were more often living with others, less often admitted compulsorily, more often diagnosed with anxiety and stress-related disorders (ICD-10 F4) and less often diagnosed with schizophrenia spectrum disorders (F2). When compared to patients who were exclusively treated on hospital wards, involvement of the HT team in patients’ care was associated with a clear-cut reduction of hospital bed days both during the RCT and under routine care conditions. However, unlike during the RCT study period, involvement of HT was associated with longer overall treatment episodes (inpatient + HT days) under routine care conditions.

HT seems to reduce the use of hospital bed days even under routine care conditions but is at risk of producing longer overall acute treatment episodes.

The present study aimed at answering three research questions: (a) Does shared decision making (SDM) yield similar effects for patients with involuntary admission or incidents of aggression compared to patients with voluntary admission or without incidents of aggression? (b) Does SDM reduce the number of patients with incidents of aggression and the use of coercive measures? (c) Does the use of coercion have a negative impact on patients’ perceived involvement in decision making?

We used data from the cluster-randomized SDM-PLUS trial in which patients with schizophrenia or schizoaffective disorder in 12 acute psychiatric wards of 4 German psychiatric hospitals either received an SDM-intervention or treatment as usual. In addition, data on aggression and coercive measures were retrospectively obtained from patients’ records.

The analysis included n = 305 inpatients. Patient aggression as well as coercive measures mostly took place in the first days of the inpatient stay and were seldom during the study phase of the SDM-PLUS trial.

Patients who had been admitted involuntarily or showed incidents of aggression profited similarly from the intervention with regard to perceived involvement, adherence, and treatment satisfaction compared to patients admitted voluntarily or without incidents of aggression. The intervention showed no effect on patient aggression and coercive measures. Having previously experienced coercive measures did not predict patients’ rating of perceived involvement.

Further research should focus on SDM-interventions taking place in the very first days of inpatients treatment and potential beneficial long effects of participatory approaches that may not be measurable during the current inpatient stay.

Healthcare services are increasingly confronted with challenges related to old age mental disorders. The survey aimed to provide an overview of existing psychogeriatric services in Albania, Bulgaria, Greece, and North Macedonia.

After identification of psychogeriatric units across the four countries, their head physicians were asked to provide data on their clinical, teaching, and research activity, as well as staff composition. Moreover, the attitudes of head physicians to current needs and future service development were explored.

A total of 15 psychogeriatric units were identified (3 in Bulgaria, 8 in Greece, and 4 in North Macedonia). Results show wide variation regarding the location, team size and composition, service availability, numbers of patients attending, and inpatient treatment length. Most head physicians underscored the urgent need for breakthroughs in the graduate and postgraduate education in psychogeriatrics of medical and nonmedical professionals, as well as in the interconnection of their units with community primary healthcare services and long-term care facilities for seniors via telemedicine. They would welcome the development of national standards for psychogeriatric units, potentially embodying clear pointers for action. A number of head physicians advocated the development of nationwide old age mental health registries.

Regional disparities in resources and services for seniors’ mental health services were unveiled. These data may enrich the dialogue on optimizing psychogeriatric services through planning future cross-border collaborations mainly based on telemedicine services, especially in the era of the novel coronavirus pandemic, and training/education in psychogeriatrics of mental health professionals.

Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care.

The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions.

We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures.

We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

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.

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.

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.

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.

Clients and therapists often have different perspectives on their therapeutic alliance (TA), affecting the process and outcome of therapy. The aim of the present meta-analysis was to assess the mean differences between clients’ and therapists’ estimations of TA among clients with severe disturbances, while focusing on two potential moderators: client diagnosis and alliance instrument.

We conducted a systematic literature search of studies examining both client perspective and therapist perspective on TA in psychotherapy among people with schizophrenia spectrum disorders, personality disorders, and substance misuse disorders. We then analyzed the data using a random-effects meta-analytic model with Cohen’s d standardized mean effect size.

