Relationship between baseline severity of depression and antidepressant treatment outcome.

INTRODUCTION: Assessment of depression severity is of key importance, since several clinical guidelines recommend choice of treatment dependent on the depression severity grade. Using different tools to assess baseline severity may result in different outcomes. METHODS: This paper describes the results of a multicentre, naturalistic study investigating the relationship between depression symptom severity (using 4 different measures of symptom severity) and clinical outcome among patients hospitalised for depression (N=1 014). Moreover, the impact of differences between methods of measuring depression severity has been investigated. Statistical analyses (univariate measurements, logistic regression models) were conducted to detect coherences and differences between the various methods of severity categorisation. RESULTS: Results revealed different associations between outcome and classification methods. Response or remission rates varied if baseline severity was assessed by different instruments. Moreover, the number of responders increased with higher baseline severity grades of depression, whereas the number of remitters decreased. Additional analyses dependent on outcome criteria using continuous instead of categorical data revealed similar results. DISCUSSION: Baseline severity may be only one of many other important clinical variables that mediate clinical outcome, but it is surely an important one deserving further research and consideration.

Selection of an immunogenic and protective epitope of the PsaA protein of Streptococcus pneumoniae using a phage display library.

Streptococcus pneumoniae is an important pathogen that causes disease in young and elderly individuals. The currently available polysaccharide vaccines have limited efficacy in those age groups most susceptible to pneumococcal infections. This study focuses on mapping the epitopes of a surface protein of S. pneumoniae by biopanning a 15 mer phage display library using 5 different monoclonal antibodies (MAbs) against the Pneumoccal surface adhesin A (PsaA). PsaA is a component of the bacterial cell wall that is highly species specific and is involved in bacterial adherence and virulence. Biopanning of the phage display library reveals three distinct epitopes on the PsaA protein. The sequence homology of these epitopes ranges from two to six amino acids when compared to the native PsaA protein type 2. Two of these epitopes have been evaluated for their immunogeneicity in mice. The peptide selected by the MAbs 8G12, 6F6, and 1B7 is referred to as the consensus peptide and is immunogenic in mice. Optimal anti-PsaA response is observed in mice immunized with 50microg of the consensus peptide complexed to proteosomes in 1:1 ratio. The anti-PsaA response is significantly lower than the response to the PsaA native protein. The peptide selected by monoclonal antibody 4E9 in its lipidated form is significantly protective in mice challenged with S. pneumoniae serotype 2 when compared to mice immunized with the native protein. These results show that the selected epitopes of PsaA protein are immunogenic and protective in mice. These epitopes need to be evaluated further as alternatives to currently available vaccines.

[Psychogram of the Auschwitz commander: insight and confrontation through destruction. On the autobiography of Rudolf Höss]. / Psychogramm des Kommandanten von Auschwitz: Erkenntnis und Begegnung durch Zerstörung. Zur Autobiographie des Rudolf Höss.

By reference to the personality of Rudolf Höss, the author illuminates once again the terrifying juxtaposition of criminality and apparent normality in the psychic life of a Nazi criminal. The inferno of the concentration camp is interpreted as a perverse explication and staging of split-off ideational contents in the mind of Höss.

The validity of self-rated psychotic symptoms in depressed inpatients.

BACKGROUND: Self-ratings of psychotic experiences might be biased by depressive symptoms. METHOD: Data from a large naturalistic multicentre trial on depressed inpatients (n=488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale. RESULTS: At discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P<0.001) and with the BDI total score (0.64, P<0.001). Moderate correlations were found for the MADRS (0.34, P<0.001), HAMD (0.37, P<0.001) and AMDP depression score (0.33, P<0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P<0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P<0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P=0.02). CONCLUSIONS: In depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.

The impact of temperament in the course of alcohol dependence.

AIMS: The aim of this study was to assess the impact of temperamental traits in alcohol dependent patients on the course of illness. METHODS: The case files of 116 alcohol dependent patients, according to ICD-10 and DSM-IV-TR, were examined retrospectively. All patients were in treatment between 02/08 and 03/09 at the Psychiatric Department of the General Hospital Vienna, either at the alcohol outpatient clinic or the psychiatric ward, which has the treatment focus on alcohol dependence. The brief TEMPS-M auto-questionnaire was used to assess the temperamental distribution. The dimensions of alcohol dependence have been assessed using the Lesch Alcoholism Typology, a computerized structured interview. The potential effect of temperamental scores on various outcomes describing the course of illness is investigated using multi-variable regression models. RESULTS: Cyclothymic score was the only temperament which significantly influenced the age of onset of alcohol abuse and age of onset of alcohol dependence. Backward selection among temperaments exhibits depressive temperament as most important effect regarding the likelihood of suicide-attempts in the patient's case history and anxious temperament as most important effect regarding having psychiatric treatment focusing on alcohol dependence prior to current in- or outpatient stay. LIMITATIONS: The sample size of this study is small compared to the number of investigated outcomes and temperaments. Further, a healthy control group, matched for age and gender, was not available for comparison of the temperament sub-scores. CONCLUSION: Dominant cyclothymic, but also depressive and anxious temperament, seem to be negative predictors for the course of illness in alcohol dependence. Regarding positive long term outcome specific evidence based medical treatment approaches are needed for these patients.

