[Body weight and mental disorders : Results from a clinical psychiatric cross-sectional study of people with intellectual disabilities]. / Körpergewicht und psychische Erkrankungen : Ergebnisse einer klinisch-psychiatrischen Querschnittsanalyse bei Menschen mit Intelligenzminderung.

BACKGROUND: People with intellectual disabilities (ID) have a shorter life expectancy and higher mortality rate and more often suffer from various physical and mental disorders (WHO: 3-4 times more often than the general population). Obesity is an important risk factor for various disorders. This cross-sectional study examined the body weight and its risk factors in a clinical population of adults with ID. METHODS: The prevalence of underweight, normal weight, and overweight was determined using the body mass index (BMI) for 633 patients of an outpatient clinic for people with ID and mental disorders. A multiple logistic regression analysis was used to assess factors for alterations in body weight. RESULTS: Approximately one out of two men and two out of three women with ID and mental disorders were overweight. Adults with mild and moderate ID, female gender, increasing age, Down's syndrome, behavioral disorders, and a less supported living situation were associated with a higher rate of obesity. People with dementia and autism spectrum disorders showed a lower rate of obesity. CONCLUSION: Young women with ID and mental disorders were particularly at risk for obesity. The respective factors may support the development of specific prevention programs to reduce the risk of overweight and thereby lead to better mental and physical health in people with ID.

[Acute and long-term cognitive consequences of treatment on intensive care units]. / Kognitive Akut- und Langzeitfolgen intensivmedizinischer Behandlung.

BACKGROUND: Following treatment on the intensive care unit (ICU) patients often suffer from acute and long-term cognitive deficits. This is true for patients of all age groups but especially for elderly patients who have undergone surgery and develop postoperative delirium (POD) or postoperative cognitive decline (POCD). Both are associated with severe limitations in the quality of life and long-term outcome. OBJECTIVE: Which acute and long-term cognitive effects develop in ICU survivors and how do they influence the outcome? How can POD and POCD be differentiated? METHOD: A selective literature search was carried out. RESULTS: Following surgery POCD can develop within days to weeks, may persist for weeks or months and can lead to problems in attentiveness even under conditions of inconspicuous consciousness. Remission is possible but may take up to more than 12 months. The POD is a phenomenon characterized by disturbances of consciousness and problems in attention, beginning acutely hours and days postoperatively, can persist for days to weeks and remission can be expected within a few days. While POD often has an organic cause, such as an infection, the pathogenesis of POCD has not been sufficiently elucidated. DISCUSSION: Both POD and particularly POCD can lead to a deterioration of cognition following ICU treatment. As efficient treatment still has to be developed preventive methods, such as preoperative screening for risk factors, thorough planning of operative and anesthetic techniques and compensation of risk factors as well as providing assistance to patients, e. g. by a trained nurse should be implemented in the clinical routine more often than is presently the case.

A study on the usefulness and reliability of the "Scheme of Appraisal of Emotional Development" (SAED) for persons with ID using direct observation in a group-based assessment procedure.

INTRODUCTION: Whereas instruments for the assessment of intellectual and social abilities are widely available, instruments for the evaluation of emotional development of persons with intellectual disabilities (ID) are rare. The Scheme of Appraisal of Emotional Development (SAED), an internationally used tool developed by Dosen (2005a. Journal of Intellectual Disability Research, 49, 1, 2005b. Journal of Intellectual Disability Research, 49, 9), is one of the latter and is based on interviews with caregivers. The present study aims to investigate the internal consistency and interrater-reliability by changing the interview procedure into a direct observation and evaluation approach by a whole team instead of by one expert. METHOD: The level of emotional development of 175 patients admitted to a psychiatric inpatient unit specialized in the treatment of adults with ID was evaluated with the SAED by the treatment team after an observation period of up to two weeks. The inter- and intra-rater-reliability was assessed by direct observation of the behaviour of an additional 50 patients by two pairs of raters. RESULTS: The internal consistency of the SAED dimensions, once rated by team approach, is excellent, and the reliability measures show also good statistical results. CONCLUSION AND IMPLICATIONS: The evaluation of the level of emotional development using the SAED by a group-led and/or direct observational procedure show to be a reliable and useful approach. The group-based procedure yields equal results compared with the usual interview guidelines and might lead to an additional training effect within the respective teams. The rater-reliability measures align with those reported in other studies.

