Naturalistic pharmacotherapy of acute episodes of schizophrenic disorders in comparison to treatment guidelines.

INTRODUCTION: This study was designed to investigate to what extent guidelines regarding the pharmacological treatment of patients suffering from schizophrenia-like psychosis are adopted in a naturalistic treatment setting. METHODS: Medical records of n=819 patients undergoing inpatient treatment for schizophrenia-like psychosis in 11 psychiatric hospitals in northwestern Germany were retrospectively analyzed and findings were compared to current schizophrenia guideline recommendations. RESULTS: The prescription rate of second generation antipsychotics increased from 47.1% on admission to 62.5% at discharge. Only half the patients (52.3%) received antipsychotic monotherapy while 47.7% took between 2 and 4 antipsychotic substances at a time. Dosage increases occurred most frequently (in 60%) within the first week of inpatient treatment, 16.6% experienced an elevation between days 15 and 29. A change within the atypical medication was found in 19.3%. Clozapine prescriptions increased throughout the treatment but were combined with other antipsychotic substances in the majority of cases. CONCLUSION: Under naturalistic conditions guideline recommendations for treatment of schizophrenia-like psychosis are adhered to only partially. Combination therapy with 2 or more antipsychotic drugs is quite common despite a clear recommendation for monotherapy.

Galantamine: a cholinergic patch in the treatment of alcoholism: a randomized, placebo-controlled trial.

OBJECTIVES: The involvement of the central cholinergic system in alcohol abuse behavior is well known. It is possible that the reinforcing effects of ethanol are partially mediated by nicotinic receptors, which modulate neurotransmitter release. It was demonstrated that the application of a cholinesterase inhibitor reduces alcohol consumption in alcohol-preferring rats. This suggests that galantamine (GAL), a cholinesterase inhibitor, could be effective when seeking to prolong abstinence in recently detoxified alcoholics. This study represents the first reported clinical trial of a cholinergic drug in alcohol-relapse prevention. PATIENTS AND METHODS: We investigated the efficacy and safety of GAL by conducting a 24-week randomized, placebo-controlled, multicentric clinical trial on 149 recently detoxified alcoholics. Survival analyses (Kaplan-Meier) were performed to reveal evidence of prolonged abstinence periods in patients who received GAL. RESULTS: Our findings did not support our hypothesis. GAL did not extend the time to first severe relapse. However, additional post hoc analyses suggest that relapsed patients treated with GAL consume less ethanol per drinking day than patients treated with placebo. CONCLUSIONS: GAL seems to be ineffective when used in relapse prevention of detoxified alcoholics. It is possible that alcohol needs to be "on board" for GAL to be beneficial. This could explain why our post hoc analysis showed that GAL possibly reduces the alcohol consumption of relapsers. If confirmed, GAL could play a role in the reduction of harmful alcohol use and at-risk consumption.

[Work, income, intimate relationships: social exclusion of the mentally ill]. / Arbeit, Einkommen, Partnerschaft: Die soziale Exklusion psychisch kranker Menschen.

OBJECTIVES: There are no valid data on the social exclusion of mentally ill people in Germany. This study analyses the social exclusion of the mentally ill. METHODS: With a Scientific Use File on early retirement in 2003, we found a nationally representative database for chronically ill persons. The inclusion in the working market, the work income and the exclusion of intimate relationships of chronically mentally ill people are compared to those of physically disabled people. RESULTS: Mentally ill persons are more excluded than physically ill persons on all three indicators. This is especially true for persons with schizophrenia and alcohol addiction. CONCLUSIONS: Scientifically sound instruments such as Supported Employment need to be implemented in Germany, too.

[Social exclusion of the mentally ill -- a critical review and outlook of community psychiatry at the beginning of the 21st century]. / Zur sozialen Exklusion psychisch Kranker -- Kritische Bilanz und Ausblick der Gemeindepsychiatrie zu Beginn des 21. Jahrhunderts.

