[Home Treatment]. / Home Treatment.

Home Treatment (HT) means acute psychiatric treatment in the patient's usual environment. Conceptually, HT is to be differentiated from other home-based services: It is limited with regard to duration and multiprofessional (e. g. psychiatrist plus psychiatric nursing staff plus social worker); the "24/7"-accessibility is frequently provided by the corresponding background hospital infrastructure. Target group are acutely mentally ill persons with an indication to inpatient treatment, who are willing to cooperate, and absence of endangerment to self and others. In contrast to the Scandinavian and many Anglophone countries where nationwide HT services are delivered, there are not many HT sites in Germany so far. Consequently, empirical data concerning HT in Germany is scarce. In summary, international studies show equivalent effects on psychopathological measures compared to inpatient treatment, reductions with regard to inpatient days, higher patient satisfaction and a trend towards cost-effectivity.

[Syndromal versus nosological diagnosis]. / Syndromale versus nosologische Diagnostik.

Against the background of the current preparation of ICD-11 and DSM-5, there is a discussion whether syndromal approaches should replace the traditional nosological diagnosis in psychiatry. From a historical point of view the syndromal approach results from a reaction to the nosological model of Emil Kraepelin. Later the syndromal diagnostic approach became more important because it enabled a quantitative-dimensional assessment and analysis of psychopathological data using modern statistical procedures. However, attempts to ascribe the traditional nosological categories to psychopathological syndromes using multivariate statistical methods have failed. The syndromal approach allows a differentiated recording of the cross-sectional symptomatology; however, a plurality of different syndromes might be registered without considering meaningful principles of classification and longitudinal aspects. The syndromal approach should be complemented by a nosological classification based mainly on the psychopathological course due to the absence of consistent neurobiological findings.

[Psychopathological differentiation of depressive syndromes]. / Psychopathologische Differenzierung depressiver Syndrome.

The historical contributions of Kurt Schneider, Karl Leonhard, Hans-Jörg Weitbrecht and Hubertus Tellenbach provide different concepts for a psychopathological differentiation of depressive syndromes. The current diagnostic systems ICD-10 and DSM-5 also contain categories for a differentiated classification of depressive disorders that trace back to the above historical concepts. The extensive diagnostic concepts of "depressive episode" or "major depression", however, are mainly based on the severity of symptomatology in terms of the number of symptoms and on their temporal duration. This approach could result in a lack of psychopathological differentiation and the limitation to a more syndromal and dimensional view of depression. In contrast, a differentiated typology of depressive phenomenology based on traditional psychopathological concepts could be useful both for clinical treatment decisions and for neurobiological research.

Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment.

OBJECTIVE: Evaluating the effects of different types of psychotropic polypharmacy on clinical outcomes and quality of life (QOL) in 374 patients with schizophrenia and schizoaffective disorder in routine care. METHOD: Psychotropic regimen, clinical outcomes, and QOL were assessed before discharge and after 6, 12, 18, and 24 months. Data were analyzed by mixed-effects regression models for longitudinal data controlling for selection bias by means of propensity scores. RESULTS: At baseline 22% of participants received antipsychotic monotherapy (APM) (quetiapine, olanzapine, or risperidone), 20% more than one antipsychotic drug, 16% received antipsychotics combined with antidepressants, 16% antipsychotics plus benzodiazepines, 11.5% had antipsychotics and mood stabilizers, and 16% psychotropic drugs from three or more subclasses. Patients receiving APM had better clinical characteristics and QOL at baseline. Patients receiving i) antipsychotics plus benzodiazepines or ii) antipsychotics plus drugs from at least two additional psychotropic drug categories improved less than patients with APM. CONCLUSION: Combinations of antipsychotics with other psychotropic drugs seem to be effective in special indications. Nevertheless, combinations with benzodiazepines and with compounds from multiple drug classes should be critically reviewed. It is unclear whether poorer outcomes in patients with such treatment are its result or its cause.

Psychotropic drug treatment, clinical characteristics and cognitive processing speed in patients with schizophrenia: results from the ELAN study.

INTRODUCTION: Psychotropic drug combinations (PDC) are common in the treatment of patients with schizophrenia but there is little research regarding the effects of PDC on cognition. OBJECTIVE: The aim of this study was to analyse the effects of antipsychotic monotherapy and various types of PDC on cognitive processing speed (CPS). METHODS: ELAN is a 24-month multi-site prospective observational controlled trial following up 374 patients with schizophrenia under routine treatment conditions following discharge from inpatient treatment. The propensity score method, multinomial logistic regression analyses and mixed effects regression models were used. RESULTS: CPS correlated significantly with PANSS and GAF scores and improved over time in the monotherapy group. Negative effects of some PDC (antipsychotics + tranquilizers/antipsychotics+at least 2 other psychopharmacological subclasses, sedative/anticholinergic drugs/high adjusted antipsychotic dose) lost significance after controlling for clinical characteristics. DISCUSSION: Indications for PDC should be examined with care although, in the present study, effects on cognition were small.

