The significance of nonurgent psychiatric emergencies in an ED: a retrospective study.

BACKGROUND: In emergency departments, patients with mental health conditions are a major concern and make up the third or fourth of the most common diagnosis seen during all consultations. Over the past two decades, there has been a noticeable rise in the number of cases, particularly due to an increase in nonurgent visits for somatic medical issues. The significance of nonurgent visits for psychiatric patients is yet to be determined. This study aims to uncover the significance and identify the characteristics of this group. METHODS: A retrospective analysis of psychiatric emergency visits at an interdisciplinary emergency department of a German general hospital in 2015 was conducted. For this purpose, patient records were reviewed and evaluated. An analysis was conducted based on the German definition of psychiatric emergencies according to the German guidelines for emergency psychiatry. RESULTS: A total of 21,124 emergency patients visited the evaluated Emergency Department. Of this number, 1,735 psychiatric patient records were evaluated, representing 8.21% of the total population. Nearly 30% of these patients did not meet any emergency criteria according to German guidelines. Significant differences were observed between previously treated patients and those presenting for the first time. CONCLUSIONS: The high proportion of nonurgent psychiatric patients in the total volume of psychiatric emergency contacts indicates a possible control and information deficit within the emergency system. Just as prior research has emphasized the importance of investigating nonurgent somatic medical visits, it is equally imperative to delve into studies centered around psychiatric nonurgent presentations.

[Legalization of Recreational Cannabis use in Germany - Implications Based on Experiences in Uruguay, Canada und USA: a Narrative Review]. / Cannabislegalisierung in Deutschland ­ Implikationen aufgrund der Erfahrungen aus Uruguay, Kanada und den USA: ein narratives Review.

The current government of Germany has agreed on legalizing the recreational use of cannabis in their coalition agreement. Legalization will be implemented in 2023. This issue has continuously been a subject of controversial discussion including most parts of society, executive authorities and science. This article refers to the experiences of other countries (Uruguay, Canada, USA) yet having legalized Cannabis in the past and tries to discuss implications for Germany.

Treatment of the Neuroleptic Malignant Syndrome in International Therapy Guidelines: A Comparative Analysis.

INTRODUCTION: The neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition associated to the use of antipsychotics. Since it requires rapid and efficient medical care, high-quality treatment guidelines should be available. In this article, we analyzed and compared different international therapy guidelines for the treatment of schizophrenia, in which NMS treatment recommendations might be contained. METHODS: We performed an Internet-based search for schizophrenia guidelines via the website of the respective medical society. Guidelines in English, French, Italian, and German from countries whose medical care meets high standards were selected for further analysis and comparison of the NMS treatment recommendations (if present), and their underlying evidence. RESULTS: The NMS is mentioned in 12 of 14 guidelines. Only 9 report concrete therapy recommendations (benzodiazepines/dantrolene/bromocriptine/amantadine/intensive care and/or electroconvulsive therapy (ECT)), however, with high heterogeneity. Only 5 guidelines included all possible drug therapy options and ECT, but with differing combination strategies, dosages, application forms, and combinability of options. The level of evidence of the different recommendations was estimated as low. DISCUSSION: One-third of the selected guidelines do not report any NMS therapy recommendations. Most guidelines mentioning the NMS do not provide therapy recommendations that include all relevant treatment options. The results show a very high heterogeneity, and the recommendations and statements are of low-evidence levels. The lack of knowledge about the NMS and its treatment may delay the onset of therapy, impair the quality of treatment, and lead to a worse outcome or death.

[Ayahuasca - religion, life-style or drug?] / Ayahuasca ­ Religion, Life-style oder Droge?

Ayahuasca is a psychoactive drug which has been used by indigenous cultures in the amazonas basin for hundreds of years for medical and religious purpose. Backpackers who came in contact with ayahuasca exported its use in the western world and increased its popularity. By presenting a case report of a patient seeking medical help due to psychotic symptoms after having attended an ayahuasca ritual we give an short overview of pharmacology, legal status, use and side effects of the substance.

[Course and complications of GHB detoxification treatment: a 1-year case series]. / Verlauf und Komplikationen des GHB-Entzuges: eine 1­Jahres-Fallserie.