The social implications and disabilities of long-term mental disorders have been well described and are known for a long time. The classical paradigm of social psychiatry postulating that dehospitalization automatically generates social integration has proven to be wrong. Along that line the view that living in the community supported by different services aiming at integration has also failed to be successful. Without explicitly labelling it: community-based psychiatry has yielded a psychiatry-based community. It never served the majority of the non-chronically mentally ill with disordered social skills who also need specific support or are as well bound for unemployment and social disadvantages. Without doubt, the progress made by community psychiatry in the past was eminently linked to the ideology and implementation of deinstitutionalization. Defining and dealing with social exclusion means a turning point for social and community psychiatry - a new paradigm that could generate a different view upon therapeutical outcomes and the way that therapy and rehabilitation have to be organised and implemented. Especially the example of vocational rehabilitation could mark a stepping stone by initiating further investigations and progress for new approaches in community support. Supported employment programmes have shown the superiority of "place and train" instead of first train in institutions or services and then place on the spot. Thus a so-called inclusion therapy could arise that takes place "in vivo et actu" and near to the individual's real world of tasks and demands. Progress in any part of multidimensional therapy is legitimized only by empirical validation of functional outcome and social inclusion measures. Such an evaluation of complex programmes taking social inclusion into account is sophisticated but seems to be necessary in the field of general psychiatric therapies as well as for the legitimation of financial resources needed. Foreseeing the perspective of social psychiatry a next substantial step could be the identification of social and functional outcome variables.

[Short-term effects of acute inpatient treatment of alcoholics. A prospective, multicenter evaluation study]. / Kurzfristige Effekte der stationären Akutbehandlung alkoholabhängiger Patienten. Eine prospektive, multizentrische Evaluationsstudie.

BACKGROUND: In spite of a high prevalence of patients with alcohol addiction being treated in mental hospitals, the acute treatment of alcoholism has seldom been evaluated. METHODS: This follow-up study was conducted in five mental hospitals in northwestern Germany. Enrolled were 479 consecutively admitted patients, of whom 411 (86%) could be interviewed 3 months after discharge. RESULTS: 3 months after discharge, 60.5% of the intention-to-treat sample and 54% of the follow-up sample had relapsed. Twenty-eight percent had taken part in inpatient rehabilitation programmes, and 26.5% had had at least one further inpatient withdrawal treatment. There were highly significant reductions in quantity of consumed alcohol, numbers of drinking days, and numbers of intoxication days. Multivariate analyses revealed that biographical, social, and treatment-related items were predictors of unfavourable outcome (excessive alcohol consumption and/or readmission to inpatient treatment). A short length of stay was identified as a predictor of unfavourable health status after 3 months. CONCLUSIONS: For many patients, inpatient acute treatment is an effective intervention which promotes abstinence, reduces alcohol consumption, and enhances integration into the addiction treatment system. For chronically addicted and repeat patients, this treatment as a repetitive crisis intervention helps in the short term but does not result in lasting changes in the course of illness.

Dominance of Fermi-surface holes in p-type tunneling.

In-plane uniaxial stress is used to tune continuously the mixing between the heavy-hole (HH) and light-hole (LH) states in a p-type double-barrier structure. The LH1 and HH2 resonant tunneling peaks shift at almost the same rate with stress, in contrast to the corresponding exciton peaks observed by photoreflectance, which exhibit a strong Fano-related anticrossing. Comparison between the observed shifts and a four-band k x p calculation of the state energies in the well provides the first experimental proof that the flow of holes through off-zone center states dominates the resonant tunneling current in p-type structures.

Effective mass anisotropy of gamma electrons in GaAs/AlGaAs quantum wells.

Resonant magnetotunneling in GaAs/Al(0.28)Ga0.72As double barrier structures is used to demonstrate that the effective mass of confined Gamma conduction electrons becomes anisotropic when an electric field is applied perpendicular to the interfaces. Although several authors have previously reported Gamma-related optical anisotropy, this is the first example of a corresponding electrical anisotropy. The results are explained using a quantum mechanical model involving interface band mixing that contains additional features not found in the optical case.

Long-term psychiatric patients in vocational rehabilitation programmes: a naturalistic follow-up study over 3 years.

OBJECTIVE: This paper aims at assessing the vocational integration attained after a 3-year period by psychiatric patients who participated in different vocational rehabilitation programmes. METHOD: In the north-western German region of Westphalia-Lippe a naturalistic follow-up study was carried out on 471 patients from three different types of vocational rehabilitation programmes. The sample comprised chronically ill patients with a history of repeated and long-term hospitalization. RESULTS: After 3 years 11% of the patients were in competitive employment, 67% (still) in sheltered employment, 7% in out-patient work therapy programmes and 15% were unemployed. It is important to notice that 74% achieved their subjective rehabilitation goals expressed at baseline. CONCLUSION: Vocational rehabilitation programmes are an essential part in the treatment of people with chronic mental illness. Integration into work varies markedly while patients' satisfaction is comparably good. Competitive employment represents a realistic objective only for patients with high motivation and favourable preconditions.