[The aggressive patient--comments on the social psychology of violence]. / Der aggressive Patient--Anmerkungen zur Sozialpsychologie der Gewalt.

The management of the violent patient in hospital requires highly skilled therapeutic staff. Prevention, restriction and therapy of aggressive behaviour needs adequate diagnosis and therapy of the underlying disorder, furthermore a well structured ward milieu. This study pays attention to maladaptive structuring of the therapeutic milieu, which interferes with the integration of the violent patient. Modernized psychiatric institutions with liberal administration tend to expel the troublesome, especially the violent patient, when the formal organization of the institution superstructure is weakened.

[The violent patient and institutional counter-violence]. / Gewalttätiger Patient und institutionelle Gegengewalt.

The treatment of violent patients confronts the individual psychiatric professional as well as the psychiatric institution as a whole with a difficult therapeutic task. In order to cope with frightening interactions an "institutionalized system of defense" (Mentzos) is needed to protect the individual staff member. Under unfavourable institutional circumstances the defence manifests itself as counter-aggression. The mutual reinforcement of patient-aggression and institutional counter-aggression is not at all specific for custodial psychiatry. Reformed institutions with a liberal attitude may develop subtle manifestations of counter-aggression to protect the professional identity of their members. The aim to maintain a "good", non-violent psychiatry proves to be an obstacle to any effort to cope with the needs of the violent patient and to reduce institutional counter-aggression to a minimum.

[Gentle psychiatry--metamorphosis of violence?]. / Sanfte Psychiatrie--Metamorphosen der Gewalt?

The basic assumptions of reform psychiatry aim at the establishment of a benign, i.e. peaceful therapeutic regime which promotes the experience of meaningful interpersonal relationships. Yet purpose and therapeutic reality often show discrepancies. The peaceful dialogue is jeopardized by the psychiatric disorder itself, furthermore by the chimera of peacefulness which prevents "gentle psychiatry" from recognizing its own strategies of stigmatization and expulsion. Ideologies which take for granted free decision making even for those who are restricted by their illness tend to give legitimation for the withdrawal of necessary help. Especially dangerous patients are at risk of being expelled by a "gentle psychiatry" which intends to preserve the professional identity of goodness for the therapist.

[Liberal or controlled approach--the management of violent patients in psychiatric clinics]. / Freizügigkeit oder Kontrolle--Zum Umgang mit gewalttätigen Patienten in psychiatrischen Kliniken.

The traditional mental hospitals are said to hamper recovery and obstruct rehabilitation by an authoritarian therapeutic regimen. Nevertheless, the claim of community-oriented hospitals that a liberal therapeutic style improves prognosis and makes treatment more human requires scrutiny. The management of violent patients who call for controlling and disciplinary measures seems to be crucial. In the light of a case-history the article describes, how a misinterpretation of liberal principles complicates the treatment of dangerous patients and supports an attitude which does not admit the double character of psychiatric therapy in regard of the inevitable conflict between safety precautions and therapeutic engagement.

[Relevance of ethnic discrimination in psychiatric diseases]. / Zur Relevanz ethnischer Diskriminierung bei psychiatrischen Erkrankungen.

Ethnic discrimination represents a social and psychological reality. As can be shown by case-material, it affects in a way specific for the individual developmental processes and psychic well-being. Referring to Goffman's concept of social identity the psychological impact of ethnic discrimination is described in psychiatric patients. Finally therapeutic and preventive implications are outlined.

Laser-assisted uvulopalatoplasty: evaluation of postoperative discomfort and the effectiveness of this procedure.

BACKGROUND AND OBJECTIVE: The Beckman Laser Institute and Medical Clinic of the University of California at Irvine began to offer laser-assisted uvulopalatoplasty to treat snoring in October 1993. Current literature at that time advised that patients should expect mild or minimal pain after each treatment. Soon, it became apparent that those instructions needed modifying as most of the patients complained of severe pain. STUDY DESIGN/MATERIALS AND METHODS: Patient surveys were developed to evaluate postoperative pain, pain management, the rate of improvement after each treatment, and the success or failure of the procedure to reduce their snoring. RESULTS: Severity of pain reported by patients declined. CONCLUSION: A combination of two primary factors reduced pain reported: 1) improved patient education regarding expected outcomes and pain management and 2) addition of anti-inflammatory medications.