EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination.

BACKGROUND: The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services. METHODS: We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases. RESULTS: We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare. CONCLUSIONS: Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Assessment of Diagnostics Tools for Sarcopenia Severity Using the Item Response Theory (IRT).

OBJECTIVE: To use the item response theory (IRT) methods to examine the degree to which the four selected tools reflect sarcopenia and to arrange them according to their ability to estimate sarcopenia severity. DESIGN: A cross-sectional study aimed at verifying the possibilities of using diagnostic tools for sarcopenia. SETTING AND PARTICIPANTS: The study included residents living in an assisted living unit at the Senior Centre in Blansko (South Moravia, Czech Republic) (n=77). Sarcopenia was estimated according to the proposals of the European Working Group on Sarcopenia in Older People (EWGSOP) using calf circumference, the EWGSOP algorithm, hand grip strength, and the Short Physical Performance Battery (SPPB). RESULTS: The results from the IRT model showed that these four methods indicate strong unidimensionality so that they measure the same latent variable. The methods ranked according to the discrimination level ranging from high to low discrimination where the calf circumference was the most discriminatory (Hi = 0.86) and the SPPB together with hand grip strength were the least discriminatory (both Hi = 0.44). CONCLUSION: We are recommending to identify mild sarcopenia by SPPB or hand grip strength, moderate sarcopenia by the EWGSOP algorithm and severe sarcopenia by the calf circumference.

The nature of delusion: psychologically explicable? psychologically inexplicable? philosophically explicable? Part 2.

The first part of this article dealt with the extant formulations of delusion, psychiatric and psychological, suggestions which, respectively, regard delusion as psychologically inexplicable or explicable. All this was subjected to critique. This second part puts forward informed philosophical thesis whereby delusion can be explained within the philosophical movement known as phenomenology and, in particular, Max Scheler's version of this.

The nature of delusion: psychologically explicable? psychologically inexplicable? philosophically explicable? Part 1.

The debate about the nature of delusion has rumbled on for over a century without resolution. The current situation is a stand-off between psychologists, who propose various theories as to the psychological explicability of delusion, and psychiatrists, who generally regard delusion as inexplicable. Our main aim in this 2-part article is to reprise the intellectual atmosphere of German psychopathology in the inter-war and immediate post-war years, when the issues concerning delusion were formulated with more sensitivity to the actual delusions encountered in clinical practice. In Part 1 we mount a critique of psychological and psychiatric theories of delusion.

EPA guidance on the role and responsibilities of psychiatrists.

Psychiatry is that branch of the medical profession, which deals with the origin, diagnosis, prevention, and management of mental disorders or mental illness, emotional and behavioural disturbances. Thus, a psychiatrist is a trained doctor who has received further training in the field of diagnosing and managing mental illnesses, mental disorders and emotional and behavioural disturbances. This EPA Guidance document was developed following consultation and literature searches as well as grey literature and was approved by the EPA Guidance Committee. The role and responsibilities of the psychiatrist include planning and delivering high quality services within the resources available and to advocate for the patients and the services. The European Psychiatric Association seeks to rise to the challenge of articulating these roles and responsibilities. This EPA Guidance is directed towards psychiatrists and the medical profession as a whole, towards other members of the multidisciplinary teams as well as to employers and other stakeholders such as policy makers and patients and their families.

[Femoroacetabular impingement syndrome: first experience with surgical treatment]. / Femoroacetabulární impingement syndrom--první zkusenosti s chirurgickou lécbou.