Establishing a nurse-based psychiatric CL service in the accident and emergency department of a general hospital in Germany.

INTRODUCTION: Patients with mental health problems in accident and emergency departments (A&E) are frequent users and often difficult to handle. Failure in managing these patients can cause adversities to both patients and A&E staff. It has been shown that nurse-based psychiatric consultation-liaison (CL) services work successfully and cost effectively in English-speaking countries, but they are hardly found in European countries. The aim of this study was to determine whether such a liaison service can be established in the A&E of a German general hospital. We describe structural and procedural elements of this service and present data of A&E patients who were referred to the newly established service during the first year of its existence, as well as an evaluation of this nurse-led service by non-psychiatric staff in the A&E and psychiatrists of the hospital's department of psychiatry. SUBJECTS AND METHODS: In 2008 a nurse-based psychiatric CL-service was introduced to the A&E of the Königin Elisabeth Herzberge (KEH) general hospital in the city of Berlin. Pathways for the nurse's tasks were developed and patient-data collected from May 2008 till May 2009. An evaluation by questionnaire of attitudes towards the service of A&E staff and psychiatrists of the hospital's psychiatric department was performed at the end of this period. RESULTS: Although limited by German law that many clinical decisions to be performed by physicians only, psychiatric CL-nurses can work successfully in an A&E if prepared by special training and supervised by a CL-psychiatrist. The evaluation of the service showed benefits with respect to satisfaction and skills of staff with regard to the management of psychiatrically ill patients. CONCLUSION: Nurse-based psychiatric CL-services in A&E departments of general hospitals, originally developed in English-speaking countries, can be adapted for and implemented in a European country like Germany. Open access: This article is published with open access at link.springer.com.

[Geropsychiatric consultation-liaison services. An answer to the challenges of dementia?]. / Gerontopsychiatrische Konsiliar- und Liaisondienste. Eine Antwort auf die Herausforderung Demenz?

BACKGROUND: The care for people suffering from dementia is difficult, independent from the setting they live in or are cared for (at home, in nursing homes, or in general hospitals).This study looks at the possibility to achieve sustained quality improvement as well as cost-offset effects by the implementation of psychogeriatric consultation-liaison services in these settings. METHODS: We compare effects of psychogeriatric consultation-liaison services in primary care patients, nursing homes, and general hospital inpatients. We re-analyze longitudinal data drawn from our own studies conducted in the respective settings. RESULTS: Our comparison shows that many patients in all settings show benefits with regard to several measures following the consultation-liaison interventions. Patient-specific improvement in delivery of services can be seen in primary care, while in both nursing homes as well as in general hospitals, we found improvement in staff competency with regard to the improvement in knowledge and expertise in dementia care practice. Cost-offset effects can be observed in all three settings. CONCLUSION: For consultation-liaison services to reach their optimum in efficiency in Germany, the transgression of sector boundaries (e.g., between primary care and general hospitals) must be addressed and improved by specific integrated service delivery contracts that help all participants to achieve a solid legal basis.

[Psychiatric and psychosomatic consulation-liaison. An overview]. / Konsiliar-Liaison Psychiatrie und Psychosomatik. Ein Überblick.

A high rate of psychiatric comorbidity is found in patients with somatic diseases in general hospitals. Reasons for psychiatric disorders in somatically ill patients are variable and can lead to or be a result of the physical illness or just occur coincidentally. Consultation-liaison services (C/L) assist the physician and the treatment team on internal surgical wards in general hospitals in paying attention to and caring for somatic psychiatric comorbidities with diagnostic, therapeutic and, if appropriate, secondary preventative methods. In this article an overview of the development of C/L psychiatry is given. Furthermore, the importance of particular psychiatric disorders seen by psychiatric C/L services and their treatment is described. Finally, specific aspects of service delivery with regard to collaborative care between general hospital physicians and private practitioners are discussed.

[The experience of being admitted to a psychiatric clinic: part 1: development of a questionnaire (QAE-P)]. / Das Erleben der Aufnahme in eine psychiatrische Klinik : Teil I: Entwicklung eines Fragebogens (FEA-P).