BACKGROUND: Gamma-hydroxybutyrate (GHB) and its precursors have gained popularity over the last decade as a drug in the party and club scene; however, the clinical knowledge of these substances is low. In the literature there have been case reports of severe dependence and withdrawal but there is a lack of systematic knowledge about the clinical course and complications of detoxification treatment. OBJECTIVE: The aim of this article is to evaluate the prevalence, treatment course, complications and compliance of GHB patients seeking inpatient qualified detoxification treatment (QDT). METHODS: A retrospective evaluation of the hospital charts of all patients admitted to this clinic in 2017 for QDT of GHB. The Jewish Hospital in Berlin (Jüdisches Krankenhaus Berlin) provides specialized inpatient units for addictive diseases and a general intensive care unit. The control population came from a prospective study of all patients with addictive diseases who were treated in the same hospital in 2012. RESULTS: In 2017 a total of 18 patients with GHB addiction were treated in this hospital. This corresponds to a 1­year prevalence of 2.28% of all addictive diseases in this year. During detoxification treatment 52% of the GHB patients had to be temporarily transferred to the intensive care unit, 5% had to be temporarily mechanically ventilated and 26% suffered from withdrawal delirium. Of the patients 42% terminated treatment prematurely against medical advice. CONCLUSION: Withdrawal treatment from GHB is a severe and potentially dangerous condition, the prevalence of complications was higher than for most other drugs and the rate of intensive care and withdrawal delirium was very high. Further studies are urgently needed with the aim of reducing the complication rates of GHB withdrawal and enhancing therapy adherence.

[Discussing possible new regulations in german cannabis policy with special regard to the experiences in the Netherlands and Colorado]. / Betrachtungen zu einer möglichen Neuregulierung der Cannabispolitik in Deutschland unter Berücksichtigung der Erfahrungen aus den Niederlanden und Colorado.

In Deutschland wird seit einiger Zeit zunehmend über eine neue Cannabispolitik nachgedacht. Von vielen Seiten wird die Forderung nach einer Liberalisierung oder Freigabe des Cannabis laut. Der vorliegende Artikel fasst die wichtigsten Erfahrungen der Cannabis-Politik aus den Niederlanden und dem US-Bundesstaat Colorado zusammen und versucht, daraus Schlussfolgerungen für eine mögliche Neuregulierung der Cannabispolitik in Deutschland abzuleiten.

A comparison of cognitive functioning in acute schizophrenia and depression.

OBJECTIVE: Even though cognitive deficits are well recognised in schizophrenia and depression, direct comparisons between the disorders are scarce in literature. This study aims to assess specificity and degree of cognitive deficits in inpatients with acute schizophrenia and unipolar major depression. METHODS: A neuropsychological test battery was administered to 76 schizophrenic patients, 102 patients with unipolar major depression and 85 healthy controls (HCs), assessing verbal learning [Rey Auditory Verbal Learning Test (RAVLT)], processing speed (Trail Making Test), verbal fluency and visual memory (Wechsler Memory Scale-Revised test). RESULTS: Both patient groups were significantly impaired compared with HCs with regard to all test outcomes. The schizophrenia group (SG) performed significantly worse in the Wechsler Memory Scale and verbal fluency than the depression group (DG). The DG reached significantly lower scores than the SG in the RAVLT delayed recall subtest. No significant group difference between SG and DG was found for the Trail Making Test and the RAVLT direct recall trails. CONCLUSION: Our results indicate that cognitive impairment is present in both disorders. Schizophrenic patients performed worse than patients with unipolar depression in only two of the administered tests. Differences in cognitive performance between the groups are not as general as often assumed. Therefore, during the acute phase of illness, a diagnostic classification on the grounds of the patients' neurocognitive performance has to be done with caution.

GHB: a life-threatening drug complications and outcome of GHB detoxification treatment-an observational clinical study.

BACKGROUND: GHB (gammahydroxybutyrate) and its precursors are popular recreational drugs due to their sedative, anxiolytic and sexually stimulating effects. Their use has been steadily increasing in recent years. The detoxification process is complex and prone to high rates of complications while little is known about the pathophysiology. This study aims to elucidate the characteristics of GHB-addicted patients and to evaluate the risks and complications of GHB withdrawal treatment. METHODS: This observational study describes prospectively the socioeconomic status, clinical history and course of inpatient detoxification treatment of a group of 39 patients suffering from GHB substance use disorder. Detoxification treatment took place in a highly specialized psychiatric inpatient unit for substance use disorders. RESULTS: GHB patients were characterised by being young, well-educated and by living alone. More than 50% of the patients had no regular income. The patients were male and female in equal numbers. Detoxification treatment was complicated, with high rates of delirium (30.8%) and high need for intensive care (20.5%). CONCLUSIONS: In our sample, GHB users were young, well-educated people and male and female in equal number. Detoxification proved to be dangerous for GHB-addicted patients. The presence of delirium and the need for transfer to an intensive care unit during detoxification treatment was extraordinarily high, even with appropriate clinical treatment. The reasons for this remain unknown. Therefore an intensive care unit should be available for GHB detoxification treatment. Further studies are needed to evaluate the options for prophylactic treatment of delirium during detoxification.

