[Guideline-oriented treatment of alcohol-related disorders]. / Leitlinienorientierte Behandlung alkoholbezogener Störungen.

Alcohol use disorders (e.g. abuse and dependence) account for a plethora of consequences for affected individuals and for a substantial proportion of the overall burden of disease for the community. To date, existing treatment options are either poorly known by doctors or they are not fully applied and only approximately 15% of potential patients are treated with a mean latent period of 10 years between early symptoms and the first intervention. So-called S3 treatment guidelines were recently developed to close this gap. Representatives of more than 50 learned societies, families and patients were involved. A systematic literature search from 2005 to 2012 was performed and more than 120 recommendations were made. Financing came exclusively from those societies and the academic and treatment institutes involved.This article summarizes the recommendations pertinent for psychiatrists and include early detection and intervention, acute withdrawal and long-term psychotherapy and pharmacotherapy. Classical and new treatment goals are discussed. If the new guidelines were properly applied an increase in patients receiving treatment to 30-40% could be expected, which would improve the quality of lives of affected persons and their families and in Germany would save several thousand lives per year.

[Prevention of burnout by stress management]. / Stressmanagement als Burn-out-Prophylaxe.

Burnout is a possible consequence of excessive demands, high levels of stress, or a consequence of lack of resources for coping with difficult tasks. Systematic stress management might be effective in reducing the risk for development of a burnout syndrome. Based on a literature search on available research papers and meta-analyses in Medline and Pubmed, current findings on the content and effectiveness of stress management programs are reported for different target groups. Stress management programs can be divided into programs focusing on primary, secondary, and tertiary prevention. In contrast to primary prevention programs, secondary and tertiary preventive programs focus on the specific needs of different target groups. Cognitive-behavioral programs have been shown to be the most effective interventions. A combination of psycho-educational treatment with follow-up or booster sessions increases the long-term outcome in the prevention of burn-out syndromes. Beside the duration of the program, focus on problems and sustainability of supply is important for the long-term effectiveness in secondary and tertiary prevention.

Psychiatric commitment: patients' perspectives.

OBJECTIVE: The literature pertaining to patients' perceptions of commitment and its consequences is limited. The object of this study was to learn more about these experiences from the patient's perspective. MATERIAL AND METHODS: 108 court-committed patients (78% of whom were schizophrenic) were identified for inclusion in a retrospective follow-up study. After an interval varying from one to 4.5 years from time of commitment to follow-up, 76 patients could be contacted, of whom 47 were included in the follow-up. RESULTS: The majority of patients felt that their court commitment had not been justified and could have been avoided. Events and circumstances identified as particularly stressful about commitment were confinement in a locked ward, side effects of medication, feelings of helplessness, and certain staffbehaviors. Adverse psychological, somatic, and social consequences were common. Coercive measures during hospitalization were strongly associated with negative feelings about the effect of commitment on mental health and about subsequent treatment. The majority, however, also remained in treatment after commitment was terminated, said they would return to hospital in event of future crisis, and had pertinent comments about how commitment could have been avoided. CONCLUSIONS: Many patients who had been court-committed reported negative feelings about their experiences, but the great majority had continued in treatment, both at the termination of commitment and later. They also had ideas about how to reduce the negative impact of commitment that are worth including in future contingency plans.

Increased serum levels of CD95 in Alzheimer's disease.

There is growing evidence for a role of apoptosis in Alzheimer's disease (AD). Recent findings suggest an increased susceptibility of lymphocytes to apoptosis in AD. To prove the hypothesis of systemic alterations in the apoptotic balance in AD, serum and cerebrospinal fluid levels of soluble CD95, which is known to mediate apoptosis, were measured. In the serum, AD patients exhibited significantly higher levels of CD95 than the controls (p = 0.017), suggesting an involvement of peripheral markers in AD.

[Treatment courses and therapeutic effectiveness of a psychogeriatric day hospital]. / Behandlungsverläufe und therapeutische Effektivität in einer gerontopsychiatrischen Tagesklinik.