BACKGROUND: The aim of the present study was to develop a questionnaire to assess the perception and evaluation of admission to a psychiatric hospital from a patient's perspective (QAE-P). MATERIAL AND METHODS: Based on existing literature and a preparatory pilot study, a questionnaire consisting of 126 items was developed, and 708 inpatients based in 6 psychiatry and psychotherapy clinics were asked to answer the items. The resulting data were split into two data sets. In the first subset, exploratory factor analysis was used to help determine the number of scales and provide the basis for item reduction. The resulting questionnaire was validated by means of confirmatory factor analyses (CFA) in the second data subset. RESULTS: The resulting questionnaire comprises 33 items in 7 scales, which assess: (1) helpful, positive relations with staff members; (2) offering of medical explanations to patients and their involvement in treatment planning; (3) evaluation of rooms and clinical environment; (4) dissatisfaction with doctors and staff members; (5) evaluation of handling of ward rules by staff; (6) perception of ward atmosphere; and (7) negative perception of other inpatients. The plausibility of this factorial structure was supported by the results of the CFA. CONCLUSIONS: The QAE-P is a short and feasible questionnaire that meets the criteria of classic test theory and assesses different dimensions of the patient's experience of admission to a psychiatric hospital.

[The experience of being admitted to a psychiatric clinic: part 2: comparative analyses of patient and hospital characteristics]. / Das Erleben der Aufnahme in eine psychiatrische Klinik : Teil II: Vergleichende Analysen von Patienten- und Klinikmerkmalen.

BACKGROUND: The purpose of this study was to investigate associations of patient's scores in the newly constructed questionnaire on patients' psychiatric admission experiences (QAE-P) and individual, institutional, and situational factors. PATIENTS AND METHODS: Data of 708 patients and 6 participating hospitals were analyzed. Patient characteristics between clinics were compared and univariate as well as multivariate analyses were applied to examine associations of QAE-P total score and individual as well as institutional variables (t tests, univariate and multivariate analyses of variance, correlation analyses, and effect sizes of significant associations). RESULTS: There was little variance of patient characteristics between hospitals. Multiple univariate associations with small to medium effect sizes were found between total QAE-P scores and demographic and clinical variables of the patients, institutional variables, and (non-independent) situational views of the patients. After multivariate analyses were applied, these associations remained significant for gender, age, diagnosis, the personal decision to be admitted, and for previous planning of admission with the outpatient doctor. The hospital variables shown to be associated with total QAE-P scores were open versus closed ward, disorder-specific organization of the ward, and the number of other patients being treated under the German Mental Health Act. CONCLUSION: Principally the QAE-P seems to be a suitable instrument of quality management. A number of factors were identified that show associations with the subjective evaluation of admission as reported by the patients. Some of these variables are within the control of the clinical management.

[The importance of a developmental approach in psychiatric assessment and treatment of adults with intellectual disability]. / Die Bedeutung des emotionalen Entwicklungsniveaus bei der psychiatrischen Behandlung von Menschen mit geistiger Behinderung.

INTRODUCTION: Mental disorders are 3-4 times more frequent in individuals with intellectual disabilities than in those without. From a developmental perspective the reason for this high prevalence could be, besides biological aberrations, a personality development with a difference between cognitive and emotional developmental levels. This discrepancy renders the person being highly vulnerable for the onset of problem behaviour and psychiatric disorders. For a proper insight into processes which have led to the disorder, it is necessary to evaluate the level of emotional development. This can be determined by the "schema of emotional development (SEO)" developed by A. Dosen. METHODS: By means of a case description the authors demonstrate the application of SEO in the assessment and utilization of the concept of the level of emotional development in clinical practice. RESULTS: The knowledge of the level of emotional development contributes to the explaining and understanding of the disorder, and also facilitates the establishment of an integrated diagnosis and the creation of appropriate integrated treatment strategies. Hence, temper tantrums, sleep patterns and mood improved in the case described. CONCLUSION: Besides biopsychosocial aspects, the developmental aspect, and in particular the level of emotional development should be taken into consideration in the diagnostic work-up and treatment of individuals with intellectual disabilities and mental health problems. The data generated by the SEO may help in understanding the disorder and developing a treatment approach for these individuals.

[Autism in adults with intellectual disabilities]. / Autismus bei erwachsenen Menschen mit geistiger Behinderung.

