[Advance directives and mental disorders: a practice recommendation of the Commission for Ethics and Law of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Patientenverfügungen und psychische Erkrankung ­ eine Praxisempfehlung der Kommission Ethik und Recht der DGPPN.

BACKGROUND: Since the creation of legal requirements for advance directives by the legislator in 2009, special aspects of their application in the treatment of people with mental illnesses have been discussed. GOAL OF THE PAPER: Important questions on dealing with advance directives in everyday life will be answered in a practice-oriented manner. RESULTS: Among other things, this document answers the question of the conditions under which a patient can refuse or consent to hospitalization and treatment in advance, and in particular how to deal with advance directives whose implementation would also affect the rights of third parties. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has addressed these and other questions in the present document and added practical advice on how to formulate advance directives for people with mental illnesses and how to deal with psychiatric advance directives. DISCUSSION: The DGPPN has developed an advance directive for the area of mental health and published it on its website together with detailed explanations. With the help of this advance directive, people can decide on their treatment in phases of incapacity to consent in the context of a mental crisis or illness.

[The situation in the German forensic commitment-Results of a survey by the DGPPN]. / Die Situation des deutschen Maßregelvollzugs ­ Ergebnisse einer Umfrage der DGPPN.

BACKGROUND AND OBJECTIVE: In German forensic psychiatry detention under Sections 63 and 64 of the German Penal Code have been repeatedly reformed over the past years; however, despite the most recent amendments to the law on detention, clinics and state authorities warn of insufficient capacities and worrying conditions. Media reports paint a defiant picture. At the same time, there is a lack of valid data that would allow an objective description of the situation in forensic psychiatry. Against this background the management of institutions in Germany has been surveyed. MATERIAL AND METHODS: The survey was conducted as an online survey and sent to all 78 forensic hospitals in Germany. The survey covered topics such as structural data of the facilities, the occupancy and staffing situation, incidents, support from supervisory authorities and funding agencies, and patient characteristics. The results are presented descriptively. RESULTS: Of the 78 facilities contacted, 45 (approximately 60%) participated at least partially in the survey. Many of the clinics (68.5%) complained of significant overcrowding. A clear lack of staff and rooms was reported, at the same time it was stated that patients do not receive adequate treatment. Approximately 1 in 5 patients have a length of stay for more than 10 years and one third of the clinics reported an increasing number of physical assaults by patients. CONCLUSION: This overview shows that the forensic psychiatric hospitals are in very different but generally strained situations. A significant number of clinics are under great pressure. Financial, structural, spatial and personnel resources were described as insufficient to properly and professionally fulfill the legal mandate. The treatment standards presented by the DGPPN in 2017 are not met in many clinics.

[Assisted suicide from a psychiatric perspective]. / Der assistierte Suizid aus psychiatrischer Sicht.

Assisted suicide has been the subject of controversial debates for years, particularly intensively since a ruling by the Federal Constitutional Court of Germany (BVerfG) in 2020, which postulated that the only prerequisite for the legitimacy of assistance is the free decision to commit suicide. This brings the issue into the focus of psychiatry. On the one hand, because people with mental illnesses can seek assisted suicide and on the other hand, because these illnesses often but not necessarily limit the ability to make a free decision on suicide. In the area of tension between the medical obligation to life and to suicide prevention on the one hand and the obligation to respect autonomous decisions of patients on the other hand, psychiatrists are not only personally challenged to develop a moral stance, but also as a profession to define the role and obligations of the discipline. This overview aims to contribute to this.

[Sleep medicine in psychiatry and psychotherapy]. / Schlafmedizin in der Psychiatrie und Psychotherapie.

Sleep medicine is a cross-disciplinary subject with high relevance for psychiatry and psychotherapy. The three most common sleep disorders (insomnia, sleep apnea syndrome and restless legs syndrome) are presented here with practical relevance. Cognitive behavioral therapy is the treatment of choice for insomnia, whereas symptomatic drug treatment (especially with GABA receptor agonists) should be used with caution. Sleep-related breathing disorders have a high prevalence of around 24% among psychiatric inpatients in Germany. Typical symptoms of obstructive sleep apnea syndrome should lead to a staged diagnostic process and, if necessary, cardiorespiratory polysomnography. It is not unusual for restless legs syndrome to be caused by psychopharmacological treatment. The primary form was usually treated with dopamine or dopamine agonists but due to the risk of augmentation, alternatives should be considered more often.

[Assisted suicide : Attitudes and experiences of members of the DGPPN]. / Der assistierte Suizid : Einstellungen und Erfahrungen der Mitglieder der DGPPN.