Since 1976, 37 psychogeriatric day hospitals have been set up in Germany. As only few empirical studies on the effectiveness of this day hospital system are available even 25 years on, the treatment course of 58 patients attending the psychogeriatric day hospital run by the Department of Psychiatry, University of Tübingen was evaluated. The course analysis was based on a series of tests comprising the following questionnaires: Social Situation Scale, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Munich Quality of Life Dimension List (MLDL), Mini Mental Status (MMS), Hamilton Depression Scale, and Cumulative Illness Rating Scale (CIRS). Women accounted for three-quarters of the sample, and men for one-quarter. The average age was 72 years. The fact that only 16% of the patients had been transferred from psychiatric hospitals and that more than half had been referred directly by their local doctors underlines the acute-psychiatric nature of the institution. More than 80% of the patients were discharged to their previous place of residence. A highly significant improvement in affective state was verified by the Hamilton Depression Scale. Significant improvements were also registered in the following items: general satisfaction with life, state of health, physical and mental performance, and scope for personal development. The quality of life, measured with the Munich Quality of Life Dimension List (MLDL), improved in nine of the nineteen items covered, with correction of the significance level alpha taken into account. The treatment outcomes confirmed the therapeutic effectiveness of this type of psychogeriatric institution from aspects of acute psychiatry too and should encourage the continued expansion of partial hospitalization facilities for the elderly.

[Community-based rehabilitation for severely ill psychiatric patients?]. / Gemeindenahe Rehabilitation für schwer psychisch Kranke?

A central aim of reformatory efforts, as a consequence of the "Psychiatrieenquete" 1975 (a fundamental report of the situation of psychiatry in Germany), had been dehospitalisation of patients with chronic mental illness and their reintegration into the community. Despite a meanwhile well-developed range of community-based services, patients with severe mental illness only rarely get adequate care by these services. This holds especially true for patients with an unfavourable course of disease such as schizophrenia, severe personality disorder, skid-row alcoholism with multiple problems or for patients with double diagnosis. The reasons are barriers set up by the various services and their underlying concepts as well as structural problems in the health care system. Adapted to the special needs for help of these patients, we present a model for the community-based care of this group, combining elements of community psychiatry, addiction treatment and help for the homeless.

Visual performance and recovery in recently detoxified alcoholics.

In order to assess the impact of chronic alcohol misuse on basic visual functions, we investigated motion perception, visual short-term memory, and visual divided attention in recently detoxified patients and matched controls by means of visual psychophysical tasks. Subjects were tested twice within the first 3 weeks of detoxification in order to assess the potential recovery of visual performance. Patients demonstrated significant impairments in visual perception of coherent motion for slow, but not faster, speeds, and in speed discrimination as assessed by random dot kinematograms. Visual short-term memory tested with a delayed vernier discrimination task, on the other hand, was not significantly affected in patients. When processing hierarchical letters, a divided attention task, detoxified patients showed neither impairments in overall attentional capacity nor attentional allocation, but slightly enhanced interference of global information on local target processing. The results of the visual divided attention task contradict the predictions of the 'right hemisphere' hypothesis of alcoholism: global target information - mediated by the right hemisphere - was not only accessible to detoxified patients, but seemed to exert an even greater influence on local processing during early detoxification, than in matched controls. Limited recovery within the first 3 weeks was seen only in visual speed discrimination. Recently detoxified patients revealed deficits similar to intoxicated social drinkers in identical tests of visual perception of motion, but not visual short-term memory.

Chronic psychiatric patients without psychiatric care: a pilot study.

BACKGROUND: The study is based on the hypothesis that in any catchment area there are patients with chronic mental illness who are unknown to a comprehensive psychiatric/psychosocial care system. METHOD: A standardized questionnaire was sent to all general practitioners in a circumscribed catchment area in southwestern Germany in an attempt to identify such a group, to ascertain what the practitioners considered to be the needs of these patients, and to find out why the patients were not receiving specialized psychiatric care. RESULTS: Of 97 general practitioners contacted, 62 returned the questionnaire. Within a study period of 3 months, 89 patients were identified as having a significant psychiatric disorder, of whom 53% were older than 60 years and 15% were schizophrenic. General practitioners most frequently said that provision of specialized psychiatric care was the most pressing need of these patients, followed by a need for psychosocial services. They also said that the major reason patients did not participate in the mental health system was patient refusal of such services. CONCLUSIONS: Having identified the existence of a group of chronic psychiatric patients who are not receiving specialized psychiatric care, further in-depth field studies to pursue some of the issues raised in this pilot study will be necessary to determine whether further efforts to reach psychiatric patients without defined psychiatric care would be worthwhile. These issues include estimates of the prevalence of such patients in a defined population, patients' more specific reasons for refusal of psychiatric care, and the quality of psychiatric care they receive from general practitioners in comparison with patients who receive more conventional psychiatric care.