Heterogeneity analyses (k = 22, Cohen’s d = −.46, 95% confidence interval = .31–1.1) produced a significant Q-statistic (Q = 94.96) and indicated high heterogeneity, suggesting that moderator analyses were appropriate.

Our findings show that the type of TA instrument moderates the agreement on TA between client and therapist, but there was no indication of the client’s diagnosis moderating the effect. The agreement between client and therapist estimations seems to be dependent on the instrument that is used to assess TA. Specific setting-related instruments seem to result in higher agreement between clients’ and therapists’ estimations than do more general instruments that are applied to assess TA.

Patients with severe mental illness, including schizophrenia, may be legally mandated to undergo psychiatric treatment. Patients’ experiences in these situations are not well characterized. This systematic review of qualitative studies aims to describe the experiences of patients with schizophrenia and related disorders who have undergone legally mandated treatment.

Four bibliographic databases were searched: CINAHL Plus (1981–2019), EMBASE (1947–2019), MEDLINE (1946–2019), and PsycINFO (1806–2019). These databases were searched for keywords, text words, and medical subject headings related to schizophrenia, legally mandated treatment and patient experience. The reference lists of included studies and systematic reviews were also investigated. The identified titles and abstracts were reviewed for study inclusion. A thematic analysis was completed for the synthesis of positive and negative aspects of legally mandated treatment.

A total of 4,008 citations were identified. Eighteen studies were included in the final synthesis. For the thematic analysis, results were collated under two broad themes; positive patient experiences and negative patient experiences. Patients were satisfied when their autonomy was respected, and dissatisfied when it was not. Patients often retrospectively recognized that their treatment was beneficial. Furthermore, negative aspects of the treatment included deficits in communication and a lack of information.

Intervention research has historically focused on clinical outcomes and the quantitative aspects of treatment. Thus, this study provides insight into the qualitative aspects of patients’ experiences with legally mandated treatment. Recognizing these opinions and experiences can lead to better attitudes toward treatment for patients with schizophrenia and related psychiatric illnesses.

While polypharmacy is common in long-term residential psychiatric patients, prescription combinations may, from an evidence-based perspective, be irrational. Potentially, many psychiatric patients are treated on the basis of a poor diagnosis. We therefore evaluated the DITSMI model (i.e., Diagnose, Indicate, and Treat Severe Mental Illness), an intervention that involves diagnosis (or re-diagnosis) and appropriate treatment for severely mentally ill long-term residential psychiatric patients. Our main objective was to determine whether DITSMI affected changes over time regarding diagnoses, pharmacological treatment, psychosocial functioning, and bed utilization.

DITSMI was implemented in a consecutive patient sample of 94 long-term residential psychiatric patients during a longitudinal cohort study without a control group. The cohort was followed for three calendar years. Data were extracted from electronic medical charts. As well as diagnoses, medication use and current mental status, we assessed psychosocial functioning using the Health of the Nations Outcome Scale (HoNOS). Bed utilization was assessed according to length of stay (LOS). Change was analyzed by comparing proportions of these data and testing them with chi-square calculations. We compared the numbers of diagnoses and medication changes, the proportions of HoNOS scores below cut-off, and the proportions of LOS before and after provision of the protocol.

Implementation of the DITSMI model was followed by different diagnoses in 49% of patients, different medication in 67%, some improvement in psychosocial functioning, and a 40% decrease in bed utilization.

Our results suggest that DITSMI can be recommended as an appropriate care for all long-term residential psychiatric patients.

The Bulgarian Ministry of Health invited the European Psychiatric Association (EPA) to evaluate Bulgarian mental health care service provision in 2018. Bulgarian mental health services face very significant challenges including a legacy of historic underfunding, internal conflicts, poor planning, and the emigration of very high numbers of younger skilled staff that had followed accession to the European Union. There were significant disputes between stakeholders regarding the way forward and had been at least two unsuccessful previous external agency interventions that had attempted to find solutions.

