The prevalence and type of Axis-I and Axis-II mental disorders in subjects with non-specific chronic back pain: results from a population-based study.

OBJECTIVE: To investigate the prevalence and the type of mental comorbidity in a population-based sample of subjects with non-specific chronic back pain. DESIGN: Representative population-based survey. SETTING: The city of Heidelberg (in southwestern Germany) and 10 adjacent communities. PATIENTS: From a random sample of individuals (N = 2,000), 1,091 subjects completed a questionnaire including a pain assessment. Of those, 188 subjects (17%) fulfilled the criteria for chronic back pain (≥45 days of back pain in the last 3 months) and were subsequently invited to undergo a detailed clinical examination; 131 subjects (70%) agreed to participate. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) (SCID-I + II) was used to assess current (defined as the previous 4 weeks) mental comorbidity and was completed in 110 subjects (84%) with non-specific chronic back pain. INTERVENTION: N/A. OUTCOME MEASURES: DSM-IV mental comorbidity diagnoses. RESULTS: The overall prevalence of mental comorbidity of Axis-I and -II disorders were 35.5% and 15.5%, respectively. Of Axis-I disorders, anxiety disorders (20.9%) and affective disorders (12.7%) were the most frequent. Of Axis-II disorders, 9.1% of diagnoses was of the Cluster C category (anxious/inhibited). Compared with the general population, the total rate of Axis-I comorbidity was significantly higher, while the total rate for Axis-II personality disorders was only slightly different. CONCLUSIONS: The consistent diagnoses of anxiety, fear, and avoidance in these subjects indicate that also primary care health professionals should consider anxiety disorders in patients with chronic pain, in addition to the affective disorders that are most frequently self-reported in pain patients.

Clinical decision making and outcome in routine care for people with severe mental illness (CEDAR): study protocol.

BACKGROUND: A considerable amount of research has been conducted on clinical decision making (CDM) in short-term physical conditions. However, there is a lack of knowledge on CDM and its outcome in long-term illnesses, especially in care for people with severe mental illness. METHODS/DESIGN: The study entitled "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR) is carried out in six European countries (Denmark, Germany, Hungary, Italy, Switzerland and UK). First, CEDAR establishes a methodology to assess CDM in people with severe mental illness. Specific instruments are developed (and psychometric properties established) to measure CDM style, key elements of CDM in routine care, as well as CDM involvement and satisfaction from patient and therapist perspectives. Second, these instruments are being put to use in a multi-national prospective observational study (bimonthly assessments during a one-year observation period; N = 560). This study investigates the immediate, short- and long-term effect of CDM on crucial dimensions of clinical outcome (symptom level, quality of life, needs) by taking into account significant variables moderating the relationship between CDM and outcome. DISCUSSION: The results of this study will make possible to delineate quality indicators of CDM, as well as to specify prime areas for further improvement. Ingredients of best practice in CDM in the routine care for people with severe mental illness will be extracted and recommendations formulated. With its explicit focus on the patient role in CDM, CEDAR will also contribute to strengthening the service user perspective. This project will substantially add to improving the practice of CDM in mental health care across Europe. TRIAL REGISTER: ISRCTN75841675.

Needs-oriented discharge planning and monitoring for high utilisers of psychiatric services (NODPAM): design and methods.

BACKGROUND: Attempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare. METHODS: This paper presents design and methods of the study "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM), a multicentre RCT conducted in five psychiatric hospitals in Germany. Inclusion criteria are receipt of inpatient psychiatric care, adult age, diagnosis of schizophrenia or affective disorder, defined high utilisation of psychiatric care during two years prior to the current admission, and given informed consent. Consecutive recruitment started in April 2006. Since then, during a period of 18 months, comprehensive outcome data of 490 participants is being collected at baseline and during three follow-up measurement points. The manualised intervention applies principles of needs-led care and focuses on the inpatient-outpatient transition. A trained intervention worker provides two intervention sessions: (a) Discharge planning: Just before discharge with the patient and responsible clinician at the inpatient service; (b) Monitoring: Three months after discharge with the patient and outpatient clinician. A written treatment plan is signed by all participants after each session. Primary endpoints are whether participants in the intervention group will show fewer hospital days and readmissions to hospital. Secondary endpoints are better compliance with aftercare, better clinical outcome and quality of life, as well as cost-effectiveness and cost-utility. DISCUSSION: If a needs-oriented discharge planning and monitoring proves to be successful in this RCT, a tool will be at hand to improve patient outcome and reduce costs via harmonising fragmented mental health service provision. TRIAL REGISTRATION: ISRCTN59603527.