Extracting transverse electron mean free paths in graphene at low energy.

The LEEM-IV spectra of few-layer graphene show characteristic minima at specific energies, which depend on the number of graphene layers. For the same samples, low-energy TEM (eV-TEM) spectra exhibit transmission maxima at energies corresponding to those of the reflection minima in LEEM. Both features can be understood from interferences of the electron wave function in a purely elastic model. Inelastic scattering processes in turn lead to a finite, energy-dependent inelastic Mean Free Path (MFP) and a lower finesse of the interference features. Here we develop a model that introduces both an elastic and inelastic scattering parameter on the wave-function level, thus reconciling the models considered previously. Fitting to published data, we extract the elastic and inelastic MFP self-consistently and compare these to recent reports.

Complementary LEEM and eV-TEM for imaging and spectroscopy.

Transmission electron microscopy at very low energy is a promising way to avoid damaging delicate biological samples with the incident electrons, a known problem in conventional transmission electron microscopy. For imaging in the 0-30 eV range, we added a second electron source to a low energy electron microscopy (LEEM) setup, enabling imaging and spectroscopy in both transmission and reflection mode at nanometer (nm) resolution. The latter is experimentally demonstrated for free-standing graphene. Exemplary eV-TEM micrographs of gold nanoparticles suspended on graphene and of DNA origami rectangles on graphene oxide further establish the capabilities of the technique. The long and short axes of the DNA origami rectangles are discernable even after an hour of illumination with low energy electrons. In combination with recent developments in 2D membranes, allowing for versatile sample preparation, eV-TEM is paving the way to damage-free imaging of biological samples at nm resolution.

Label-Free Plasmonic Detection of Untethered Nanometer-Sized Brownian Particles.

Optical detection of individual nanometer-sized analytes, virus particles, and protein molecules holds great promise for understanding and control of biological samples and healthcare applications. As fluorescent labels impose restrictions on detection bandwidth and require lengthy and invasive processes, label-free optical techniques are highly desirable. Here, we introduce an optical technique capable of transforming gold nanorods commonly used as photostable labels into highly localized high-speed probes. Our method detects single untethered 5 nm diameter gold particles as they traverse subattoliter volumes in Brownian motion with a time resolution below microseconds.

Efficacy of an algorithm-guided treatment compared with treatment as usual: a randomized, controlled study of inpatients with depression.

OBJECTIVE: Medication algorithms have been proposed as effective means to offer optimal treatment and improved outcome for patients with severe mental illness. This single-center prospective study compared the efficacy and effects on treatment prescriptions of an algorithm-guided treatment regimen with treatment as usual (TAU) in depressed inpatients. METHODS: Depressed inpatient participants were randomized to an algorithm-guided standardized stepwise drug treatment regimen (SSTR, n = 74) or TAU (n = 74). The SSTR regimen included sleep deprivation, antidepressant monotherapy, lithium augmentation, monoamine oxidase inhibitor therapy, or electroconvulsive therapy guided by scores on the clinician-rated Bech-Rafaelsen Melancholia Scale. The primary outcome was time to remission (defined as a Bech-Rafaelsen Melancholia Scale score of < or =7). Secondary outcomes were remission rates, number of changes in treatment strategies (types), and the number of different prescribed medications over the treatment period. RESULTS: Patients receiving SSTR had a significantly shorter time to remission (7.0 +/- 0.9 weeks vs 12.3 +/- 1.8 weeks for TAU). Compared with that in remitters in SSTR, the number of strategy changes was significantly higher in TAU remitters (3.0 +/- 2.7 and 1.0 +/- 1.5) and had more psychotropic medications (fix agents: 3.0 +/- 1.5 and 1.9 +/- 1.1; optional agents: 1.5 +/- 1.0 and 0.9 +/- 0.7). Although more patients dropped out of the SSTR group (33 of SSTR, 12 of TAU), the probability of remission tended to be higher in SSTR. CONCLUSIONS: Algorithm-guided treatment produces better outcomes and less frequent medication changes than TAU. A systematic, stepwise, measurement-based approach to the treatment of depressed inpatients is warranted.