According to the World Health Organization (WHO) the estimated prevalence of intellectual disabilities (ID) is about 1-3% and 1 out of 4 individuals with ID suffer from an additional autistic spectrum disorder (ASD) (arithmetic mean 24.6%, 19 studies, n=9,675) whereby the prevalence increases with the severity of ID (IQ 50-70: 9.9%, IQ<50: 31.7%). Therefore, it is of particular importance for physicians treating individuals with ID who have psychiatric disorders or behavioral problems to take ASD into account as a differential diagnosis so that appropriate treatment can be initiated.Irrespective of the IQ the diagnosis is based on an impairment of social interaction and communication and restricted repetitive interests presenting before the age of 3 (infantile or Kanner autism). ASD can be diagnosed as a separate disorder in adults with ID, however, the social and communicative abilities in respect of the cognitive and developmental level have to be considered.Due to reduced verbal capacity, high prevalence of physical and mental disorders, difficulties in taking the past medical history and presentation of atypical symptoms, the diagnostic assessment for autism in adults with ID is challenging.This article describes the typical symptoms, diagnostic approach, frequent comorbidities, differential diagnoses treatment options and their limitations for adults with ID suspected of having ASD.

[Psychotherapy in intellectual disability. Theoretical background and implementation]. / Psychotherapie bei Menschen mit Intelligenzminderung. Theoretischer Hintergrund und praktische Umsetzung.

BACKGROUND: Every third person with intellectual disability suffers from additional mental health problems, among others phobic disorders. Yet we do not know whether psychotherapeutic methods that are effective in the normal population are applicable to people with intellectual disabilities. PATIENTS AND METHODS: We give a survey of the development and the present state of the art of psychotherapy, particularly with regard to phobic disorders in intellectual disability. Therapeutic recommendations described in the literature will be evaluated in a case study of one patient. RESULTS: The confrontation with the phobic stimulus is the basis of behavior therapy for people with intellectual disability as well. However, with respect to the special needs of these people, some modifications need to be considered in the treatment strategy. In addition to some general rules like simple language or the use of visual materials, some techniques of intervention turned out to be particularly effective, e.g., graduated in vivo exposure, involving significant others, contingency management, and coping strategies. CONCLUSION: Specific phobias in intellectual disability can be treated with behavior therapy as well. However, the special needs of these people need to be considered.

A double-blind placebo-controlled discontinuation study of zuclopenthixol for the treatment of aggressive disruptive behaviours in adults with mental retardation - secondary parameter analyses.

INTRODUCTION: Earlier studies showed risperidone to be effective in the treatment of aggression and self-injurious behaviour in adults with mental retardation but also having adverse side effects. This study was conducted to evaluate the effects of zuclopenthixol withdrawal. METHODS: After open treatment with zuclopenthixol (n=49) responders were randomly assigned to continue (n=19) or discontinue (n=20) zuclopenthixol treatment during a 12-week double-blind, placebo-controlled period. Effects were measured using the Disability Assessment Schedule (DAS), improvement on the Clinical Global Impression Scale (CGI-I), and the Nurse's Observation Scale for Inpatient Evaluation (NOSIE). RESULTS: Ten patients (20%) discontinued the study due to insufficient therapeutic effect or adverse events in the open period. EFFICACY: The superiority of zuclopenthixol over placebo among all randomized patients was supported not only by primary efficacy measure but also by the comparisons of mean scores of all secondary efficacy measures tested in a step-down-procedure (DAS, p<0.001; CGI-I, p<0.002, NOSIE, p<0.005). SAFETY: In both groups, one patient discontinued (5%) for adverse events. Adverse events were generally mild or moderate in severity. DISCUSSION: Zuclopenthixol proved to be safe and effective to keep a low rate of aggressive behaviour in adults with mental retardation.

Implementation of a psychiatric consultation service: a single-site observational study over a 1-year-period.

This study describes changes in consultation process variables and referral patterns after implementation of a psychiatric consultation service at a university hospital in Germany. Two hundred eighty consecutive medical-surgical inpatient referrals for psychiatric consultation during a 1-year period were documented prospectively with a structured database. Changes took place in referral patterns and in psychiatric interventions and recommendations but not in psychiatric diagnoses. In addition, information is given on psychiatric and psychosomatic consultation service delivery in Germany.

Fatty acid ethyl esters in hair as markers of alcohol consumption. Segmental hair analysis of alcoholics, social drinkers, and teetotalers.