PURPOSE OF THE STUDY: Femoroacetabular impingement syndrome (FAI) represents a mechanical conflict between acetabulum and proximal part of the femur. This disorder may gradually result in the development of the hip osteoarthritis. FAI may be caused by an acetabular retroversion, rarely by coxa profunda or by asphericity of the femoral head and missing femoral head-neck offset respectively. However, a combination of both conditions is the most frequent. Before FAI treatment was adopted as a standard technique for hip preservation at our department, detailed cadaver studies of the vascular anatomy of the hip were performed and the relevant literature was reviewed. The aim of this study was to assess the efficiency of hip preserving surgery in relation to the technique used. We hypothesized that surgical intervention helped to alleviate pain and improve hip function. MATERIAL AND METHODS: In the period from October 11, 2005 to June 30, 2012, a total of 168 patients (190 hips) had surgery for FAI. After we met exclusion criteria, 83 hips were treated by surgical hip dislocation (SHD) and 17 undergoing anterior minimally invasive surgery (AMIS). The minimum follow-up was 12 months, with an average of 3 years and 4 months, and a range of 12 months to 7 years and 8 months. The subjective evaluation by the patients and the functional hip assessment were based on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the non-Arthritic Hip Score (nAHS) questionnaires. To assess the efficiency of the techniques, the pre- and post-operative scores were compared in each group (SHD group, n=83; AMIS group, n=17). A comparison of pre- and post-operative data was also made for the groups joined together to evaluate the benefit of surgery as such in FAI treatment. The results were statistically analysed using the Wilcoxon test for paired samples; the level of significance was set at 0.05. RESULTS: There was a statistically significant increase in the scores obtained after surgery, as compared with the pre-operative data, in the SHD and AMIS groups and in all patients evaluated together. Hip survival without the necessity of conversion to total hip replacement was 96.4% (80/83 hips) in the SHD group and 94.1% (16/17 hips) in the AMIS group. no serious complications were recorded. DISCUSSIOn The rate of failure in the surgical treatment of FAI syndrome in our patients was in accordance with the literature data, as was the number of the patients requiring conversion to total hip replacement. Also the other results were comparable with those of relevant studies. CONCLUSIONS: Hip preservation surgery is an issue which has slowly been gaining consensus although opinions on it, including FAI surgical treatment, still vary. As FAI syndrome is a condition leading to degenerative changes in the hip, it is important to pay attention to a thorough diagnostic evaluation and a correct, though often long-term, therapy.

Motor skills in Czech children with attention-deficit/hyperactivity disorder and their neurotypical counterparts.

Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed neurobehavioural disorder. Characterized by recurring problems with impulsiveness and inattention in combination with hyperactivity, motor impairments have also been well documented in the literature. The aim of this study was to compare the fine and gross motor skills of male and female children with ADHD and their neurotypical counterparts within seven skill assessments. This included three fine motor tasks: (1) spiral tracing, (2) dot filling, (3) tweezers and beads; and four gross motor tasks: (1) twistbox, (2) foot tapping, (3) small plate finger tapping, and (4) large plate finger tapping. It was hypothesized that children with ADHD would display poorer motor skills in comparison to neurotypical controls in both fine and gross motor assessments. However, statistically significant differences between the groups only emerged in four of the seven tasks (spiral tracing, dot filling, tweezers and beads and foot tapping). In line with previous findings, the complexity underlying upper limb tasks solidified the divide in performance between children with ADHD and their neurotypical counterparts. In light of similar research, impairments in lower limb motor skill were also observed. Future research is required to further delineate trends in motor difficulties in ADHD, while further investigating the underlying mechanisms of impairment.

EPA guidance on the quality of mental health services.

The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.

[The history of schizophrenias: philosophical roots]. / Die unterschiedliche Herkunft von Schizophrenien und ihre philosophischen Grundlagen.

Although the term "schizophrenia" has been introduced in medical usage by E. Bleuler, all variations of schizophrenia developed afterwards trace back to E. Kraepelin. In his work on dementia praecox he intended to discover a yet unknown entity from nature definitely following the principles and maxima of positivism. In the following a great number of different concepts of schizophrenia were developed and the psychiatrist of the seventies and eighties of the last century was left confronted with an abundance of varying schizophrenic criteria. The upcoming globalization in diagnostic stopped this process of diversity and the ideas of Kraepelin reappeared in the ICD-10 criteria for schizophrenia with only a few modifications. The main problem of positivistic research approaches is that nature obviously is completely unimpressed by human made principles of rules and systems. Nature itself does not know these forms and categories invented by human beings. That is one of the reasons why positivistic schizophrenic research considering human made categories as natural has not been quite successful. A possible way out of this diagnostic dilemma -- insufficient categorical classification systems on the one hand and the necessity of apprehending psychopathological phenomena for an effective therapy on the other -- can be a change of paradigms from the usual categorical diagnostics based on the maxima of positivism to dimensional diagnostics developed in the frame of post-modern strategies of thinking. Such process-oriented diagnostic approaches considering the singular phenomenon as well as its significance for the individual and its pathogenesis as main foci of diagnostics provide the possibility for post-modern psychiatrists to start a new dialogue overcoming a positivism based monologue made by experts on the sufferers.

