European Psychiatric Association Guidance Research Articles

EPA guidance on treatment of cognitive impairment in schizophrenia

AbstractAlthough cognitive impairment is a core symptom of schizophrenia related to poore outcome in different functional domains, it still remains a major therapeutic challenge. To date, no comprehensive treatment guidelines for cognitive impairment in schizophrenia are implemented.The aim of the European Psychiatric Association (EPA) guidance paper was to provide a comprehensive meta-review of the current available evidence-based treatments for cognitive impairment in schizophrenia, structured into three sections: pharmacological treatment, psychosocial interventions, and somatic treatments.Based on the reviewed evidence, the EPA guidance recommends an appropriate pharmacological management as a fundamental starting point in the treatment of cognitive symptoms in schizophrenia. Among psychosocial interventions, cognitive remediation and physical exercise are recommended for the treatment of cognitive impairment in schizophrenia. As for cognitive remediation, some variables have been confirmed as core elements for treatment effectiveness.The dissemination of the EPA guidance paper may promote the development of shared guidelines concerning the treatment of cognitive functions in schizophrenia, with the purpose to improve the quality of care and to achieve clinical recovery in this population.Disclosure of InterestNone Declared

Prevention and treatment of psychiatric disorders through physical activity, exercise, and sport

Prevention and treatment of psychiatric disorders through physical activity, exercise, and sport

Time to go green?

Time to go green?

Developing a physical activity initiative for a community mental health service

Developing a physical activity initiative for a community mental health service

Web-based exercise therapy for the treatment of depression

Web-based exercise therapy for the treatment of depression

EPA guidance on assessment of negative symptoms in schizophrenia.

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent. In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice. Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.Several recommendations are provided for the identification of secondary negative symptoms in clinical settings. The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination.

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.

EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH)

Physical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.

Implementation of EPA guidance - One way for all countries?

The European Psychiatric Association (EPA) guidance project launched in 2008 has the aim of providing European psychiatry with guidance in topics, which are relevant for European mental health care. Guidance from a European perspective can be favorable against the background of a growing sense of Europe and the desirable associated harmonization on all levels of health care policy.More precisely, the mission of the EPA guidance is defined as ‘to improve quality of mental health care in Europe by disseminating written information based on best evidence and psychiatric practice, to facilitate countries learning from each other’.In consonance with this need of a wider multinational perspective of European psychiatry, EPA adopted in 2012 through a deep change of its statutes a new membership structure that allows National Psychiatric Societies/Associations (NPAs) in Europe the possibility to become full members of EPA. Up to 40 NPAs corresponding to 37 countries and representing over 80.000 psychiatrists have responded positively to the offer and are now part of the Council of National Psychiatric Societies, the body within EPA that integrates them.The Council of NPAs has become, in this way, a forum for its members to meet, discuss and work on issues concerning European psychiatry. One of the major issues is about the implementation of European guidance in mental health policy, teaching and learning psychiatry, best clinical practice in different areas, and quality indicators. This presentation provides further details on how participating societies could put these policies and recommendations into practice.Disclosure of interestThe author has not supplied his declaration of competing interest.

Détection et traitement précoce des sujets à haut risque clinique de psychose : définitions et recommandations

In children and adolescents, psychotic disorders already represent one of the leading causes of disability-adjusted life years. During the past two decades, early detection of risk for psychosis has been intensively investigated, and in particular, predictive power for early signs of risk has been initiated and translated into clinical practice. In particular, the attenuated and transient positive symptoms of the ultra-high risk criteria, and the basic symptom criterion “cognitive disturbances”, open promising routes to an indicated prevention and have recently been considered by the European Psychiatric Association (EPA) as diagnostic criteria of a psychosis-risk syndrome. The EPA recently provided evidence-based recommendations on the early detection of clinical high risk (CHR) for psychosis in patients with mental distress. In 2015, experts in the field of early detection conducted a meta-analysis reporting on studies examining conversion rates to psychosis in non-overlapping samples meeting at least one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria, examining the effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates. In the 42 identified samples, comprising more than 4000 CHR patients who had been mainly identified by means of UHR criteria and/or the basic symptom criterion ‘cognitive disturbances’ (COGDIS), conversion rates showed considerable heterogeneity. While UHR and COGDIS criteria were related to comparable conversion rates until a 2-year follow-up, rates for COGDIS were significantly higher for follow-up periods beyond 2 years. Differences in onset and frequency requirements of symptomatic UHR criteria, or in their different consideration of functional decline, substance use and co-morbidity, did not seem to have an impact on conversion rates. The ‘genetic risk and functional decline’ UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for the early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states. The EPA guidance on early intervention aimed to provide evidence-based recommendations on early intervention in CHR states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were also made by experts in the field of early intervention in psychoses and derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. In addition to analyses of treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n=1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status. Overall, age-related specificities and developmental transitions in the early detection and intervention in psychoses should be better accounted for in future research.

