Increase in coercive measures in psychiatric hospitals in Germany during the COVID-19 pandemic.

OBJECTIVE: To examine whether the pandemic in 2020 caused changes in psychiatric hospital cases, the percentage of patients exposed to coercive interventions, and aggressive incidents. METHODS: We used the case registry for coercive measures of the State of Baden-Wuerttemberg, comprising case-related data on mechanical restraint, seclusion, physical restraint, and forced medication in each of the State's 31 licensed hospitals treating adults, to compare data from 2019 and 2020. RESULTS: The number of cases in adult psychiatry decreased by 7.6% from 105,782 to 97,761. The percentage of involuntary cases increased from 12.3 to 14.1%, and the absolute number of coercive measures increased by 4.7% from 26,269 to 27,514. The percentage of cases exposed to any kind of coercive measure increased by 24.6% from 6.5 to 8.1%, and the median cumulative duration per affected case increased by 13.1% from 12.2 to 13.8 hrs, where seclusion increased more than mechanical restraint. The percentage of patients with aggressive incidents, collected in 10 hospitals, remained unchanged. CONCLUSIONS: While voluntary cases decreased considerably during the pandemic, involuntary cases increased slightly. However, the increased percentage of patients exposed to coercion is not only due to a decreased percentage of voluntary patients, as the duration of coercive measures per case also increased. The changes that indicate deterioration in treatment quality were probably caused by the multitude of measures to manage the pandemic. The focus of attention and internal rules as well have shifted from prevention of coercion to prevention of infection.

Aggressive incidents in psychiatric hospitals on heat days.

This study explores the relationship between temperature and the number of aggressive incidents and coercive interventions in the years 2007-2019 in six psychiatric hospitals in the south of the Germany with a total of 1007 beds. The number of aggressive incidents among 164 435 admissions was significantly higher on 'heat days' (≥30°C). Furthermore, there was a dose-response relationship between the number of aggressive incidents and increasing temperature. In contrast, the number of coercive interventions was not related to temperature. Considering the background of global warming, rising temperature could result in more frequent aggressive behaviour during in-patient treatment of psychiatric patients.

Incidents of aggression in German psychiatric hospitals: Is there an increase?

INTRODUCTION: In a meta-analysis of international studies, 17% of admitted patients in psychiatric hospitals had exhibited violent behavior toward others. Reported data from studies in Germany were considerably lower until recent years. However, studies examining only single hospitals, as well as the quality of the data itself, have raised questions as to the validity of these findings. Indeed, a debate currently exists as to whether there has, in fact, been an increase of violent incidents in German mental institutions. METHODS: In a group of 10 hospitals serving about half the population of the Federal State of Baden-Wuerttemberg with 11 million inhabitants, the Staff Observation Aggression Scale-Revised (SOAS-R) was introduced into patients' electronic charts as part of routine documentation. Data recording was strongly supported by staff councils and unions. A completed data set is now available for the year 2019. For one hospital, data are available since 2006. Due to some doubts with respect to fully covering self-directed aggression, we restricted the analysis to aggression toward others and toward objects. RESULTS: In 2019, 17,599 aggressive incidents were recorded in 64,367 admissions (1,660 staying forensic psychiatric inpatients included). 5,084 (7.90%) of the admitted cases showed aggressive behavior toward others. Variation between hospitals was low to modest (SD = 1.50). The mean SOAS-R score was 11.8 (SD between hospitals 1.20%). 23% of the incidents resulted in bodily harm. The percentage of patients showing violent behavior was highest among patients with organic disorders (ICD-10 F0) and lowest among patients with addictive or affective disorders (F1, F3, F4). Forensic psychiatry had the highest proportion of cases with aggressive behavior (20.54%), but the number of incidents per bed was lower than in general adult psychiatry and child and adolescent psychiatry (indicating a lower risk for staff). In the hospital with longer-term recordings available, an increase could be observed since 2010, with considerable variation between years. CONCLUSIONS: This is the most robust estimate of the frequency of violent incidents in German psychiatric hospitals thus far. The incidence is about half of what has been reported internationally, probably due to sample selection bias in previous studies and a relatively high number of hospital beds in Germany. Available data suggest an increase of violent incidents over the last ten years; however, it is unclear to which extent this is due to increased reporting.