[Deconstructing schizophrenia. Dimensional models or division into subtypes?]. / Auflösung des Schizophreniebegriffes. Dimensionale Modelle oder Aufteilung in Subtypen?

Against the background of the arrangements of ICD-11 and DSM-V, future approaches in order to diagnose schizophrenic psychoses are currently being discussed. In this context, the current concepts of schizophrenia are questioned because attempts at neurobiological validation and validation based on family and follow-up studies have not succeeded. Therefore, dimensional diagnostic models or a division into subtypes are suggested. Both of these proposals would imply a deconstruction of the current concept of schizophrenia. A historical review shows that the psychopathological roots of the current discussion can be traced back to Kurt Schneider's nominalistic concept of schizophrenia which is based upon the so-called first-rank symptoms. In contrast, the psychopathological foundation of dimensional concepts and a division into several subtypes date from contributions of Klaus Conrad and Karl Leonhard. A triaxial diagnostic system with the axes of syndromes, course types and aetiology could provide a bridge between the different approaches.

[Schizophrenic psychoses with bipolar course--implications for nosology and treatment]. / Schizophrene Psychosen mit bipolarem Verlauf - Implikationen für Nosologie und Therapie.

Based on a description of the psychopathological symptoms and clinical course of three patients, the diagnostic classification of schizophrenia, schizoaffective disorder and bipolar affective disorder is discussed. The reported cases are characterised by a rapid change of cognition, affect and psychomotor domain with fluctuations in two opposite directions and an incomplete remission of symptoms between acute episodes of illness. Such cases are not adequately represented in the current diagnostic systems ICD-10 and DSM-IV. This renders both the diagnostic classification and the development of evidence-based treatment guidelines more difficult. In accordance with the historical concepts of Emil Kraepelin and Kurt Schneider, the reported patients can be considered to suffer from a subtype of schizophrenia with bipolar course. The identification of such psychopathological course types could help to develop more concise and individualised treatment guidelines. In contrast, the characterisation of the reported cases using dimensional models seems doubtful.

[Erik Essen-Möller and the roots of multiaxial classification in psychiatry]. / Erik Essen-Möller und die Wurzeln der Multiaxialen Diagnostik in der Psychiatrie.

Against the background of the preparation of ICD-11 and DSM-V, the historical roots of a multiaxial diagnostic assessment in psychiatry are reviewed. The principles of such an approach are traced back to the Swedish psychiatrist Erik Essen-Möller who had proposed a distinction between aetiological and descriptive aspects in the classification of mental disorders. Furthermore, he suggested to break down the descriptive classification into the cross-sectional psychopathological picture and the clinical course. Nowadays, a multiaxial assessment is used in diagnostic systems such as DSM-IV. However, these current concepts differ considerably from Essen-Möller's suggestions. A return to the original approach of multiaxial diagnostic assessment comprising the axes "syndromes", "course types" and "aetiology" would be in line with current neurobiological findings and may provide a bridge between the traditional categorical diagnostic approach and dimensional models.

Treatment of schizoaffective disorder - a challenge for evidence-based psychiatry.

OBJECTIVE: Schizoaffective disorder is a common diagnosis in mental health services. The aim of the present article was to review treatment studies for schizoaffective disorder and draw conclusions for clinical decision making. METHOD: We searched MEDLINE and Cochrane Library for relevant clinical trials and review articles up to the year 2008. RESULTS: Thirty-three studies using standardized diagnostic criteria, 14 of which were randomized controlled trials, could be identified. The comparability of studies is limited by the use of different diagnostic criteria. The studies reviewed do not permit consistent recommendations as to whether schizoaffective disorder should be treated primarily with antipsychotics, mood stabilizers or combinations of these drugs. The relevance of diverse subtypes of schizoaffective disorder for treatment recommendations is unclear. CONCLUSION: The pertinent empirical database is small and heterogeneous. The lack of conclusive recommendations is related to issues of nosological status, plurality of diagnostic criteria and validity of the concept of schizoaffective disorder.

Effects of symptom reduction and psychotropic medication on cognitive impairment in depression.