The EPA guidance on suicide treatment and prevention needs to be adjusted to fight the epidemics of suicide at the North Pole area and other autochthonous communities

More and more, youth suicide in the Inuit community is gaining importance, with a frequency in Greenland rising from 14.4 (1960–64) to 110.4 per 100,000 person-years (2010–11). The huge cultural/educational changes during the last 20 years and the role of globalization, especially of the occidental influence on this community may be at the origin of such an “epidemics” of suicide in this cultural region. Recently, a political organization representing the Inuit community in Canada (ITK for Inuit Tapiriit Kanatami) launched a National Inuit Suicide Prevention Strategy (NISP) based on the specificities of this community in comparison to the occidental civilization. In fact, not only the Canadian Inuit community is concerned by this epidemics of suicide, but also many other autochthonous groups. In this context, the European Psychiatric Association (EPA) guidance on suicide treatment and prevention needs to be adjusted to autochthonous individuals’ needs.

EPA guidance on mental health and economic crises in Europe

This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.

European Psychiatric Association Guidance on psychotherapy in chronic depression across Europe

PurposePatients with chronic depression (CD) by definition respond less well to standard forms of psychotherapy and are more likely to be high utilizers of psychiatric resources. Therefore, the aim of this guidance paper is to provide a comprehensive overview of current psychotherapy for CD. The evidence of efficacy is critically reviewed and recommendations for clinical applications and research are given. MethodsWe performed a systematic literature search to identify studies on psychotherapy in CD, evaluated the retrieved documents and developed evidence tables and recommendations through a consensus process among experts and stakeholders. ResultsWe developed 5 recommendations which may help providers to select psychotherapeutic treatment options for this patient group. The EPA considers both psychotherapy and pharmacotherapy to be effective in CD and recommends both approaches. The best effect is achieved by combined treatment with psychotherapy and pharmacotherapy, which should therefore be the treatment of choice. The EPA recommends psychotherapy with an interpersonal focus (e.g. the Cognitive Behavioural Analysis System of Psychotherapy [CBASP]) for the treatment of CD and a personalized approach based on the patient's preferences. DiscussionThe DSM-5 nomenclature of persistent depressive disorder (PDD), which includes CD subtypes, has been an important step towards a more differentiated treatment and understanding of these complex affective disorders. Apart from dysthymia, ICD-10 still does not provide a separate entity for a chronic course of depression. The differences between patients with acute episodic depression and those with CD need to be considered in the planning of treatment. Specific psychotherapeutic treatment options are recommended for patients with CD. ConclusionPatients with chronic forms of depression should be offered tailored psychotherapeutic treatments that address their specific needs and deficits. Combination treatment with psychotherapy and pharmacotherapy is the first-line treatment recommended for CD. More research is needed to develop more effective treatments for CD, especially in the longer term, and to identify which patients benefit from which treatment algorithm.