[Importance of Psychiatric Outpatient Clinics in Primary Care of Somatic Disorders]. / Die Bedeutung Psychiatrischer Institutsambulanzen in der somatischen Grundversorgung.

OBJECTIVE OF THE STUDY: General practitioners are mainly responsible for primary health care. Patients with mental disorders, in particular patients with complex or multiple needs, use these services infrequently in case of somatic complaints. Psychiatric outpatient clinics have to deal with these patients and have perhaps an additional role in diagnosing and treating somatic co-morbidities. This should be evaluated. METHODS: Physicians in outpatient clinics of the Centre of Psychiatry Suedwuerttemberg were asked about their attitude towards somatic co-morbidities, somatic co-treatment and prescribing somatic drugs. In addition, data of the outpatient clinic documentation were evaluated with respect to the treatment by general practitioners and somatic diagnosis. RESULTS: 72% of all patients said that they have a general practitioner. Physicians in outpatient clinics said that they had a high responsibility for somatic co-treatment especially for those patients who did not have a general practitioner. The frequency and type of a somatic co-morbidity was different in patients from general psychiatric, geriatric psychiatry and addiction outpatient clinics. CONCLUSIONS: Our results demonstrate that psychiatric outpatient clinics play a crucial role in diagnosing and treating somatic disorders. Their extent depends on the type of the psychiatric and the somatic disorder but also on the financing of the outpatient clinic.

[Persistent Perpetrator Contact in a Patient with Dissociative Identity Disorder]. / Persistierender Täterkontakt bei einer Patientin mit dissoziativer Identitätsstörung.

The case of a young woman with still ongoing incest and forced prostitution is presented. The criteria for a dissociative identity disorder (DID) were met. Due to persistent contact to the perpetrator she was repeatedly revictimized. Based on the model of trauma-related dissociation we discuss to what extent she was capable of self-determined decision making as well as therapeutic consequences resulting therefrom.

[Effects of implementation of psychiatric out-patient clinics ("institutsambulanzen") on hospital admissions]. / Auswirkungen der Einrichtung von Institutsambulanzen auf die Inanspruchnahme stationärer Behandlung.

OBJECTIVE: In the German federal state Baden-Wuerttemberg psychiatric out-patient clinics ("Institutsambulanzen") have been implemented since 2002, later than elsewhere. The effects of these new out-patient services on the use of in-patient services should be examined in a defined catchment area. METHOD: Data on the use of in-patient services 2002 - 2011 was recorded from psychiatric hospitals and day hospitals in a catchment area of 862 000 inhabitants as well as data from the corresponding out-patient clinics. RESULTS: While the number of patients in the out-patient clinics increased from 1986 in 2002 to 7925 in 2011, the number of hospitalised patients increased only moderately, from 4452 in 2002 to 4930 in 2011. An increasing percentage of patients in the out-patients clinic did not use in-patient services in the respective year. This concerned particularly patients with adjustment and personality disorders, who do not find other appropriate psychotherapeutic care as out-patients. CONCLUSIONS: The implementation of out-patient clinics had no significant effect on the number of hospitalisations and occupied beds.

[Analysis of patterns of in-patient and out-patient mental health care by use of routine data]. / Sektorübergreifende Analyse psychiatrischer Behandlungs- und Versorgungsleistungen mittels Routinedaten.