[Community psychiatric management of severely ill schizophrenic patients. An exemplary case study]. / Die gemeindepsychiatrische Versorgung schwerstkranker Schizophrener. Eine exemplarische Fallstudie.

Psychiatric care for chronic schizophrenic patients has improved in recent years, but for severely ill patients, often with multiple comorbid psychiatric conditions and in great need of care, the situation remains unsatisfactory. Community-based psychiatric care is limited and psychiatric hospitals are now cutting back on inpatient care. The quality of care that chronically mentally ill patients receive at independent psychiatric nursing homes removed from population centers is undetermined, and many patients end up in asylums or homeless shelters unable to provide for their psychiatric needs. Neither a reliable way to assess the needs of these complicated patients nor a scientific basis for therapeutic intervention exists yet. The case study presented here illustrates an interdisciplinary approach to the care and treatment of a chronic schizophrenic patient with several comorbid conditions. Based on the individual needs of the patient and developed over the last 4 years, this approach had positive effects on the course and outcome of treatment and resulted in an impressive reduction of costs. The average annual number of days of hospitalization over a 3-year period was reduced from 206 to two and the total cost of care was reduced from US$70,000 annually to $8000. The results from this single case study are promising. Further investigation of the development and evaluation of highly individualized treatment plans for severely disturbed schizophrenic patients is warranted.

[Video technology--a medium for milieu therapy?]. / Video--Ein milieutherapeutisches Medium?

Video technology has been in use in the psychiatric field for more than 20 years for diagnostic, scientific, co-therapeutic or educational purposes. However, little is known of its potential applications and impact as an instrument in psychotherapy or environmental therapy. For this reason a new cinematographic project applying widespread video technology in environmental therapy, too, has been launched. All patients at our psychiatric hospital are involved in film selection, can cooperate at different organizational levels, and have regular opportunities to see films. The technical, the organizational and, in particular, the legal preconditions are set out, followed by a report on experience gained in use of video films within the setting of a psychiatric hospital. Reference is also made to economic aspects, therapeutic effects and contraindications.

[Trial employment: a provisional work setting for psychiatric patients]. / Der therapeutische Arbeitsversuch- Eine Annäherung an die Arbeitswelt für Psychiatriepatienten.

OBJECTIVE: This study investigates the effects of probationary work for psychiatric patients in community-based small businesses during their inpatient or day care. METHODS: Patients were evaluated for working capacity, psychopathology, motivation for work and patient satisfaction (n = 69). RESULTS: The results confirm a high degree of acceptance of this approach as well as significant improvements on various clinical scales such as the Brief Psychiatric Rating Scale (BPRS), the Beck Depression Inventory (BDI), the Global Assessment of Functioning Scale (GAF), choice reaction time (Wiener Determinationsgerät, WDG), attention (Revisionstest) and self-rating of work-relevant skills. CONCLUSIONS: This approach, with its complex demand characteristics, may be an effective alternative to occupational therapy, at least for small therapeutic units.

Treatment outcome in alcoholism - a comparison of self-report and the biological markers carbohydrate-deficient transferrin and gamma-glutamyl transferase.

The primary source for evaluating treatment outcome in alcoholism is usually verbal self-report. Because the validity of self-report is often doubted, more objective markers for treatment outcome are needed. In this study, we compared self-report data from 238 male alcohol-dependent patients participating in a combined 6-week inpatient followed by a 1-year outpatient treatment program with the biological markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyl transferase (GGT). According to self-report, over 70% of the patients had a positive treatment outcome (57% abstinence, 16% intermediate relapse). These results are supported by the general reduction of CDT and GGT during the treatment period (p < 0. 001). When we performed a cross-sectional analysis at 6 months during the outpatient program, there was a high consistency of self-report data with the biological markers (CDT 93%, GGT 91%, CDT/GGT 85%). Our results support the hypothesis that in abstinence- oriented treatment programs, self-reports are valid and can be used as the basis of measurement for treatment outcome.

[Effects of regional obligatory health care exemplified by a university clinic]. / Auswirkungen der regionalen Versorgungsverpflichtung am Beispiel einer Universitätsklinik.

