Prevalence of psychotropic medication and factors associated with antipsychotic treatment in adults with intellectual disabilities: a cross-sectional, epidemiological study in Germany.

BACKGROUND: Mental health services in people with intellectual disabilities (ID) are frequently limited to psychotropic medication (PM), especially antipsychotics. The objectives of this study were to assess the prevalence rates of PM treatment in adults with ID in Germany and to identify factors associated with antipsychotic treatment. METHODS: This study is an epidemiological, cross-sectional study. Sampling was realised by a random selection of service-providing institutions, followed by a random selection of adults with ID within these participating institutions. Interviews were conducted with formal and informal carers of n = 197 adults with ID. Data were analysed using descriptive statistics and risk ratios. RESULTS: The 4-week prevalence rate of PM was 53.8%. Antipsychotics were the most frequent PM (43.7%). Polypharmacy and off-label use were common. Antipsychotic treatment is associated with living in a residential home [relative risk (RR) = 2.99], not working in a sheltered workshop (RR = 1.46), autism spectrum disorder (RR = 1.89), a documented psychiatric diagnosis (RR = 1.61), psychiatric symptomatology (RR = 1.44) and (mild) challenging behaviours (RR = 4.58). CONCLUSIONS: Further efforts are needed to provide adequate mental health care, specifically to improve PM treatment regarding amount, indication and the consideration of non-psychopharmacological treatment options.

[Determinants of psychotropic medication in adults with mild or moderate intellectual disabilities]. / Bedingungsfaktoren psychopharmakologischer Behandlung bei leichter oder mittelgradiger Intelligenzminderung.

BACKGROUND: During the past years the provision of mental healthcare for adults with intellectual disabilities (ID) has repeatedly been criticized; however, the number of relevant studies is still relatively few. OBJECTIVE: The aim of the present study was to identify determinants for utilization of mental healthcare services and prescription of psychotropic medication in adults with mild to moderate ID. MATERIAL AND METHODS: Analyses were based on data from 417 adults with mild to moderate ID, which had been collected within the cross-sectional MEMENTA study in three different regions of Germany. Logistic regression analyses were conducted to identify clinical and sociodemographic variables as predictors of utilization of mental healthcare services (n = 282) and psychotropic medication (n = 351). RESULTS: Utilization of healthcare services and psychotropic medication were both associated with mental disorders and problem behavior. In addition, the likelihood of being treated with psychotropic medication and antipsychotic drugs was higher in adults living in residential homes. CONCLUSION: The findings indicate a lack of adherence to existing guidelines in the treatment of adults with ID living in residential homes.

Course of post-traumatic stress disorder following war in the Balkans: 1-year follow-up study.

BACKGROUND: Prevalence rates of post-traumatic stress disorder (PTSD) following the experience of war have been shown to be high. However, little is known about the course of the disorder in people who remained in the area of conflict and in refugees. Method We studied a representative sample of 522 adults with war-related PTSD in five Balkan countries and 215 compatriot refugees in three Western European countries. They were assessed on average 8 years after the war and reinterviewed 1 year later. We established change in PTSD symptoms, measured on the Impact of Events Scale - Revised (IES-R), and factors associated with more or less favourable outcomes. RESULTS: During the 1-year period, symptoms decreased substantially in both Balkan residents and in refugees. The differences were significant for IES-R total scores and for the three subscales of intrusions, avoidance and hyperarousal. In multivariable regressions adjusting for the level of baseline symptoms, co-morbidity with depression predicted less favourable symptom change in Balkan residents. More pre-war traumatic events and the use of mental health services within the follow-up period were associated with less improvement in refugees. CONCLUSIONS: Several years after the war, people with PTSD reported significant symptom improvement that might indicate a fluctuating course over time. Co-morbid depression may have to be targeted in the treatment of people who remained in the post-conflict regions whereas the use of mental health services seems to be linked to the persistence of symptoms among refugees.

[Course of trauma sequelae in ex-political prisoners in the GDR: a 15-year follow-up study]. / Verläufe von Traumafolgen bei ehemaligen politisch Inhaftierten der DDR: Ein 15-Jahres-Follow-up.