OBJECTIVE: The Centre of Psychiatry Suedwuerttemberg routinely records data on service use of in-patient units, day hospitals and out-patient services on a daily basis as well as data on the respective patients according to the German Basic Documentation (BADO). Other psychiatric services in the catchment area of the districts Ravensburg and Bodenseekreis such as services of sheltered living, residential homes and vocational services collect identical data per day of use. Aim of the study is to compare routinely recorded data of mental health service use and direct cost of service use with sample data. We compared analyses of mental health service use and direct cost of service use with routinely recorded data with analyses using sample data. METHODS: Concerning the year 2008, we joined these different data sets, processing them in order to obtain pseudonymity and fulfil data protection requirements. This joint data set maps the total expenditures for psychiatric care utilisation in this region. RESULTS: Using a data set of this kind, analyses of health economy are possible which are comparable or even superior to those from sample data. CONCLUSION: Routinely recorded data are a cost-saving alternative to sample data.

[Assessment and treatment of patients with nonepileptic dissociative seizures in a department of epileptology]. / Diagnostik und Therapie von Patienten mit nicht-epileptischen dissoziativen Krampfanfallen in einer Abteilung fur Epileptologie.

OBJECTIVES: We examined the frequency of dissociative seizures in inpatients of a specialized ward for epilepsy as well as their diagnostic and therapeutic course. The basic principle of the latter is the therapeutic triad of value-free communication of the diagnosis, training of techniques for seizure interruption and problem solving of inner conflicts. METHODS: All inpatients in a department of epileptology with a diagnosis of dissociative seizures were examined retrospectively for the year 2009. RESULTS: 65 patients (11 %) were diagnosed with dissociative seizures, 23 patients with a primary diagnosis of epilepsy and 42 with a secondary diagnosis, epilepsy being the primary diagnosis. Symptoms occurred in the 23 patients with dissociative seizures as primary diagnosis between 2 weeks and 40 years. Possible predisposing factors and psychological comorbidities for the development of dissociative seizures were manifold. A psychopharmacological medication was established in 9 patients (39 %), and psychotherapy was recommended explicitly in all patients. CONCLUSIONS: There is a great heterogeneity in patients with dissociative seizures with a sometimes long course of the disorder.

[PGI-I (patient's global impression) as an outcome and quality indicator of psychiatric in-patient treatment: results and concordance with doctor's assessments]. / PGI-I (Patient's Global Impression) als Outcome und Qualitätsindikator bei stationärer Behandlung: Ergebnisse und Übereinstimmung mit Beurteilungen der Behandler.

OBJECTIVE: To examine the Patient Global Impression Scale of Improvement (PGI) as a quality indicator in routine psychiatric in-patient treatment and to determine its concordance with doctors' assessments. METHODS: Patients treated in 2007 in 5 hospitals and 4 day-clinics were included. A set of patient and treatment characteristics (German BADO) and CGI scales were recorded in all patients. Patients were required to give a PGI rating at discharge. RESULTS: PGI ratings could be obtained in 70.3 of the patients (N = 3957). PGI and doctors' CGI-I ratings were in agreement with no more than one degree of difference on the 7-point scale of the PGI in 89.8 %. Characteristics of those patients who significantly deviated from the doctors' assessments were determined. CONCLUSIONS: The PGI scale is appropriate as a quality indicator for routine clinical treatment which can rather easily be obtained.

[Effects of a training of power and balance on the use of mechanical restraint among in-patients with dementia]. / Effekte eines Kraft- und Bewegungstrainings auf die Fixierungshäufigkeit bei Demenzpatienten in der stationären gerontopsychiatrischen Versorgung.

BACKGROUND: Patients with dementia are most frequently affected by mechanical restraint in psychiatric hospitals, most frequently due to falls. There is evidence for beneficial effects of a training of power and balance on the frequency of falls in residential homes. METHODS: An adapted training of power and balance was developed by specialists of training in sports. In 2007, 159 patients with dementia were trained. The frequency and duration of mechanical restraint was compared with a control group of a different hospital (n = 217) and the patients treated in the year before (n = 164). RESULTS: The percentage of patients with mechanical restraint and the mean duration of restraint per admission were significantly lower than in the control group. However, only a non-significant reduction could be achieved in comparison with the patients treated in the year before without an increase of falls. CONCLUSIONS: A considerable reduction of the use of mechanical restraint in patients with dementia is feasible. An unequivocal association with the training could not be confirmed due to other influencing factors.