The EPa Guidance Project

The EPA Guidance Project Introduction In European countries, guidelines are important tools in quality assurance in mental healthcare. However, not all topics relevant to the quality of mental healthcare provision are covered by guidelines, e.g. due to limited availability of data and data protection constraints. Therefore, in 2008, the European Psychiatric Association (EPA) established the EPA Guidance project with a view to produce practical guidance papers on topics relevant to quality assurance in mental healthcare. Objectives To improve the quality of mental healthcare in Europe by disseminating written information based on best evidence and psychiatric practice, especially in areas where guidelines are lacking. Aims To describe the current status of the EPA Guidance project. Methods Review of the EPA Guidance project and its Guidance documents. Results EPA Guidance documents provide evidence- and consensus-based recommendations on topics relating to the quality assurance of mental health services, such as quality of mental health service structures and processes, and building trust in mental health services. Conclusions European harmonization of the quality assurance of mental healthcare may be advanced on a supranational level with the help of the European Guidance. Its recommendations may be adapted to national or regional conditions to suit the needs, priorities and legislation of European constituents. Reference Gaebel W, Becker T, Janssen B, Munk-Jorgensen P, Musalek M, Rossler W, Sommerlad K, Tansella M, Thornicroft G, Zielasek J. EPA guidance on the quality of mental health services. Eur Psychiatry 2012 27:87–113 Gaebel W Moller H-J. European Guidance – a project of the European Psychiatric Association. European Psychiatry 2012 27:65-67

EPA guidance on the early intervention in clinical high risk states of psychoses

This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n=1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.

European Psychiatric Association (EPA) guidance on quality assurance in mental healthcare

PurposeTo advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance. MethodsWe performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding). ResultsAlthough quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level). DiscussionThere was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels. ConclusionEvidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.

The EPA Guidance Project: Guidance for Mental Healthcare in Europe

Summary Background: The development of guidelines is an important and common method to assure and improve quality in mental healthcare in European countries. While guidelines have to fulfill predefined criteria such as methodological accuracy of evidence retrieval and assessment, and stakeholder involvement, the development of guidance was not standardized yet. Aim: In 2008, the European Psychiatric Association (EPA) initiated the EPA Guidance project in order to provide guidance in the field of European psychiatry and related fields for topics that are not dealt with by guideline developers – for instance due to lack of evidence or lack of funding. The first three series of EPA Guidance deal with diverse topics that are relevant to European mental healthcare, such as quality assurance for mental health services, post-graduate training in mental healthcare, trust in mental health services and mental health promotion. Results: EPA Guidance recommendations address current and future challenges for European psychiatry. They are developed in accordance with the World Health Organization (WHO) European Mental Health Action Plan.

EPA Guidance on Tobacco Dependence and Strategies for Smoking Cessation in People with Mental Illness

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.

2473 – EPA guidance papers and their impact in reducing the burden of mental disorders

The European Psychiatric Association (EPA) established the project “EPA Guidance” in order to improve the quality of mental healthcare in Europe by disseminating written information based on best evidence and expert consensus. To provide information on good clinical practice to national societies, health authorities and clinicians. The development of guidance for selected mental healthcare topics in order to improve the practice of psychiatry in Europe. Systematic literature searches and consensus processes. In order to improve the quality of mental healthcare and thereby reducing the burden of mental disorders, a first series of guidance documents on the quality of services structures, prevention and treatment of suicidal crises, prevention of mental disorders in general (illness prevention and health promotion), pharmacotherapy of depression, and how to deal with conflicts of interest in research and other professional activities, was published. The series of EPA guidance formulates recommendations and proposes strategies that may help to reduce the burden of mental disorders. The burden of mental disease is sought to be reduced by evidence-based, effective mental health prevention and promotion strategies as well as by optimizing the structures and processes of mental health services by the development of recommendations in the EPA guidance on the quality of mental health services. Many important clinical situations or problems beyond treatment that until now lacked proper guidance are addressed by the EPA guidance.

European Psychiatric Association guidance on the conflicts of interest

Conflict of interest (COI) is a set of circumstances that creates a risk that professional judgments or actions regarding a primary interest will be unduly influenced and compromised by a secondary interest. It might arise in clinical practice, research, and education, and might include individuals and institutions. Primary interests include the pursuit of well-being of patients, ensuring the independence of medical education, and protecting the objectivity and integrity of medical research. Secondary interests might involve financial interests, pursuit of recognition and professional career advancement. COI might result from the multiple roles of physicians in patient care, research, administration, provision of expert opinion and policy advice, and consultancy to commercial organizations. The purpose of the COI policy is to protect the interests of the patients, strengthen the integrity of the profession, and preserve public trust in medicine and psychiatry. The aim of the guidance is to eventually prevent these conflicts from arising rather than remediate them ex post. It is desirable to identify factors that might lead to their occurrence, offer a framework for their recognition and assessment, introduce the principles and standards of their disclosure, and provide recommendations for their transparent resolution.