BACKGROUND: In a sample of ex-political prisoners in the GDR examined in the middle of the 1990s, a follow-up examination carried out 15 years later investigated alterations in the diagnosis and symptom prevalence of post-traumatic stress syndrome PTSS) as well as other psychiatric disorders. The diagnosis course given by the clinicians was compared with the retrospective subjective estimations by participants. METHODS: A total of 93 ex-political prisoners participated in the follow-up study (85 %) with an average age of 64 years. Diagnoses and symptoms were collated using structured clinical interviews and questionnaires. The retrospective subjective estimation of progression of the participants was calculated using a PTSS symptom index based on four symptom groups (intrusions, avoidance, numbing and hyperarousal). RESULTS: At the time of follow-up PTSS was present in 33 % of participants (in 1997 it was 29 %). In 1994 this was present in only approximately 50 % of cases and in the other 50 % it concerned newly incident or remission cases. The next most common diagnoses were major depression episodes (26 %), panic (with or without agoraphobia 24 %) and somatoform disorders (19 %). In the PTSS symptom profile intrusions, flashbacks and alienation feelings decreased with time but in contrast irritability and shock reactions increased. The subjective self-estimation of the course of PTSS symptoms by the participants often gave a resilient (never PTSS) or delayed and rarely a remission course pattern in comparison to the diagnosing clinicians. CONCLUSIONS: The results indicate a trauma-related long-term morbidity which is, however less stable than previously assumed.

Dementia quality of life instrument--construct and concurrent validity in patients with mild to moderate dementia.

BACKGROUND AND PURPOSE: To translate the Dementia quality of life instrument (DQoL) into German and assess its construct and concurrent validity in community-dwelling people with mild to moderate dementia. METHODS: Dementia quality of life instrument data of two pooled samples (n=287) were analysed regarding ceiling and floor effects, internal consistency, factor reliability and correlations with corresponding scales on quality of life (Quality of Life in Alzheimer's Disease and SF-12), cognition (Mini-Mental State Examination, Alzheimer's Disease Assessment Scale - cognitive), depression (Cornell Scale for Depression in Dementia) and activities of daily living (Interview of Deterioration in Daily Living Activities in Dementia). RESULTS: We found no floor effects (<2%), minor ceiling effects (1-11%), moderate to good internal consistency (Cronbach's α: 0.6-0.8) and factor reliability (0.6-0.8), moderate correlations with self-rated scales of quality of life (Spearman coefficient: 0.3-0.6) and no or minor correlations with scores for cognition, depression or activities of daily living (r<0.3). The original five-factor model could not be confirmed. CONCLUSION: The DQoL can be used in dementia research for assessing positive and negative affect, feelings of belonging and self-esteem. The findings suggest further research to improve the structure of the scales aesthetics, feelings of belonging and self-esteem.

Social disability in different mental disorders.

OBJECTIVE: To assess the social disability of people with different psychiatric disorders. METHODS: Cross-site survey in five psychiatric hospitals (Dresden, Wroclaw, London, Michalovce and Prague). Working-aged patients diagnosed (ICD-10) with schizophrenia and related disorders (F2), affective disorders (F3), anxiety disorders (F4), eating disorders (F5) and personality disorders (F6), were assessed at admission (n=969) and 3 months after discharge (n=753) using the Brief Psychiatric Rating Scale and the Groningen Social Disability Schedule. The main outcome measure was Interviewer-rated social disability. RESULTS: During acute episodes patients with personality, eating and schizophrenic disorders functioned less effectively than those with affective or anxiety disorders. After controlling for age and severity of psychopathology, there was no significant effect of the diagnosis (during remission), sex, education and history of disorder on disability. Site, employment and partnership were significant factors for the level of social disability in both measure points. CONCLUSION: Severity of psychopathological symptoms, not the diagnosis of a mental disorder, was the most significant factor in determining the level of social functioning, particularly during the remission period. Site, employment and partnership appeared as significant factors influencing the level of social disability.

[Personality of schizophrenic and schizoaffective patients]. / Zur Persönlichkeit schizophrener und schizoaffektiver Patienten.

At time of discharge 33 patients with ICD-9 schizophrenia and 16 patients with ICD-9 schizoaffective psychosis were assessed by the Freiburg Personality Inventory (FPI). Psychological profiles were analyzed individually and compared to controls. In addition, a hierarchical cluster analysis was carried out. Psychopathological findings at time of discharge were documented by the AMDP system. Impact of psychopathology on response behavior in the FPI was not evident. There were but few schizophrenic or schizoaffective patients without any abnormal FPI score. For the schizophrenics abnormal (high and low) scores could especially be found on the scales "Nervousness", "Depressiveness" and "Masculinity", for the schizoaffective patients on the scales "Nervousness", "Depressiveness", "Excitability", "Extraversion" and "Neuroticism". With regard to personality both groups turned out to be heterogenous. The schizophrenics differed significantly from the controls by higher means on the scales "Nervousness" and "Depressiveness" and a lower mean on the scale "Masculinity". The schizoaffective patients differed significantly from the controls by higher means on the scales "Depressiveness" and "Inhibition". Hierarchical cluster analysis resulted in 3 clusters for the schizophrenics: 1. introverted-schizoid type (42%), 2. extraverted-aggressive type (36%), 3. normal type (22%), and 2 clusters for the schizoaffective patients: 1. emotional labile type (56%), 2 normal type (44%). Results are compared to literature.