Number of dementia sufferers in Europe between the years 2000 and 2050.

Several authors have pointed out that in the next few decades dementia will affect a considerably increasing number of the elderly. To our knowledge there exist no calculations of the number of demented persons for the whole European region. We made calculations on the number of dementia cases for the period 2000-2050 based on the population projections of the United Nations. For this purpose, we used the results of several meta-analyses of epidemiological studies. The number of prevalent dementia cases in the year 2000 was 7.1 million. Within the next 50 years, this number will rise to about 16.2 million dementia sufferers. The number of new dementia cases per year will increase from about 1.9 million in the year 2000 to about 4.1 million in the year 2050. Contrarily, the working-age population will considerably decrease during the next 50 years. In the year 2000, 7.1 million dementia cases faced 493 million persons in working-age. This equals a ratio of 69.4 persons in working-age per one demented person. Until the year 2050, this ratio will decrease to only 21.1. Thus, the financial and emotional burden placed by dementia on the working-age population will markedly rise.

Dysphoria from a transnosological perspective.

The objective of our psychopathological analyses is to shed light on the position of irritable mood (dysphoria) in psychiatric diagnostics and nosology. In today's most commonly applied classification systems, the ICD-10 and the DSM-IV, dysphoria is mentioned mostly in the context of diagnostic criteria of personality and affective disorders. Other authors have emphasized the importance of dysphoric states in organic psychoses and delusional disorders. Summarizing the various publications on the nosological position, dysphoria is a nosological nonspecific syndrome which may occur in the course of all psychiatric disorders and illnesses. According to the results of our psychopathological analyses, the pathogenesis of dysphoria has to be considered as a multidimensional circular process in which various mental, physical and social factors act as predisposing, triggering and disorder-maintaining factors. Stressors induced by particular experiences and perceptions and by impaired health may lead to a dysphoric state if adequate coping mechanisms are missing. Dysphoria itself usually leads to a deterioration in the mental and physical state of the patient, and shows a clear impact on the patient's social network. The reactions of people close to the patient combined with the impaired mental and physical conditions of the patient cause the circle to restart. As contemporary diagnostic entities do not refer to pathogenesis, classical categorical diagnostics cannot provide the basis for effective pathogenesis-oriented therapy. A change of paradigm in diagnostics from a categorical to a dimensional approach thus becomes necessary. Following a dimensional diagnostic approach based on a dynamic model of vulnerability, a precise differential diagnosis of the complex constellation of conditions and their interactions becomes necessary in order to develop effective treatment strategies. Disorder-maintaining factors determine the treatment of the acute symptomatology, whereas predisposing and triggering factors serve as the basis for the prophylactic treatment.

Induced hallucinatory psychosis (folie à deux hallucinatoire): pathogenesis and nosological position.

A rare case of a folie a deux in a married couple is presented. The inducing partner (IND) suffered from paranoid hallucinatory psychosis and induced similar symptomatology in his wife. Different from most cases reported in the literature, the induced partner (recipient, REC) also experienced auditory hallucinations (commenting and conversing voices). While the IND recovered fully with a combination of psychotherapeutic as well as neuroleptic treatment, the REC was cured by the psychotherapeutic intervention and the recovery of the IND alone. According to the criteria of current diagnostic systems (DSM, ICD), both patients should have been classified as schizophrenic, due to the presence of the described auditory hallucinations. We conclude that the presence of hallucinations is less specific for a certain diagnosis than implied by such categorical systems and should be regarded as nosologically non-specific symptoms. Modern neurocomputational models of psychopathology, dimensional approaches in the description of hallucinations, as the findings of new functional brain imaging studies support this view. We propose a multidimensional diagnostic process of hallucinations and to classify cases such as the one presented as 'induced hallucinatory psychosis' or 'folie a deux hallucinatoire'.