BACKGROUND: Depression is related to cognitive performance. This follow-up study examines the influence of depression symptoms and psychopharmacological treatment on change in the cognitive performance of patients with depressive episodes over a 2-year period. SAMPLING AND METHODS: Sixty-two in- and outpatients with depression of varying severity (ICD-10: F31-F33) were examined in an open prospective naturalistic observational study with 3 points of measurement and tested by use of 3 computerized cognitive performance tests [Visual Attentiveness Test (VAT), Continuous Attention Test (CAT), Word Recognition Test (WRT)], while the psychotropic medication was classified by subclass and dosage. Statistical analysis was performed by random-effects regression models. RESULTS: The raw values of VAT speed, CAT speed and WRT quality improved over time. However, the positive time trend disappeared after the patients' clinical and personal characteristics were controlled for. The processing speed of the VAT was found to be negatively influenced by depressive symptoms. That of the CAT developed favorably with increasing level of education. The performance qualities of the VAT, WRT and CAT were positively related to the participants' educational level. The patients who received antipsychotic treatment performed worse on WRT quality than those who were not treated with antipsychotics. CONCLUSIONS: The cognitive performance was relatively stable during the treatment process and not affected by clinical characteristics or type of medication. Cognitive deficits in patients with depression could be a trait rather than a state marker.

Schizoaffective disorder--an ongoing challenge for psychiatric nosology.

OBJECTIVE: Schizoaffective disorder is a common diagnosis in mental health services. The present article aims to provide an overview of diagnostic reliability, symptomatology, outcome, neurobiology and treatment of schizoaffective disorder. METHOD: Literature was identified by searches in "Medline" and "Cochrane Library". RESULTS: The diagnosis of schizoaffective disorder has a low reliability. There are marked differences between the current diagnostic systems. With respect to psychopathological symptoms, no clear boundaries were found between schizophrenia, schizoaffective disorder and affective disorders. Common neurobiological factors were found across the traditional diagnostic categories. Schizoaffective disorder according to ICD-10 criteria, but not to DSM-IV criteria, shows a more favorable outcome than schizophrenia. With regard to treatment, only a small and heterogeneous database exists. CONCLUSION: Due to the low reliability and questionable validity there is a substantial need for revision and unification of the current diagnostic concepts of schizoaffective disorder. If future diagnostic systems return to Kraepelin's dichotomous classification of non-organic psychosis or adopt a dimensional diagnostic approach, schizoaffective disorder will disappear from the psychiatric nomenclature. A nosological model with multiple diagnostic entities, however, would be compatible with retaining the diagnostic category of schizoaffective disorder.

[The crisis of the operational diagnostic approach in psychiatry]. / Die Krise der operationalen Diagnostik in der Psychiatrie.

Based on historical and current contributions, the operational diagnostic approach is examined from a psychopathological point of view. Operational diagnostic systems in psychiatry are characterised by an atomising approach. In this context, psychopathological symptoms are interpreted as elementary entities which can be combined into a specific diagnostic category. Many years before operational diagnostic systems were introduced into psychiatry, however, such an atomising procedure was criticised by authors like Karl Jaspers, Willy Mayer-Gross or Klaus Conrad. Furthermore, validation of diagnostic criteria of operational diagnostic systems has not succeeded so far using biological findings or results of family and follow-up studies. This may be one reason for the fact that categorical approaches in psychiatric diagnosis are questioned increasingly and dimensional diagnostic models are suggested.

[New ways in psychiatric diagnostics?]. / Neue Wege in der psychiatrischen Diagnostik?

There is an increasing criticism of the current operational diagnostic approach of ICD-10 and DSM-IV in psychiatry. It has not been possible to validate the respective diagnostic categories with neurobiological findings or to detect sharp boundaries between the diagnostic categories with respect to psychopathological symptoms. Therefore, dimensional diagnostic models are suggested in order to supplement the categorical diagnostic approach. Based on a historical review and a survey of the current criticism of the diagnostic approach of ICD-10 and DSM-IV proposals are made in order to solve the current problems. In conclusion, a multiaxial diagnostic model is suggested that comprises the axes "syndromes", "course types" and "etiology" and that may provide a bridge between the traditional categorical diagnostic approach and dimensional models.

[The significance of regular physical exercise for health and well-being]. / Die Bedeutung regelmässiger körperlicher Aktivität für Gesundheit und Wohlbefinden.

