Kerem Böge

Zusammenfassung: Während das Stigma gegenüber Depressionen und Angststörungen abgenommen hat, ist es bei Psychosen gewachsen. Gleichzeitig bleibt die Versorgung weiterhin lückenhaft, und nur wenige Betroffene erhalten psychotherapeutische Unterstützung, obwohl vielfältige evidenzbasierte Verfahren zur Verfügung stehen. Eine Psychosebehandlung im 21. Jahrhundert erfordert daher einen Paradigmenwechsel.

Background: Auditory verbal hallucinations (AVHs) are common and distressing symptoms across a range of psychiatric disorders, including schizophrenia spectrum disorders. Audio Visual Assisted Therapy Aid for Refractory Auditory Hallucinations (AVATAR) is an innovative therapeutic approach that facilitates dialogue with a digital avatar representing the voices that patients hear. Aims: This systematic review and meta-analysis aimed to assess the efficacy, tolerability and acceptability of AVATAR therapy in reducing voice-related symptoms. Method: Following preregistration, we conducted a systematic review and meta-analysis of controlled trials of AVATAR therapy in samples primarily diagnosed with schizophrenia spectrum disorders. PubMed, CINAHL, Embase, PsycInfo, ClinicalTrials.gov, ISRCTN and Web of Science were searched in March 2025. We assessed bias and certainty with the Cochrane Risk-of-Bias 2 tool and the GRADE approach. Random-effects models were used to synthesise outcomes. Results: Eight AVATAR trials ( N = 978) were included. Compared with usual treatment, waitlist and active control groups, AVATAR therapy decreased the primary outcome of AVH severity at post-treatment (Hedges’ g = −0.40, 95% CI −0.54 to −0.25) and short-term follow-up (Hedges’ g = −0.25, 95% CI −0.40 to −0.10). AVH subscales showed small significant effect sizes at post-treatment (frequency: Hedges’ g = −0.38, 95% CI −0.52 to −0.24; distress: Hedges’ g = −0.32, 95% CI −0.46 to −0.18), which were maintained at short-term follow-up. The certainty of evidence was rated moderate for AVH severity at post-treatment. AVATAR therapy was largely tolerable and acceptable, with adverse events mostly unrelated to the treatment and a comparable drop-out rate to control groups. Conclusions: Findings suggest that AVATAR therapy is effective at reducing AVH symptoms. Considering heterogeneous control groups and less clear evidence for secondary outcomes and longer follow-ups, further research is warranted.

Background and Hypothesis: Psychotic and traumatic-stress symptoms commonly co-occur. Psychological interventions have increasingly targeted these co-occurring symptoms. However, information on their efficacy, tolerability, and acceptability is limited in this evolving field. Study Design: After preregistration at PROSPERO (CRD42024553934), we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) of psychological interventions with persons aged 16+ reporting both psychotic and traumatic-stress symptoms. PubMed, CINAHL, Embase, PsycINFO, Clinicaltrials.gov, and Web of Science were searched in July 2024. We used the Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB-2) for bias assessment. Random-effects models were used to synthesize clinical outcomes, while meta-regression was applied when 10 effect sizes were reported per outcome. Study Results: We included 10 RCTs with 559 participants. Interventions primarily targeted trauma-related symptoms and were seemingly tolerable and acceptable, with low adverse event profiles and a dropout rate of 14%. In comparison to usual treatments and active control treatments, interventions significantly decreased traumatic-stress symptoms at post-treatment (g = 0.33, 95% CI [0.08, 0.57]), with meta-regression favoring interventions primarily employing exposure (gdiff = 0.59, [0.22, 0.97]). Interventions significantly decreased traumatic-stress symptoms at follow-up (g = 0.34, [0.12, 0.56]), but not total psychotic, positive, or negative symptoms at either timeframe. Conclusions: Findings suggest that psychological interventions for co-occurring psychotic and traumatic-stress symptoms are safe, tolerable, and may reduce traumatic-stress symptoms when employing exposure. Considering the substantial risk of bias, the small number of trials, non-significant results for other clinical and functional outcomes, and unexplained heterogeneity, further research is needed.

Summary: User engagement remains a challenge in digital mental health. This editorial reconsiders engagement as a process rather than an outcome, introducing a four-step model to define, measure and link engagement to outcomes. The approach promotes standardisation, interpretability and scalability, advancing the science and implementation of digital health interventions.