[Artificial edema of the extremity]. / Zum Problem des artefiziellen Extremitätenödems.

Our report describes a 46-year-old woman with self-inflicted oedema of the left leg and the left arm. She induced leg oedema by an elastic bandage tourniquet and arm oedema by holding her arm dependent and immobile. A preexisting disorder of the affected leg (postthrombotic syndrome) and of the affected arm (hypoesthesia subsequent to surgical injury of the plexus brachialis) delayed the diagnostic proceedings. Our case report shows that: Confirmed presence of organic disease does not exclude limb oedema of self-inflicted origin. Oedema resulting from a tourniquet and "hysterical oedema" can be developed by one and the same patient. Effective care of such patients is only possible if dermatologist and psychiatrist work together all the time (liaison psychiatry).

[Carbamazepine poisoning: protracted course with development of intestinal atony and hepatic toxicity]. / Intoxikation mit Carbamazepin: Protrahierter Verlauf unter Entwicklung von Darmatonie und Hepatotoxizität.

A 43 year-old female patient with a history of manic-depressive illness and prophylactic carbamazepine (CBZ) medication ingested a potentially lethal overdose of 20 g of the substance. Neurotoxic symptoms reached full intensity after about 24 hours. Subsequently, the patient developed a gastrointestinal atony, which proved to be refractory to treatment for several days. Moreover, there was an increase of bilirubin. Parallel to this we observed the persistence-and even intermittent re-increase--of toxic serum CBZ concentrations for one week with corresponding protracted clinical symptomatology.

The position of delusional parasitosis in psychiatric nosology and classification.

Discussions on the nosological position of delusional parasitosis (DP) have resulted in a wide range of opinions. In the present study in 34 patients with DP, the various and contradictory opinions concerning DP positioning in psychiatric nosology were examined through clinical, psychopathological, and polydiagnostic analyses using VRC, DSM-III, DSM-III-R and ICD-9. The psychopathological analyses with VRC as well as the polydiagnostic comparisons with other classification systems indicated that DP is neither a nosological entity nor due to a specific psychiatric illness. As our results showed, DP is a nosologically unspecific syndrome, which may occur superimposed on all psychiatric disorders.

Diagnosis of chronic alcoholism--classificatory problems.

Since Magnus Huss introduced the diagnosis of 'chronic alcoholism' into medical literature in 1849, two unsolved problems concerning classification have remained: (1) Differentiation between problem drinkers and chronic alcoholics fluctuates, whereby the cut point of differentiation between abuse and addiction remains differently defined by different authors. Some authors view alcohol-induced damage as a building-stone of diagnosis of chronic alcoholism whereas other authors define these damages as illnesses developed as a consequence of chronic alcohol intake. This fact is also mirrored in the different definitions of chronic alcoholism by different classification systems, like ICD-9, DMS-III or DMS-III-R. Valid and reliable questionnaires, like the Munich Alcoholism Test or the Problem Drinking Scale did not succeed in solving this problem of definition, either. (2) The fact that chronic alcoholics are sick--in the sense of a biological-medical approach--is undoubted. Our research group was able to prove that chronic alcoholic patients metabolize methanol in a different way from that of healthy persons. The biological, sociological and psychopathological heterogeneity of this illness has been stressed for more than a century. A prospective long-term study carried out over 4-7 years has led to the development of a new typology in chronic alcoholism that is able to differentiate subgroups of chronic alcoholic patients cross-sectionally in a clinical, biochemical and neurophysiological way. Diagnosis according to this typology qualitatively differentiates patients in many spheres other than drinking behavior. These subgroups also require correspondingly modified therapeutic strategies.

A contribution to classification of hallucinations.

Proceeding from the hypothesis that auditory hallucinations in psychotic patients have another biological basis than hallucinations provoked by hypnotic suggestion in healthy persons, we performed a symptom-comparative study by means of 99mTc-HMPAO single photon emission computed tomography. The results confirm the importance of pathogenesis in symptom-oriented psychiatric research.