Successful interventions on an organisational level to reduce violence and coercive interventions in in-patients with adjustment disorders and personality disorders.

BACKGROUND: Self-directed and other violence as well as subsequent coercive interventions occur in a substantial proportion of patients with personality disorders during in-patient treatment. Different strategies may be required to reduce coercive interventions for patients of different diagnostic groups. METHODS: We specialised one of our acute admission wards in the treatment of personality disorders and adjustment disorders (ICD-10 F4 and F6). Patients are not transferred to other acute wards in case of suicidal or violent behaviour. Violent behaviour and coercive interventions such as seclusion or restraint were recorded in the same way as in the rest of the hospital. We recorded the percentage of subjects affected by diagnostic group and average length of an intervention in the year before and after the change in organisational structure. RESULTS: The total number of coercive interventions decreased by 85% both among patients with an F4 and those with an F6 primary diagnosis. Violent behaviours decreased by about 50%, the proportion of involuntary committed patients decreased by 70%. CONCLUSION: The organisational change turned out to be highly effective without any additional cost of personnel or other resources.

Synthesis and membrane binding properties of a lipopeptide fragment from influenza virus a hemagglutinin.

Hemagglutinin from influenza virus A is a S-palmitoylated lipoglycoprotein in which the lipid groups are thought to influence the interaction between cell membrane and capsid during budding of viral offspring as well as fusion processes of the viral membrane with the endosome after entry of the viral particle into the cell. The paper describes the development of a method for the synthesis of characteristic lipidated hemagglutinin derived peptides which additionally carry the fluorescent 7-nitrobenz-2oxa-1,3-diazole (NBD) group. To achieve this goal the enzyme-sensitive para-phenylacetoxybenzyloxycarbonyl (PAOB) ester was developed. It is cleaved from the peptides and lipidated peptides under very mild conditions and with complete selectivity by treatment with the enzyme penicillin G acylase; this results in the formation of a phenolate. This intermediate spontaneously undergoes fragmentation thereby releasing the desired carboxylates. The combined use of this enzyme-labile fragmenting ester with the acid-labile Boc group, the Pd(0)-sensitive allyl ester and the corresponding Aloc urethane gave access to a mono-S-palmitoylated and a doubly S-palmitoylated NBD-labelled hemagglutinin peptide. The binding of these lipopeptides to model membranes was analyzed in a biophysical setup monitoring the transfer of fluorescent-labelled lipopeptide from vesicles containing the non-exchangeable fluorescence quencher Rho-DHPE to quencher-free vesicles. The experiments demonstrate that one lipid group is not sufficient for quasi-irreversible membrane insertion of lipidated peptides. This is, however, achieved by introduction of the bis-palmitoyl anchor. The intervesicle transfer always implies release of peptides localized at the outer face of the vesicles into solution followed by diffusion to and insertion into acceptor vesicles. For peptides bound at the inner face of the vesicle membrane, however, an additional flip-flop diffusion to the outer face has to occur beforehand. The kinetics of these processes were estimated by fast chemical quench of the outside fluorophores by sodium dithionite.

Solid-phase synthesis of lipidated peptides.

Characteristic partial structures of lipidated proteins embodying different lipid groups as well as additional fluorescent tags or a maleimide for coupling to proteins can be synthesized readily by means of a new solid-phase technique employing the oxidative cleavage of the hydrazide linker as well as on-resin farnesylation and palmitoylation after appropriate deprotection of cysteine thiol groups as the key steps.

Synthesis and Membrane-Binding Properties of a Characteristic Lipopeptide from the Membrane-Anchoring Domain of Influenza Virus A Hemagglutinin.

On the trail of the influenza virus! Fluorescent-labeled lipopeptides, such as the characteristic S-palmitoylated partial structure from influenza virus hemagglutinin A, can be synthesized efficiently by employing a new enzymatic protecting-group technique in the key steps. Their binding to model membranes was determined in a kinetic assay, so leading to a first approximation of the membrane-anchoring ability of the corresponding lipopeptide motif in the parent protein.