Trauma and suicidality in war affected communities.

PURPOSE: The aim was to assess whether experiences of war trauma remain directly associated with suicidality in war affected communities when other risk factors are considered. MATERIALS AND METHODS: In the main sample 3313 participants from former Yugoslavia who experienced war trauma were recruited using a random sampling in five Balkan countries. In the second sample 854 refugees from former Yugoslavia recruited through registers and networking in three Western European countries. Sociodemographic and data on trauma exposure, psychiatric diagnoses and level of suicidality were assessed. RESULTS: In the main sample 113 participants (3.4%) had high suicidality, which was associated with number of potentially traumatic war experiences (odds ratio 1.1) and war related imprisonment (odds ratio 3) once all measured risk factors were considered. These associations were confirmed in the refugee sample with a higher suicidality rate (10.2%). DISCUSSION AND CONCLUSIONS: Number of potentially traumatic war experiences, in particular imprisonment, may be considered as a relevant risk factor for suicidality in people affected by war.

Patients' subjective initial response and the outcome of inpatient and day hospital treatment.

OBJECTIVE: This study aimed to establish whether psychiatric patients' subjective initial response (SIR) to hospital and day hospital treatment predicts outcomes over a one-year follow-up period. METHOD: We analysed data from 765 patients who were randomised to acute psychiatric treatment in a hospital or day hospital. SIR was assessed on day 3 after admission. Outcomes were psychiatric symptom levels and social disability at discharge, and at 3 and 12 months after discharge. RESULTS: After controlling for socio-demographic and clinical characteristics, a more positive SIR was significantly associated with lower symptom levels at discharge and 3 months after discharge and lower social disability at 3 months and 12 months after discharge. CONCLUSION: SIR can predict outcomes of complex interventions over a one-year period. Patients' initial views of acute hospital and day treatment should be elicited and considered as important.

[Psychometric properties of dimensional measures derived from the latest German version of the Schedules for Clinical Assessment in Neuropsychiatry 2.1]. / Dimensionale Diagnostik mit der deutschsprachigen Version der Schedules for Clinical Assessment in Neuropsychiatry 2.1.

BACKGROUND: The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a comprehensive set of clinical assessment instruments developed by the World Health Organisation. This is the first study to report psychometric properties of dimensional measures derived from the latest German version SCAN 2.1. METHODS: Within a randomized controlled trial comparing psychiatric day-hospital treatment to inpatient treatment, 202 acute mentally ill patients were interviewed by clinically experienced interviewers. Forty-seven items of Part I of SCAN 2.1 were selected for constructing dimensional measures. Six scales were generated using principal component analyses (PCA). They were compared to five scales constructed according to the items' affiliation to specific sections of SCAN 2.1. RESULTS AND CONCLUSIONS: Cronbach's alpha coefficients qualify the reliability of most scales as moderate (0.500.70). With respect to high correlations between the scales generated using PCA and the section-specific scales, using the latter is recommended. Research into psychotic disorders, however, is missing, given that the present analyses are based on items from Part I of SCAN 2.1 only.

[Early intervention following trauma. An overview of programs and their effectiveness]. / Frühinterventionen nach traumatisierenden Erfahrungen. Ein Uberblick über Massnahmen und deren Wirksamkeit.

A powerful motivation for clinicians working in the field of trauma is the wish to prevent or minimize chronic posttraumatic reactions by early interventions. This paper illustrates the process and the elements of important programs that have been introduced into the psychological or psychiatric literature. Studies that have been done to evaluate these programs are discussed. With regard to early interventions given to traumatized victims regardless of whether they suffer from posttraumatic stress or not, it is clearly shown that the evidence that these programs have a substantial positive benefit is disappointingly scarce. However, with regard to the treatment of acute stress disorder, a brief cognitive-behavioral program appears to effectively prevent the development of chronic posttraumatic stress disorders. In summary, it has to be noted that much more research on this issue is needed.

Long-term effects of political imprisonment: a group comparison study.