Toll-Like Receptor-Mediated Upregulation of CXCL16 in Psoriasis Orchestrates Neutrophil Activation.

Innate immune processes are central in the development of the chronic inflammatory skin disease psoriasis. Studying stimulation of keratinocytes, monocytes, and dendritic cells by type I interferons or ligation of Toll-like receptors 1/2, 2/6, or 7, but not 7/8, resulted in enhanced surface expression and secretion of CXC chemokine ligand (CXCL) 16. The corresponding CXC chemokine receptor 6 was expressed on neutrophils whose recruitment into skin is important, especially in early psoriatic disease. Using the recently developed technique real-time deformability cytometry demonstrated that CXCL16 and IL-8 decreased the stiffness and enhanced deformation of neutrophils facilitating transmigration through vessel wall. In addition, CXCL16 potently induced migration of neutrophils and enhanced the chemotactic effect of IL-8. The positive feedback loop was supported by IL-8 enhancing CXCL16 production of neutrophils. Blocking of CXCL16 expression by effective treatment of psoriasis patients with tumor necrosis factor-α blockers further supported the pathogenic role of this chemokine. In summary, the data link innate immune stimulation to CXCL16 upregulation and neutrophil infiltration into skin. CXCL16 could therefore represent a potent future target for treatment of psoriasis.

[RCT on discharge planning for high utilisers of mental health care: conduct and quality of the intervention]. / Entlassungsplanung bei Menschen mit hoher Inanspruchnahme psychiatrischer Versorgung in einer randomisierten kontrollierten Multicenterstudie: Durchführung und Qualität der Intervention.

OBJECTIVE: To evaluate feasibility of a structured discharge planning intervention for high utilisers of mental health care developed in a multicentre RCT. METHODS: Data of N = 241 participants (discharge and 3-month follow-up) allocated to the intervention group are analysed with regard to the intervention's quality of implementation, acceptance, and changes in needs. RESULTS: The intervention was well accepted among patients and staff. However, a subgroup of participants showed manual violations. Total and unmet needs could be reduced between baseline and follow-up. Amount and change of needs substantially varied by centre and there was a trend towards variation by dose. CONCLUSIONS: The intervention was feasible. Further analyses are needed to explore differential efficacy.

[Randomised controlled multicenter trial on discharge planning in high utilisers of mental health care]. / Entlassungsplanung bei Menschen mit hoher Inanspruchnahme psychiatrischer Versorgung in einer randomisierten kontrollierten Multizenterstudie.

OBJECTIVE: A simple, systematic and targeted manualised intervention was developed and applied in the German multicentre randomised controlled trial "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM). BACKGROUND: Rational of the intervention is outlined. Similarities and differences in comparison with other approaches (Care Programme Approach, "Integrierter Behandlungs- und Rehabilitations plan", Critical Time Intervention) are delineated. INTERVENTION: The intervention consists of two sessions led by an intervention worker with patient, keyworkers (at inpatient and outpatient services), and - optionally - carer(s) participating. During each intervention session needs identified by the patient are discussed, a treatment plan is developed and subsequently circulated to all participants. CONCLUSIONS: Strengths (high structure, simplicity, compatibility with routine care) and disadvantages (e. g. shortness, insufficient dispersion of time, lack of integration with clinical process) of the intervention are discussed.