The health behaviour prevailing in our western world (lack of exercise, unhealthy diet, overweight, coping with stress) can be considered a risk factor for cardiovascular diseases as well as for mental disorders (especially with depressive symptoms), which both are among the most frequent and most expensive diseases. Depressive disorders and metabolic syndromes exhibit some pathophysiological similarities and are mutually interrelated - a fact that induces multiple effects of corresponding prophylactic and therapeutic interventions: Regular physical activity in terms of aerobic dynamic endurance whose neurobiological effects will be communicated in this paper has the potential of reducing depression and stress, of increasing stress tolerance, of improving cardiovascular health, and, eventually, of protecting against the risks of dementia. In times of scarce financial resources the lack of emphasis on physical exercise as an important and inexpensive preventive measure is really surprising.

[Conceptual foundation of the operational diagnostic approach in psychiatry]. / Konzeptuelle Grundlagen der operationalen Diagnostik in der Psychiatrie.

Based on the pioneering work of Emil Kraepelin, Karl Jaspers, Kurt Schneider and representatives of logical empiricism, the basic principles of the operational diagnostic approach in psychiatry are described. Operational diagnostic systems like ICD-10 and DSM-IV aimed at a standardisation of psychiatric language which can be accepted by different schools in psychiatry. However, ICD-10 and DSM-IV should not be misinterpreted as "nosology" because they do not reflect a specific model of psychiatric diseases. The advantages of operational diagnostic systems as instruments for communication in a clinical and scientific context are limited by the fact that they disregard the subjective psychopathology. This dimension, however, deserves attention in clinic and research.

Health behavior in psychiatric in-patients compared with a German general population sample.

OBJECTIVE: To compare the health relevant behavior of psychiatric patients and the general population. METHOD: Health behavior of 363 psychiatric in-patients with ICD-10 diagnoses of schizophrenia, bipolar disorders, major depressive disorders and neurotic, and somatoform disorders was compared with health behavior of a representative sample of 7200 persons from German general population. RESULTS: Increased prevalence rates for smoking and illicit drug use were found for all diagnostic groups. Risk alcohol consumption was increased in patients with schizophrenia and depression. Smokers with schizophrenia had an excess cigarette consumption compared with general population. The number of unhealthy food habits was increased in all diagnostic groups, and the body mass index was found to be increased for patients with schizophrenia. Patients with depression were more physically active than general population. CONCLUSION: Poor health behavior is widespread in patients with all major psychiatric diagnoses. Interventions to reduce risk behavior and strengthen health preventive lifestyles are necessary.

[Olanzapine and pregnancy. 2 case reports]. / Olanzapin und Schwangerschaft. Zwei Kasuistiken.

We report on two schizophrenic females who both had unexpected first pregnancies in their mid-thirties while being treated with olanzapine. Both patients had histories of psychosis of several years with some relapses and were treated previously with traditional antipsychotics. Since they wished to have children, no contraception had been performed past the age of 30. Both pregnancies occurred within a few months after the drug treatment was switched from traditional agents to olanzapine. Olanzapine was continued throughout the pregnancies, which were without complication. It is well known that treatment with traditional neuroleptics may lead to elevated prolactin levels and thus to relative infertility. Like clozapine, olanzapine has minimal effects on prolactin levels. These cases indicate that after switching from traditional neuroleptics to atypical agents, fertility may normalize and unplanned or even unwanted pregnancies may occur. Since olanzapine is widely prescribed, it is essential to inform women about the increased probability of pregnancy and the need of appropriate contraception.

[Economic aspects of psychotherapy management in psychosomatics and psychiatry. A systematic survey of the literature]. / Okonomische Aspekte psychotherapeutischer Verfahren in Psychosomatik und Psychiatrie. Ein systematischer Literaturüberblick.

Economic evaluations have become more and more important in the somatotherapeutic field. This survey's objective was to examine if the current economic evaluation techniques can be applied to psychotherapy. 8 data banks, 17 key words from the psychotherapeutic field and 14 economic key words were used, the identified original studies were classified in accordance with Drummond, the methodical quality of each study was assessed at a score between 0 and 10 points. 21 studies were found: 16 cost-benefit analyses, 4 cost-effectiveness analyses and one cost-utility analysis. The quality of the representation of the clinical results (mean value 8.6) was better than that of the economic results (mean value 6.1). It was perfectly possible to evaluate psychotherapeutic interventions with regard to economic aspects by means of the current techniques but in most cases there was a considerable lack of quality in both representation and calculation. Furthermore the evaluation type of cost-utility analysis, which is the only one that takes quality of life aspects into consideration and therewith seems to be the most appropriate approach regarding the psychotherapeutic field, has been greatly ignored.