[Homeless men in inpatient psychiatric treatment--a controlled study. 1: Health status and self assessment at intake]. / Wohnungslose Männer in stationär psychiatrischer Behandlung--Eine kontrollierte Studie. Teil 1: Gesundheitszustand und Selbstwahrnehmung bei Aufnahme.

OBJECTIVE: This study examines the objective and the subjectively reported state of health, the social network and the utilisation of mental health services in a representative group of homeless men (n = 50) at time of admission to a psychiatric hospital and compares these results with a control group (matched by diagnosis) of non-homeless men. METHOD AND PATIENTS: The BPRS, the SF-12 Health Survey and a neglection index were administered. The main psychiatric diagnosis (ICD-10) were alcohol addiction (n = 29), drug addiction (n = 13), schizophrenia (n = 7) or personality disorder (n = 1). RESULTS: No differences were found according to sociodemographic basis data, but the homeless group had a smaller social network and less financial resources. There was a higher rate of involuntary admission in the homeless group, less contact to mental health services in the weeks before admission, more psychopathological symptoms and more physical neglection. Self-rating of mental and physical health, however, did not differ significantly. There was a positive correlation between thought disturbance and positive self-rating of mental health. CONCLUSION: The mental and physical health of the homeless patients was markedly worse. Beneath structural barriers symptoms, the extreme distress of their living situation and the decreased insight and motivation for treatment are characteristics of this group of patients which make them difficult to treat.

[Homeless men in inpatient psychiatric treatment--a controlled study. 2: Effects of treatment]. / Wohnungslose Männer in stationär psychiatrischer Behandlung--Eine kontrollierte Studie. Teil 2: Behandlungseffekte.

OBJECTIVE: This study examines the objective and the subjectively reported state of health in a regional representative sample of homeless men (n = 50) at time of admission into a psychiatric hospital and shortly before discharge and compares the results with a control group (matched by diagnosis) of non-homeless men. METHOD AND PATIENTS: The BPRS and the SF-12 Health survey were administered. The main psychiatric diagnosis (ICD-10) were alcohol or drug addiction (84%), schizophrenic disorders (14%) and personality disorders (2%). RESULTS: The median of hospitalisation was 26 days with no significant differences between the two groups. At discharge outpatient treatment was planned for only 16% of the homeless patients but for 40% of the controls. There was a significant improvement in symptoms and self reported state of health. On admission and discharge thought disturbance and a positive self-rating of mental health were significantly correlated. CONCLUSIONS: Against the wide-spread clinical prejudice that inpatient treatment of homeless mentally ill men is not effective our results show that the objective state of health as well as the self-perceived mental and physical health was improved by a regular psychiatric in-patient treatment. The results furthermore indicate the limitations of inpatient treatment the need for outpatient treatment programmes.

[Predictors of success in supported employment programmes--results of a prospective study]. / Prädiktoren einer erfolgreichen beruflichen Eingliederung. Ergebnisse einer prospektiven Studie.

BACKGROUND: Vocational integration of mentally ill patients is confronted not only with illness-related restrictions but also with the current situation on the labour market and prejudices on the part of potential employers. The Consultancy Centres for Vocational Integration work with a supported employment approach which was adapted to the German situation. It includes prevocational training, assistance in finding appropriate jobs, cooperation with employing companies and long-term job site support. METHODS AND PATIENTS: Within the scope of a major study on vocational rehabilitation in the German region of Westphalia-Lippe, we carried out a prospective study of the further vocational course of 61 patients who had already been placed in competitive employment within the framework of the Consultancy Centres. These patients (30 men, 31 women) had a mean age of 31 years (+/- 6.9); 54% of them were suffering from schizophrenic disorders; mean duration of illness was 8.2 years (+/- 6.8). RESULTS: After two years (and for a subsample of 33 patients also after 3 years) two-thirds of patients were still in competitive employment. Predictors of success proved to be 1) a higher ability to cope with vocational stress on introduction of the measure, 2) an earlier start to rehabilitation, and 3) financial assistance for the company. A close correlation was recorded between course of illness (rehospitalizations) and success of rehabilitation. CONCLUSIONS: Even in the current situation of high unemployment rates vocational integration of mentally ill patients is possible and stable in medium term. Especially highly-motivated patients with favourable preconditions (early start of rehabilitation measures, higher ability to cope with work stress) are successful if intensive long-term support--including efforts involving employers--is provided.