BACKGROUND AND OBJECTIVE: After the Federal Constitutional Court overturned the ban on business-like assisted suicide in 2020, politicians, society and the medical profession are discussing legal protective measures to prevent abuse. This survey among members of the DGPPN is the first to record the attitudes and experiences regarding assisted suicide of psychiatrists and other mental health workers in Germany, as suicidality and assisted suicide are highly relevant topics for medicine and especially for psychiatry and psychotherapy. MATERIAL AND METHODS: The survey was conducted as an online survey with a specially created questionnaire and a DSGVO-compliant data protection concept and sent to a total of 9356 members. In addition to the descriptive analysis of the questionnaire, the free-text responses were subjected to an additional qualitative analysis. Finally, correlations between sociodemographic variables and relevant items were examined. RESULTS: A total of 2048 members participated in the survey (22%). Most participants (88%) considered a (new) legal regulation of assisted suicide to be necessary; the separation of counselling, assessment and execution of assisted suicide was mentioned most frequently (76%). The majority considered assisted suicide to be legitimate under certain circumstances when the suicide wish is freely made (72%), especially in cases of high suffering and near the end of life (67%). Age, gender, and religious beliefs were found to be significant influencing factors in several responses. CONCLUSION: A large majority of the DGPPN members consider it necessary to find a legal regulation that prevents abuse of assisted suicide; however, while most participants did not consider assisted suicide to be legitimate or illegitimate in principle, but rather made this dependent on the specific circumstances of the suicide wish, more than half ruled out to assist with suicide. The results represent an important contribution to the political debates about legal protective measures.

[Dramatic changes in the age structure for medical specialists in the field of mental health]. / Dramatische Veränderungen der Altersstruktur bei Fachärzten im Bereich psychischer Gesundheit.

BACKGROUND: Over the past 20 years the importance of treatment of people with mental and neurological disorders has greatly increased. Parallel to this development it has become more difficult to attract young physicians to this field. The aim of this study was to examine the development of the number of physicians specialized in the care of patients suffering from neurological, mental and psychosomatic disorders with special consideration of the age structure. MATERIAL AND METHODS: The analyses were based on the number of professionally active physicians and specialized physicians published by the German Medical Association for the years 2000-2020. Separate age groups were looked at for psychiatry and psychotherapy (PPT), psychosomatic medicine and psychotherapy (PMPT), Nervenheilkunde (formerly psychiatry and neurology together, NHK) and neurology. RESULTS: In comparison to the year 2000 the number of specialized physicians working in PPT (4736 vs. 12,053), neurology (2226 vs. 8355) and PMPT (3543 vs. 4130) increased in 2020, while the number of specialists actively working in NHK decreased (5184 vs. 2301). Parallel to this the proportion of women increased. Dramatic changes occurred concerning the age structure. Currently, 77.7% of specialists working in NHK and 59.7% working in PMPT are over 60 years old. In 2020 there were 2988 specialists aged over 60 years in the discipline of PPT compared to only 1070 under 40 years, which is dramatically different from 20 years earlier when only 181 were over 60 years but 1491 were under 40 years old. CONCLUSION: The overaging of professional specialists and the shortage of junior physicians jeopardize modern and adequate provision of care for mentally ill patients. Possible solutions include a marked increase in medical school capacities as well as strategies to convince young physicians to work in the disciplines of PPT and PMPT.

European guideline and expert statements on the management of narcolepsy in adults and children.

BACKGROUND AND PURPOSE: Narcolepsy is an uncommon hypothalamic disorder of presumed autoimmune origin that usually requires lifelong treatment. This paper aims to provide evidence-based guidelines for the management of narcolepsy in both adults and children. METHODS: The European Academy of Neurology (EAN), European Sleep Research Society (ESRS), and European Narcolepsy Network (EU-NN) nominated a task force of 18 narcolepsy specialists. According to the EAN recommendations, 10 relevant clinical questions were formulated in PICO format. Following a systematic review of the literature (performed in Fall 2018 and updated in July 2020) recommendations were developed according to the GRADE approach. RESULTS: A total of 10,247 references were evaluated, 308 studies were assessed and 155 finally included. The main recommendations can be summarized as follows: (i) excessive daytime sleepiness (EDS) in adults-scheduled naps, modafinil, pitolisant, sodium oxybate (SXB), solriamfetol (all strong); methylphenidate, amphetamine derivatives (both weak); (ii) cataplexy in adults-SXB, venlafaxine, clomipramine (all strong) and pitolisant (weak); (iii) EDS in children-scheduled naps, SXB (both strong), modafinil, methylphenidate, pitolisant, amphetamine derivatives (all weak); (iv) cataplexy in children-SXB (strong), antidepressants (weak). Treatment choices should be tailored to each patient's symptoms, comorbidities, tolerance and risk of potential drug interactions. CONCLUSION: The management of narcolepsy involves non-pharmacological and pharmacological approaches with an increasing number of symptomatic treatment options for adults and children that have been studied in some detail.