BACKGROUND: Fatty acid ethyl esters (FAEEs) are products of nonoxidative ethanol metabolism. After incorporation in hair, they should be suitable long-term markers of alcohol abuse. METHODS: Hair samples from 19 alcoholics in a treatment program, 10 fatalities with verified excessive alcohol consumption, 13 moderate social drinkers who consumed up to 20 g ethanol/day, and 5 strict teetotalers were analyzed in 1-12 segments for four FAEEs (ethyl myristate, ethyl palmitate, ethyl oleate, and ethyl stearate) by external degreasing with n-heptane, extraction with a dimethyl sulfoxide-n-heptane mixture, headspace solid-phase microextraction of the extracts, and gas chromatography-mass spectrometry with deuterated internal standards. The n-heptane washings were analyzed in the same way for FAEEs from the hair surface. RESULTS: The sum of the four ester concentrations in hair calculated for the proximal 0-6 cm segment was 2.5-13.5 ng/mg (mean, 6.8 ng/mg) for the fatalities, 0.92-11.6 ng/mg (mean, 4.0 ng/mg) for 17 of the alcoholics in treatment, 0.20-0.85 ng/mg (mean, 0.41 ng/mg) for the moderate social drinkers, and 0.06-0.37 ng/mg (mean, 0.16 ng/mg) for the teetotalers. In almost all cases the segmental concentrations increased from proximal to distal. There was no agreement between the self-reported drinking histories of the participants and the FAEE concentrations along the hair length. Ethyl oleate was the dominant ester in all samples. CONCLUSIONS: FAEEs are deposited in hair mainly from sebum. Despite large individual differences, FAEE hair concentrations can be used as markers for excessive alcohol consumption with relatively high accuracy.

[Dementia screening in psychiatric consultation for elderly patients in a general hospital]. / Demenz-Screening bei älteren psychiatrischen Konsiliarpatienten im Allgemeinkrankenhaus.

BACKGROUND: Elderly patients on medical-surgical wards in general hospitals often suffer from cognitive dysfunction that hampers medical treatment of somatic diseases. Symptoms of cognitive dysfunction may not be recognized adequately by non-psychiatric physicians. PATIENTS AND METHOD: We studied the usefulness of a short screening instrument for cognitive dysfunctions (short mini mental state test) in a consecutive sample of 222 psychiatric consultation liaison patients older than 60 years of age. Normative data for the screening test from an epidemiological sample, the Berlin Aging Study, are given and compared with the consultation sample. RESULTS: Mild to moderate deficits in cognitive functions were found in 32% of patients, severe deficits indicating dementia- or delirium syndromes were found in 17.7%. Applying the cut off 4/5, 88.9% correct classifications of dementia patients were obtained. The item analysis demonstrates significant differences with respect to the age-matched population sample for the orientation items, the 2nd and subsequent subtractions of the serial seven task and, to a lesser degree, the memory items. CONCLUSION: A standardized assessment of the 15 items of the SMMS represents a practical, reliable and valid screening for relevant cognitive deficits, which may also serve as documentation of the time course especially in acute organic-psychiatric syndromes.

Further evolution of a literature database: the international use of a common software structure and methodology for the establishment of national consultation/liaison databases.

Every day there are 6000-7000 papers published in science. Since the C-L psychiatrist may be asked to consult on a patient with any medical illness, and who may be on any medical drug, methods need to be developed to review the recent literature and have an awareness of current findings. At the same time, teachers need to develop a current listing of seminal papers for trainees and practitioners of this subspecialty of psychiatry. Experts chosen because of their writings and acknowledged contributions to their subspecialty interests have sifted through thousands of articles to select the ones they regard as the most important for trainees in C-L psychiatry. In addition, certain countries--Spain, Portugal, Germany, Mexico, Australia and Brazil are developing national databases of C-L literature not only for their own use, but also to bring them to the attention of other parts of the world. This fifth iteration of the C-L literature database has especially targeted the period of 1996-1999--the millennium issue--in order to have easier access to contemporary essential studies on common problems. Part II of this issue describes the seminal cardiac drug-psychotropic drug interactions that the C-L psychiatrist may encounter in the most common medical disease in the United States--coronary heart disease--with advise to the practitioner as to their management. The use of the Internet and institutional Intranets is described.