Background: Recent meta-analyses support the inclusion of cognitive behavioral therapy (CBT) in schizophrenia treatment. Metacognitive Training (MCT) for psychosis is a psychoeducational program derived from CBT, with most meta-analyses showing favorable results. Although meta-analyses are commonly used in clinical practice to guide evidence-based decision-making, the grading system provides complementary results by offering a structured approach for assessing the strength and reliability of evidence and deriving grades of recommendations accordingly. Methods: Our research applies the guidelines from the World Federation of Societies of Biological Psychiatry (WFSBP) to propose grades of recommendation for MCT for psychosis, analyzing 38 randomized controlled trials (RCTs) (n = 1942) and 10 meta-analyses. The primary outcome was positive symptoms, with secondary measures including negative symptoms, general psychopathology, self-esteem, functioning, insight, and cognitive function. Results: Our findings are primarily based on the risks of bias attributed to RCTs (11 high, 19 moderate, 6 low) and, when necessary, on the overall confidence attributed to meta-analyses (3 low, 7 critically low). According to the WFSBP guidelines, strong recommendations should be made for using MCT for psychosis to improve post-treatment positive symptoms, delusions, and total psychotic symptoms (WFSBP-grade 1). Limited recommendations (WFSBP-grade 2) could be made for using MCT to improve post-treatment visuospatial abilities and to maintain benefits over time in psychopathology, functioning, self-esteem, episodic memory, and attention. Conclusions: MCT for psychosis is an evidence-based program, especially for positive symptoms, with long-lasting clinical benefits. These recommendations should be interpreted with caution given potential residual biases and heterogeneity among studies.

Der Krankheitsbegriff “Schizophrenie”, abgeleitet aus den altgriechischen Wörtern schizein („spalten, zersplittern“) und phrēn („Geist, Seele“), geht auf den Schweizer Psychiater Eugen Bleuler (1911) zurück, der genaugenommen bereits den Plural Schizophrenien vorschlug. Im Vergleich zu dem zuvor von Emil Kraepelin (1896) verwendeten Begriff „Dementia praecox“, der seinerseits auf den französischen Psychiater Bénédict Augustin Morel (1860) zurückgeht, war Bleulers Begriff eine inklusivere Weiterentwicklung. So wäre auch Kraepelins “Dementia praecox”, ein lateinisch verschleierter Ausdruck für “vorzeitige Verblödung”, von psycho-erfahrenen Personen abgelehnt worden. Im Verlauf korrigierte auch Kraepelin, ab der siebten Auflage seines Psychiatrie Werkes, seine frühere Auffassung, dass eine Remission selten und ein chronischer Verlaufstyp die Regel sei und damit eine zentrale Annahme seines Dementia praecox Konzepts. Der auf Kraepelin folgende Vorschlag Bleulers “Dementia praecox oder Gruppe der Schizophrenien” legte nun einen stärkeren Fokus auf Psychopathologie, wie formale Denkstörungen, und verwies bereits auf teils passagere auftretende Kernphänomene gestörter Integrationsprozesse im Denken, Wahrnehmen und Zuschreibungen. Der später klinisch oft im Singular verwendete Krankheitsbegriff der Schizophrenie verengte jedoch den klinischen Blick auf das heterogene Spektrum primärer psychotischer Störungen (ICD-11). Article published online: 11 April 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Background: Despite social transitions in attitude toward the LGBT+ community, homonegativity, genderism, or transphobia persist, even found in healthcare providers (HCPs), which can hamper the goal of equality and equity in general health and that of gender minorities. The lack of knowledge about the community is also a problem, especially in developing countries. Aim: To investigate the influences of attitudes toward and knowledge about the LGBT+ community of HCPs who are not LGBT+ on how they practice in clinical settings. Methods: A survey was conducted on HCPs, mainly working in urology, nephrology, and andrology, who attended the annual congress on Urology and Nephrology in August 2023. The survey evaluated homophobia, genderism/transphobia, and knowledge about LGBT+ using the Attitude Toward Lesbians and Gay Men Scale–Short Version (ATLG-S), Genderism and Transphobia Scale–Revised–Short Form (GTS-R-SF), and Knowledge About Homosexuality Questionnaire (KAHQ). The behaviors of HCPs toward LGBT+ were also investigated. Outcome: HCPs’ attitudes toward and knowledge about LGBT+ were affected by individual-related factors and modulated behaviors toward LGBT+ patients in clinical settings. Results: Among 362 qualified respondents, levels of negative attitudes toward lesbians, gay men, and transgender people are mild at 5.5%, 13.0%, and 11.1%, respectively. Most respondents (93.4%) have a low to moderate level of knowledge, as measured by the KAHQ, about the LGBT+ community. Respondents having LGBT+ friends have more positive attitudes toward LGBT+ people and higher levels of knowledge about the community than others. Findings from the structural equation model indicate that improving knowledge is the key factor to change the attitudes and practices of Vietnamese HCPs while in contact with LGBT+ clients. Clinical Implications: Developing official and thoughtful curricula on the diversities of gender identities and sexual orientations for medical staff is crucial to reducing gender and sexual orientation discrimination. Strengths and Limitations: This study used validated questionnaires with the ability to exclude unintended respondents, improving the analyses’ accuracy. Since the sample did not represent all HCPs and other specialties, further studies are required. Conclusion: This study indicates the existence of mild levels of homophobia, genderism, and transphobia among HCPs. Improving the knowledge of HCPs about LGBT+ people plays a critical role in improving attitudes toward the community and ensuring equality and equity in providing health services for all patients regardless of their gender identity and sexual orientation.