Sleep medicine catalogue of knowledge and skills - Revision.

The 'catalogue of knowledge and skills' for sleep medicine presents the blueprint for a curriculum, a textbook, and an examination on sleep medicine. The first catalogue of knowledge and skills was presented by the European Sleep Research Society in 2014. It was developed following a formal Delphi procedure. A revised version was needed in order to incorporate changes that have occurred in the meantime in the International Classification of Sleep Disorders, updates in the manual for scoring sleep and associated events, and, most important, new knowledge in sleep physiology and pathophysiology. In addition, another major change can be observed in sleep medicine: a paradigm shift in sleep medicine has taken place. Sleep medicine is no longer a small interdisciplinary field in medicine. Sleep medicine has increased in terms of recognition and importance in medical care. Consequently, major medical fields (e.g. pneumology, cardiology, neurology, psychiatry, otorhinolaryngology, paediatrics) recognise that sleep disorders become a necessity for education and for diagnostic assessment in their discipline. This paradigm change is considered in the catalogue of knowledge and skills revision by the addition of new chapters.

European guideline and expert statements on the management of narcolepsy in adults and children.

BACKGROUND AND AIM: Narcolepsy is an uncommon hypothalamic disorder of presumed autoimmune origin that usually requires lifelong treatment. This paper aims to provide evidence-based guidelines for the management of narcolepsy in both adults and children. METHODS: The European Academy of Neurology (EAN), European Sleep Research Society (ESRS) and European Narcolepsy Network (EU-NN) nominated a task force of 18 narcolepsy specialists. According to the EAN recommendations, 10 relevant clinical questions were formulated in PICO format. Following a systematic review of the literature (performed in Fall 2018 and updated in July 2020) recommendations were developed according to the GRADE approach. RESULTS: A total of 10,247 references were evaluated, 308 studies were assessed and 155 finally included. The main recommendations can be summarized as follows: (i) excessive daytime sleepiness in adults-scheduled naps, modafinil, pitolisant, sodium oxybate (SXB), solriamfetol (all strong), methylphenidate, amphetamine derivates (both weak); (ii) cataplexy in adults-SXB, venlafaxine, clomipramine (all strong) and pitolisant (weak); (iii) excessive daytime sleepiness in children-scheduled naps, SXB (both strong), modafinil, methylphenidate, pitolisant, amphetamine derivates (all weak); (iv) cataplexy in children-SXB (strong), antidepressants (weak). Treatment choices should be tailored to each patient's symptoms, comorbidities, tolerance and risk of potential drug interactions. CONCLUSION: The management of narcolepsy involves non-pharmacological and pharmacological approaches with an increasing number of symptomatic treatment options for adults and children that have been studied in some detail.

[Revision of §64 of the German Penal Code from a psychiatric perspective-Position paper of a task force of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Neuregelung des § 64 StGB aus psychiatrischer Sicht ­ Positionspapier einer Task-Force der DGPPN.

In Germany every second offence occasioning bodily harm and every fourth sexual offence occur under the influence of alcohol or drugs. Untreated substance use disorders are a risk factor for further offences. The §64 of the German Penal Code (StGB) regulates the commitment of offenders to a Forensic addiction treatment unit as a result of an addiction to excessive consummation of intoxicating substances. The previous regulation has come under criticism because too many patients are committed, the sentence is often given to the wrong persons, the treatment is often terminated without success and the sentence consumes to many resources. From a psychiatric perspective the reform of commitment to a Forensic addiction treatment unit (§64 StGB) must fulfil the principles of medical ethics, in particular the respect for the autonomy of the patient, the principle of distributional justice and the code of medical professional ethics. The commitment according to §64 must be restricted to the treatment of people with a clinically relevant substance use disorder. From a psychiatric perspective, decisive for the prospect of success are the willingness to be treated and self-determination for admission to the clinic. In order to release the treatment from the extrinsic influences of the enforcement law, on admission to treatment a sufficient amount of the sentence should have already been served that the commitment only serves the purpose of the treatment and resocialization, so that the risk of further substance-related offences is reduced. The legal term "Entziehungsanstalt" should be replaced by "Forensic Clinic for Dependancy Diseases".