Cognitive impairment in schizophrenia and depression: A comparison of stability and course.

Cognitive deficits are clinically relevant features in schizophrenia and depression, yet little comparative data on changes in both disorders is available. This study compares cognitive performance of inpatients with schizophrenia (N = 52) and unipolar major depression (N = 67) during psychiatric treatment, assessing performance twice: after admission to hospital (acute) and prior to discharge (postacute) on average seven weeks later. A group of healthy controls was tested at comparable intervals. Data was analyzed using a multivariate linear model. Patients with schizophrenia and depression showed significantly impaired performance compared to healthy controls. On follow-up both patient groups showed improved performance. Contrary to expectation, patients with schizophrenia showed greater improvement in verbal memory, visual memory, and psychomotor speed than depressive patients. Verbal fluency presented as a possible candidate to differentiate between both disorders. Similar profiles of generalized cognitive deficits were observed in both patient-groups on acute and postacute assessment, which might indicate trait-like deficits with persistent functional implications in both disorders. Findings do not support assumptions of greater cognitive impairment in schizophrenia compared to depression. A distinction of the disorders on the grounds of cognitive functioning seems to be less specific than presumed.

The Effect of Detoxification on Sleep: How Does Sleep Quality Change during Qualified Detoxification Treatment?

Aims. Sleep disturbances are common in addiction and withdrawal. This study examined the course of sleep quality in a population of alcohol dependent patients during qualified detoxification treatment in a psychiatric hospital. Methods. The Pittsburgh Sleep Quality Index (PSQI) was administered to 77 electively admitted alcohol dependent patients hospitalized for qualified detoxification treatment. Sleep quality was measured at admission and at discharge. Results. The prevalence of bad sleep as measured by a PSQI-score > 5 was 70.1% at admission. During detoxification, male and female patients were equally affected by sleep disturbances and improvement of sleep was not significantly different between males and females. The PSQI score at admission predicted the change of the PSQI score during qualified detoxification treatment. After inpatient detoxification, sleep disturbances persisted in 59.7% of the patients. Conclusions. Contrary to our expectations, the average patient's sleep quality improved in our study after two weeks of detoxification treatment. Sleep disturbances nevertheless persisted in almost two-thirds of the patients. In the view of that finding, patients may require individual evaluation of sleep quality and insomnia-specific treatment in the course of detoxification therapy.

Nerve growth factor serum concentrations rise after successful cognitive-behavioural therapy of generalized anxiety disorder.

Generalized anxiety disorder (GAD) is a chronic stress disease with permanent physical tension and cognitive strain. Raised nerve growth factor (NGF) serum levels were reported as an acute stress reaction in soldiers before their first parachute jump even before the rise in cortisol. Taking GAD as a clinical model of chronic stress, we measured NGF in the serum of 22 patients with GAD before and after cognitive-behavioural therapy (CBT) and compared them to those of healthy normal controls. Treatment response was tested by the values of the State and Trait of Anxiety Inventory (STAI) and the Hamilton Anxiety Scale (HAM-A) as treatment outcome variables. The NGF values of patients and controls were similar at baseline (p=0.8941); however, with successful treatment, corresponding to a mean reduction in the HAM-A by more than 50% and a reduction in the clinical global impression scale (CGI) median from 4 to 1, the patients' NGF serum concentrations rose significantly (p=0.0006) which might correspond to an altered stress reaction, possibly contributing to good therapeutic response with CBT. There were 3 patients with a HAM-A decrease of less than 15%. In those patients NGF rose only marginally. Hence, the increase in serum NGF seems to indicate good treatment response.

Predicting Inpatient Detoxification Outcome of Alcohol and Drug Dependent Patients: The Influence of Sociodemographic Environment, Motivation, Impulsivity, and Medical Comorbidities.