Long-term effects of a psychoeducational psychotherapeutic intervention for schizophrenic outpatients and their key-persons--results of a five-year follow-up.

The study examines long-term effects on rehospitalization rates of a psychoeducationally and cognitive-behaviorally oriented intervention for schizophrenic outpatients and their key-persons. 191 patients and their key-persons were allocated by random into four different treatment groups and one control group. Five years after completion of treatment 126 patients were reexamined by interviews or case notes. The rate of patients experiencing psychiatric rehospitalization during the follow-up was assessed in each respective treatment group. Concerning rehospitalization rates there was no significant difference between controls (n = 35) and patients of the four treatment groups (n = 91). There were, however, fewer rehospitalized patients in the group with combined psychoeducational and cognitive treatment, including key-person counselling (42%), than in the control group (69%). Regarding the overall functioning, the patients in this treatment group did slightly better than those in the control group. These results are in accordance with the findings of comparable studies.

[Psychiatric vocational therapy--concepts, practice and scientifically-based results]. / Psychiatrische Arbeitstherapie--Konzepte, Praxis und wissenschaftliche Ergebnisse.

Work therapy is a widespread form of socio-therapy. In contrast to pharmacological and somatic forms of treatment, proof of efficacy is difficult to produce in multimodal therapy of psychiatric patients. Within the framework of an extensive study on vocational rehabilitation of mentally ill patients, we carried out a naturalistic follow-up study of 112 mostly schizophrenic patients attending outpatient work therapy programmes. The courses of illness and rehabilitation were documented prospectively over a three-year period. At the end of the study 23% of the patients were integrated into the open labour market, 25% were working in sheltered employment, 25% remained in work therapy, and 27% were unemployed. Controlled studies with schizophrenic patients show, that work therapy contributes to improved vocational integration, a reduction of rehospitalizations and a stabilisation of the psychopathological status.

[Homeless and mentally ill. Review of recent research and results on a doubly disadvantaged minority]. / Wohnungslos und psychisch krank. Uberblick über den Forschungsstand und eigene Ergebnisse zu einer doppelt benachteiligten Randgruppe.

There are about 200,000 homeless persons in Germany, 35,000 of them living on the streets. They suffer from unemployment, poverty, social isolation and physical impairments. More than two-thirds of them suffer from mental illness as well. Substance abuse predominates, but also schizophrenic and affective disorders and personality disorders show a higher prevalence than among the general population. Comorbidity is found frequently. However, mental disorders are just one of several factors contributing to the process of becoming homeless. Due to the complex combination of mental, physical, social and economic problems of the homeless mentally ill psychiatric care is not sufficient. Yet recent US studies show that a combination of multimodal clinical measures and a network of outpatient assistance can improve both physical and mental health and the social situation. Having established reliable epidemiological data, future research should concentrate on analysing the influence of homelessness on mental health, and on planning and evaluating specific programmes for the homeless mentally ill.

[The course of illness and rehabilitation of schizophrenic patients in ambulatory vocational therapy. A prospective study over 3 years]. / Krankheits- und Rehabilitationsverläufe schizophrener Patienten in ambulanter Arbeitstherapie. Eine prospektive Studie über 3 Jahre.

Within the framework of a study on vocational rehabilitation of the mentally ill, we examined 83 schizophrenic outpatients enrolled in a work therapy program. The course of illness and rehabilitation was documented over a 3-year period by means of annual follow-up examinations. The sample comprised 44 men and 39 women with an average age of 35 years (SD +/- 8.5). The majority were chronically ill patients with a history of frequent and long psychiatric hospitalization. After 3 years, 22% of the patients were integrated into the general labor market, 26% had sheltered employment, 23% were still in work therapy, and 29% were unemployed. Besides the patients' subjective expectations, early introduction of rehabilitative measures and a favourable course of illness were found to be predictors of a successful rehabilitation leading to vocational integration. Outpatient work therapy is a contemporary, effective organizational form of sociotherapy. It may contribute to improved vocational competence and integration, reduced psychiatric hospitalization and stabilized psychopathology.