[Coercive measures and the SARS-CoV-2 pandemic]. / Zwangsmaßnahmen und die SARS-CoV-2-Pandemie.

In the clinical daily work of psychiatry, the question regularly arises under which legal conditions patients who are not able to form free will due to a mental illness should be treated in case of an additional suspicion of a SARS-CoV-2 infection or with a confirmed Covid-19 disease. However, physicians may be uncertain about the legal basis for coercive measures during the corona pandemic: when and under which legal conditions such measures are required. This article presents and discusses in detail the legal regulations currently applicable in Germany.

[Internet-based cognitive behavioral therapy of insomnia and nightmare disorder]. / Internetbasierte kognitive Verhaltenstherapie der Insomnie und Albtraumstörung.

Cognitive behavioral therapeutic interventions are considered to be one of the most effective forms of treatment of various mental disorders. Besides being very frequent, sleep disorders, such as insomnia and nightmare disorder are often not treated effectively and guideline-conform, mainly due to the lack of qualified psychotherapists. Implementation of modern technical options, such as web-based psychotherapy can help to overcome this problem. This article presents the current situation in the treatment of insomnia and nightmare disorders as particularly well-suited fields of application. For insomnia there are several English language and also recently German language options, which for example were also evaluated for the application to work-related stress and sleep disorders. In this respect, procedures with and without contact to a therapist or multicomponent procedures and single interventions can be differentiated. For nightmare disorders imagery rehearsal therapy provides a structure, which can also easily be transferred to an internet-based therapy program. The currently beginning use of internet-based treatment of sleep disorders does not yet utilize all theoretically available technical possibilities. The potential of internet-based therapy is extremely versatile and it remains for medical sleep experts to consider which method can be used for which indications.

[Recommendations on performing polygraphy or polysomnography in the fields of psychiatry and psychotherapy : Position paper of the working group on sleep medicine of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Empfehlungen zur Durchführung einer Polygraphie oder Polysomnographie im Bereich Psychiatrie und Psychotherapie : Positionspapier des DGPPN-Referats Schlafmedizin.

Difficulties in falling asleep and maintaining sleep, nonrestorative sleep and decreased daytime wakefulness represent very common but relatively unspecific health complaints. Around 100 specific sleep-related disorders will be classified in their own major chap. 7 (sleep wake disorders) for the first time in the upcoming 11th version of the International Classification of Diseases (ICD 11). With respect to the disciplines of psychiatry and psychotherapy there is a bidirectional relationship between mental health and sleep wake disorders. Sleep wake disorders can be an independent risk factor for the onset of a mental disorder and have a negative influence on the course of the disease. In addition, sleep wake disorders can also precede a mental disease as an early symptom and therefore be an important indication for early recognition. Many sleep wake disorders can be diagnosed based on the anamnesis and routine clinical investigations. In special cases, examination in a specialized sleep laboratory and treatment in a sleep medicine center following a staged care approach can be mandatory. Polysomnography represents the gold standard for the differential diagnostics; however, there is no legal foundation in the field of neuropsychiatric disorders for remuneration in the German healthcare system. This review summarizes the current guidelines with respect to the criteria for an investigation in a sleep laboratory from the perspective of the disciplines of psychiatry and psychotherapy. From this the requirements for guideline-conform diagnostics and treatment are derived.

[Autonomy focusing as guiding idea of minimally restrictive psychiatry]. / Autonomiefokussierung als Leitgedanke einer minimal-restriktiven Psychiatrie.

Coercion and violence in psychiatric inpatient settings represent a serious challenge. This challenge cannot be successfully met just by denying any legitimation of coercive measures or by assuming that violence from the patients' side is a fateful complication. Coercive measures are essentially approximative solutions of interpersonal and intrapersonal conflicts of autonomy, if these cannot be resolved without violence. Therefore, prevention of coercive measures can only succeed when the focus is on the needs and rights for autonomy of all subjects involved, including patients, relatives and staff. Autonomy-focused psychiatry targets transparency of conflicts of interests and aims at limiting coercive measures to the absolute minimum necessary by preventive means. A number of effective measures are available to achieve a comprehensive implementation strategy. Using these measures in clinical practice must evolve, however, during a dynamic continuous improvement process and implementation should be based on the local as well as legal, administrative and architectural situation and the available human resources. The presently widespread prioritization of opening closed psychiatric wards is insufficient to effectively minimize coercion and violence in psychiatric inpatient settings.