This EPA position paper describes in detail the EPA mission to Bulgaria including methodology, findings, recommendations, and finally the positive actions and changes that are now underway as a result of the EPA report and intervention aimed at contributing towards improving Bulgarian mental health services.

After meetings with multiple stakeholders in the Bulgarian mental health system and analysis of data on service delivery, workforce, funding and configuration the EPA Panel agreed a list of twenty recommendations for change.

The EPA mission, with the collaboration of multiple stakeholders in Bulgaria, was successful in stimulating high level government action to improve mental health services. Despite longstanding differences, it was possible to involve the stakeholders in constructive dialogue. The importance of “speaking with one voice” was a key lesson learned.

Functional capacity (FC) has been identified as a key outcome to improve real-world functioning in schizophrenia. FC is influenced by cognitive impairments, negative symptoms, self-stigma and reduced physical activity (PA). Psychosocial interventions targeting FC are still under-developed.

we conducted a quasi-experimental study evaluating the effects of an exercise-enriched integrated social cognitive remediation (SCR) intervention (RemedRugby [RR]) compared with an active control group practicing Touch Rugby (TR). To our knowledge, this is the first trial to date evaluating the effectiveness of such a program provided in a real-life environment.

Eighty-seven people with schizophrenia were included and allocated to either the RR group (n = 57) or the TR group (n = 30) according to the routine clinical practice of the recruiting center. Outcomes were evaluated at baseline and post-treatment in both groups and after 6 months of follow-up in the RR group using standardized scales for symptom severity, social functioning, self-stigma, and a large cognitive battery. After treatment we observed moderate to large improvements in social function (Personal and Social Performance Scale [PSP], p < 0.001, d = 1.255), symptom severity (Positive and Negative Syndrome Scale [PANSS] negative, p < 0.001, d = 0.827; PANSS GP, p < 0.001, d = 0.991; PANSS positive, p = 0.009, d = 0.594), verbal abstraction (p = 0.008, d = 0.554), aggression bias (p = 0.008, d = 0.627), and self-stigma (stereotype endorsement, p = 0.019, d = 0.495; discrimination experiences, p = 0.047; d = 0.389) that were specific to the RR group and were not observed in participants playing only TR. Effects were persistent over time and even larger between post-treatment and follow-up.

Exercise-enriched integrated SCR appears promising to improve real-life functioning in schizophrenia. Future research should investigate the potential effects of this intervention on neuroplasticity and physical fitness.

Schizophrenia is a leading cause of disability. People living with schizophrenia (PLWS) present unemployment, social isolation, excess mortality and morbidity, and poor quality of life. Early recognition and appropriate treatment reduce the risk of chronicity and comorbidity. Personalization and integration of pharmacological and psychosocial interventions, as well as accurate identification and management of psychiatric and somatic comorbidities, can significantly improve mental and physical health of PLWS, promoting recovery.

A three-step Delphi approach was used to explore consensus on the essential components of early recognition and intervention, personalization, and integration of care to improve schizophrenia outcome, and on barriers and challenges to close treatment gaps. The consensus involved 8 Italian experts of schizophrenia, 100 psychiatrists from academic and nonacademic settings, including representatives of Italian Society of Psychiatry, and 65 trainees in psychiatry.

A strong consensus (from mostly agree to totally agree) emerged on the importance of early diagnosis (97%), standardized assessments (91%), correct management of somatic and psychiatric comorbidities (99%), and personalization and integration of care (94%). Lack of time, human resources, and training were identified as the main barriers and challenges to the translation of knowledge into clinical practice.

The results of this Delphi study demonstrated a strong consensus on main components of schizophrenia care, as well as on unmet needs to promote best practice and gaps between knowledge and clinical practice. The involvement of a large group of professionals and trainees in this in-depth consensus process might contribute to raise awareness and stimulate innovative strategies to improve the outcome of PLWS.