Aims. This prospective study aims to identify patient characteristics as predictors for treatment outcome during inpatient detoxification treatment for drug and alcohol dependent patients. Methods. A mixed gender sample of 832 consecutively admitted drug and alcohol dependent patients were interviewed by an experienced physician. The impact of a variety of factors concerning social environment, therapy motivation, impulsivity related variables, medical history, and addiction severity on treatment outcome was examined. Results. 525 (63.1%) of the patients completed detoxification treatment whereas 307 (36.9%) dropped out prematurely. Being female, living in a partnership, having children, being employed, and having good education were predictive for a positive outcome. Family, health, the fear of losing the job, prosecution, and emergency admission were significant motivational predictors for treatment outcome. Being younger, history of imprisonment, and the number of previous drop-outs were predictive for a negative outcome. Conclusions. Variables concerning social environment and the number of previous drop-outs have been identified as best predictors for treatment outcome. Socially stable patients benefit from the current treatment setting and treatment shall be adapted for patients with negative predictors. Treatment may consequently be tailored with respect to intervention type, duration, and intensity to improve the outcome for those patients that fulfil criteria with negative impact on treatment retention.

When Habits Are Dangerous: Alcohol Expectancies and Habitual Decision Making Predict Relapse in Alcohol Dependence.

BACKGROUND: Addiction is supposedly characterized by a shift from goal-directed to habitual decision making, thus facilitating automatic drug intake. The two-step task allows distinguishing between these mechanisms by computationally modeling goal-directed and habitual behavior as model-based and model-free control. In addicted patients, decision making may also strongly depend upon drug-associated expectations. Therefore, we investigated model-based versus model-free decision making and its neural correlates as well as alcohol expectancies in alcohol-dependent patients and healthy controls and assessed treatment outcome in patients. METHODS: Ninety detoxified, medication-free, alcohol-dependent patients and 96 age- and gender-matched control subjects underwent functional magnetic resonance imaging during the two-step task. Alcohol expectancies were measured with the Alcohol Expectancy Questionnaire. Over a follow-up period of 48 weeks, 37 patients remained abstinent and 53 patients relapsed as indicated by the Alcohol Timeline Followback method. RESULTS: Patients who relapsed displayed reduced medial prefrontal cortex activation during model-based decision making. Furthermore, high alcohol expectancies were associated with low model-based control in relapsers, while the opposite was observed in abstainers and healthy control subjects. However, reduced model-based control per se was not associated with subsequent relapse. CONCLUSIONS: These findings suggest that poor treatment outcome in alcohol dependence does not simply result from a shift from model-based to model-free control but is instead dependent on the interaction between high drug expectancies and low model-based decision making. Reduced model-based medial prefrontal cortex signatures in those who relapse point to a neural correlate of relapse risk. These observations suggest that therapeutic interventions should target subjective alcohol expectancies.

Evidence for impaired cortical inhibition in patients with unipolar major depression.

BACKGROUND: Several lines of evidence suggest that central cortical inhibitory mechanisms, especially associated with gamma-aminobutyric acid (GABA) neurotransmission, may play a role in the pathophysiology of major depression. Transcranial magnetic stimulation is a useful tool for investigating central cortical inhibitory mechanisms associated with GABAergic neurotransmission in psychiatric and neurological disorders. METHODS: By means of transcranial magnetic stimulation, different parameters of cortical excitability, including motor threshold, the cortical silent period, and intracortical inhibition/facilitation, were investigated in 20 medication-free depressed patients and 20 age- and gender-matched healthy volunteers. RESULTS: Silent period and intracortical inhibition were reduced in depressed patients, consistent with a reduced GABAergic tone. Moreover, patients showed a significant hemispheric asymmetry in motor threshold. CONCLUSIONS: This study provides evidence of reduced GABAergic tone and motor threshold asymmetry in patients with major depression.

Cerebrovascular reactivity following administration of mirtazapine in healthy probands--a randomized, placebo controlled double-blind clinical study.

INTRODUCTION: Cerebrovascular reactivity (CVR) reflects the compensatory dilatory capacity of cerebral arterioles to a dilatory stimulus and is important for maintaining constant cerebral blood flow. A reduced CVR increases the risk of stroke. We recently found that CVR was reduced in patients with depression. This might contribute to the higher risk of stroke that has been found in subjects suffering from depression. The characterization of pathophysiological conditions in the cerebral circulation requires the knowledge of influencing factors on CVR. We therefore investigated the influence that antidepressant administration might have on CVR in humans. METHODS: We investigated CVR in 48 healthy men before and after a 10-day application of either mirtazapine or placebo. CVR was determined by calculating the increase in cerebral blood flow velocity after stimulation with acetazolamide. Blood flow velocities were measured by transcranial Doppler ultrasound. RESULTS: There was no significant group-difference of CVR after the treatment trial compared to baseline. DISCUSSION: Mirtazapine does not seem to have an influence on CVR, or any impact on CVR might have been quickly limited by a cerebral autoregulatory response.