The study investigated the long-term effects of political imprisonment in the former German Democratic Republic. A group of non-treatment-seeking former political prisoners (n = 146) was compared with an age- and sex-matched group (n = 75). Assessments included the structured Diagnostic Interview for Psychiatric Disorders (German abbreviation: DIPS) for DSM-III-R/-IV diagnoses, a checklist of persecution and maltreatment, and other self-rated measures of post-traumatic stress disorder (PTSD), anxiety, depression, and dissociation. PTSD was assessed by the DIPS as current and lifetime diagnoses. Former political prisoners were imprisoned for 38 months on average. The former prisoners had a lower educational and lifetime occupational level than the comparison group. Results regarding diagnoses show a frequency of 30% current and 60% lifetime PTSD in the former prisoners group. Other anxiety disorders (e.g., claustrophobia, social phobia) outnumbered comorbid affective disorders. The level of dissociation was elevated in the former prisoners group. Intrusive recollections and hyperarousal were more common than avoidance/numbing symptoms. Despite differences in imprisonment duration between three historically defined eras of persecution, no differences appeared in the level of symptomatology. The results suggest that political imprisonment in the former German Democratic Republic had long-term psychological effects. Compared with an age- and sex-matched comparison group, the former political prisoners showed higher levels not only of post-traumatic symptomatology but also of other anxiety disorders and dissociation.

[Patient evaluation of inpatient psychiatric occupational therapy. Determinants of reported patient satisfaction]. / Patientenbewertungen stationärer psychiatrischer Ergotherapie. Bedingungsfaktoren der berichteten Patientenzufriedenheit.

OBJECTIVE: The present study, which falls back on data collected within an extensive evaluation of indoor psychiatric ergotherapy, aims at the investigation of the interaction between patients' satisfaction and patients' characteristics, duration of treatment, and patients' assessments of specific single treatment aspects. METHODS: Fifty-eight inpatients assigned to three ergotherapeutic treatment programs were included into study. Assessments included--among others--a German version of the Client Satisfaction Questionnaire as well as a 74-items questionnaire on specific treatment aspects, such as perceived support, perceived practical orientation, and perceived personal problem orientation. RESULTS: As expected, a high level of satisfaction with treatment was reported. Patients' satisfaction is correlated with some variables under study, such as patients' subjective well-being and patients' assessments of psychosocial and professional treatment aspects. CONCLUSIONS: Findings indicate that--for the purpose of high patient satisfaction--ergotherapeutic treatment programs should distinguish themselves by supportive therapists, practical orientation, and personal problem orientation.

Anger in former East German political prisoners: relationship to posttraumatic stress reactions and social support.

Anger is a salient symptom of traumatized victims and a major sign for posttraumatic stress disorder (PTSD). However, the causes for the increased level of anger remain almost unknown. The present study investigates the interrelationship of anger, posttraumatic stress reactions, and social support in a group of former East German political prisoners (N = 91). Assessments included the German version of the Anxiety Disorders Schedule (DIPS) as well as measures of anger (STAXI), posttraumatic stress reactions (IES-R), and social support (SSQ). As expected, participants reported a high level of anger. Most measures of anger, posttraumatic stress reactions, and social support were significantly correlated. Within structural equation modeling, trait-anger was shown to be directly activated by the experience of chronic posttraumatic intrusions. Social support appeared to lessen the level of anger. The results confirm findings from studies on other traumatic events and provide additional information on the relationship between posttraumatic anger and social support. The findings indicate that treatments for PTSD might be effectively supplemented by addressing anger and social support.

Effects of varying diagnostic criteria for posttraumatic stress disorder are endorsing the concept of partial PTSD.

The purpose of the present study was to investigate the appropriateness of different diagnostic criteria sets for posttraumatic stress disorder (PTSD). This was done by varying diagnostic criteria on the diagnosis of PTSD in a study group of N = 146 former political prisoners, and comparing the resulting diagnostic groups with a study group of N = 75 nontraumatized controls with regard to mean scores on measures of subjective distress (i.e., IES-R, BDI, BAI, SCL-90-R). The findings did not support the diagnostic boundaries as defined by the DSM-IV or the lowering of the avoidance criterion from three to two symptoms. The concept of partial PTSD appeared to be the most appropriate way to provide diagnostic coverage for those who did not meet full DSM IV criteria.

[Randomised controlled trials in mental health services research: practical problems of implementation]. / Randomisierte kontrollierte Studien in der psychiatrischen Versorgungsforschung: Probleme der Durchführungspraxis.

This article outlines problems of implementation and clinical practice of randomised controlled trials in mental health services. Furthermore, it offers practical solutions taking into account the experiences with a randomisation process in a multi-site EC-funded (EDEN-) study on the evaluation of acute treatment in psychiatric day hospitals. Identification of the problems follows the time-course of a research project: 1. Problems to be solved prior to the study's commencement: Definition of the eligibility criteria, information of clinically working colleagues. 2. Problems referring to the process of randomisation: Influence of clinical experience of the research fellows, precise time-point of implementing the randomisation into the process of admission, assessment of the patient's ability to give informed consent, patient's refusal of randomisation but agreement to study participation, availability of treatment places. 3. Problems which might occur after randomisation: Early break-off of treatment, transfer from one treatment setting to another. General conclusion: Detailed definitions of the randomisation procedure do not guarantee high performance quality and randomisation rates. Continuous precise assessment of the implementation into the clinical routines of every study centre, adaptation according to specific conditions and personal discussions with all participants are obligatory to establish and maintain a high quality of this important research procedure.

[AIDS prevention: cognitive-emotional approach to the topic of AIDS and behavioral change]. / AIDS-Prävention: Kognitiv-emotionale Auseinandersetzung mit dem Thema AIDS und Verhaltensänderung.

This study investigates the cognitive-emotional arguments advanced by young adults on the subject of AIDS within the frame-work of a multivariate approach. The centre of all the deliberations is the question as to which factors exercise a major influence on emotional experience and on changes in sexual behaviour. The random sample study comprises 354 Göttingen students. Implications of the findings on AIDS prevention are discussed.

[Formulating a diagnosis in psychiatry]. / Zur Diagnosenstellung in der Psychiatrie.

Referring to some critical comments on operational diagnostics in view of the adoption of the 10th Revision of the International Classification of Diseases, the relevance of symptomatology for diagnosis using ICD-8 and ICD-9 was investigated in a retrospective study. Inpatients with neurotic depression, endogenous depression, schizoaffective psychosis, manic psychosis and paranoid schizophrenia were included in the study. Data came from routine documentation of every episode of treatment, symptoms being assessed according to the AMP system. Discriminant analyses revealed psychopathology at admission to be the most important information for diagnosis both at admission and at discharge. Psychopathology at discharge seemed to be of no importance for diagnosis, whereas inclusion of the reasons for referral improved discrimination between categories of depressive disorder. When in addition sex, age, and chronicity were included in computation of the discriminant function, a further improvement in the prediction of psychiatric diagnosis at discharge resulted. These findings are compared to others reported in the literature.

Trauma severity and initial reactions as precipitating factors for posttraumatic stress symptoms and chronic dissociation in former political prisoners.

This study explores the relationships among trauma severity, initial trauma reactions, posttraumatic stress disorder (PTSD) symptoms, and dissociation in a group of 98 former East-German political prisoners. Trauma severity and initial reactions were assessed using a persecution checklist and a coping process questionnaire. PTSD symptoms were assessed through a structured clinical interview. Chronic dissociation was evaluated using the Dissociative Experiences Scale. The two assumptions of the study were confirmed by structural equation modeling: (1) Lifetime PTSD symptoms were predominantly predicted by initial reactions to trauma and (2) chronic dissociation was predominantly predicted by trauma severity. The first finding is discussed in relation to the participants' initial trauma processing. The second finding is discussed especially in the context of trauma duration and dissociation-prone coping attempts. Limitations concerning the long-term interval between traumatization and data collection are discussed.

[The personality of unipolar depressive and bipolar manic-depressive patients]. / Zur Persönlichkeit unipolar depressiver und bipolar manisch-depressiver Patienten.

Starting from central hypotheses on the relationship between personality and affective disorders, the profiles in the Freiburg Personality Inventory (FPI-A) of 23 unipolar depressives, 26 bipolar manic-depressives and 30 healthy controls of the standardization sample were analysed. Assessment by the Freiburg Personality Inventory was carried out at the time of discharge under the instruction to refer the answers to the time before the beginning of the illness. Parallel to the personality assessment the degree of remission was documented by the scales "Depressive Syndrome", "Apathetic Syndrome" and "Manic Syndrome" of the AMDP system and the d2 concentration test. In intraclass covariance analyses the following scales showed significant differences between unipolar depressives, bipolar manic-depressives and normal controls: FPI3 "Depressiveness", FPI8 "Inhibition" and FPIE "Extraversion". The differences cannot be explained by age or sex. In contrast to manic-depressives, unipolar depressives characterize themselves as more depressive, inhibited and introverted. The bipolar manic-depressives do not differ from the norms in any scale of the FPI. These findings are compared both with the starting hypotheses and with results reported in the literature.