OBJECTIVE: Local care provision for the chronically mentally ill entails responsibility to be taken by all institutions involved in the care system of their respective area. In the clinical sphere regional responsibility is implement-ed to a large extent apart from a few university clinics. The University Psychiatry and Psychotherapy Clinic Tuebingen look after an area with obligatory provision of care consisting of 140,000 inhabitants in 1995. RESULTS: The comparative evaluation of the basic documentation showed minimal overall changes but an increase of older patients, of patients who are frequently hospitalised, and of addicts. The number of emergencies remained unchanged. The concomitant questioning of colleagues indicated delayed acceptance of the change. According to experiences made to date, the conditions for research and teaching have improved in certain areas thanks to the obligatory provision of care.

Antibrain antibodies in mental disorder: no evidence for antibodies against synaptic membranes.

Antibody reactivity in serum to synaptic membranes from human was investigated in major depressive disorder (N = 20), paranoid schizophrenia (N = 20), schizoaffective psychosis (N = 20), and in controls (N = 20) using Western and Immunoblots and ELISA technique. None of the patients showed a significant immune response to synaptic membranes. There was a base-line activity in both controls and patients with antibodies directed to a double band of proteins at 66kD. These antibodies may represent natural autoantibodies. The authors conclude from this and other studies that there is at present no proof of antibrain antibodies in mental disorder.

[Changes in the self-concept of alcohol dependent women and men during inpatient psychotherapy]. / Veränderungen des Selbstbilds alkoholabhängiger Frauen und Männer während stationärer Psychotherapie.

At the beginning and at the end of a six week treatment programme, the self-concepts of 82 male and 31 female alcoholic inpatients were assessed. The Giessen test (a 40 item questionnaire comprising six scales oriented towards psychosocial aspects of personality) was applied. Compared to normative data from the general population, patients described themselves as being more depressed, less controlled, less socially responsive and more reserved. During inpatient treatment, patients approached the levels of the general population. With regard to control and depressiveness, however, there were still significant differences at the end of inpatients treatment. Changes on scales relating to interpersonal contact (social responsiveness, openess) are discussed as specific effects of group psychotherapy. Social potency showed a significant interaction effect, with women responding better to treatment than men.

[The German Alzheimer Family Groups. An assessment of current status]. / Die deutschen Alzheimer-Angehörigengruppen. Eine Bestandsaufnahme.

Counselling the relatives of psychiatric patients is becoming increasingly important. This includes the relatives of patients with Alzheimer's disease. Since little is known about the organization and function of support groups for family caregivers of Alzheimer patients, in 1994 we wrote to all such groups known to us and asked them to fill in a questionnaire. The response rate was 85% (84/99), and 66 of the forms could be used for further analysis. The results were as follow: Most groups for relatives of Alzheimer patients admitted new members at any time. 69% had existed for more than 1 year and 19% for more than 5 years. 81% consisted of 6-15 participants. 73% of the groups met once in a month. Health professionals organized the groups in 65% of cases. The main topics were trading information about the disease and support as well as daily care requirements. 73% of the groups were associated with health institutions or nationwide support organizations. Public relations were managed by personal contacts and press reports; did the groups rarely advertise. Based on a review of the literature, the impact of structure upon the function of groups is discussed.

[Psychosomatic aspects of patients with primary keratoconjunctivitis sicca]. / Psychosomatische Aspekte bei Patienten mit primärer Keratoconjunctivitis sicca.

PURPOSE: To evaluate the extent of psychosomatical complaints in patients with primary keratoconjunctivitis sicca (pKCS). METHODS: 20 patients (m:f = 1.19; mean age 49 +/- 7 years) with pKCS were rated according to the von Zerssen Symptom List (psychosomatical discomfort), the Maudsley Personality Inventory (MPI)-N (emotional status) and -E (extroverted-introverted) and to Beck Depression Inventory (BDI). 54 subjects (m:f = 35:17; mean age 46 +/- 17 years) without any ocular or general chronic disease were used as control group. RESULTS: In comparison to the control group the patients with pKCS showed significantly (p < 0.0001) more complaints (von Zerssen Symptom List), were more (p < 0.0001) emotionally unstable (MPI-N) and more (p < 0.0001) depressive (BDI). No group differences were found regarding extroversion-introversion (MPI-E). CONCLUSION: Our results demonstrate that many patients with pKCS showed psychological problems and disturbances. We therefore recommend an additional psychological treatment (e.g. autogenic training) for these patients to stabilize their emotional condition, which may even have a positive effect on their dry eye problems.

Do women develop alcoholic brain damage more readily than men?

Chronic alcoholism is related to brain damage (i.e., volume changes) in both men and women. There is an open question whether the brains of women are more vulnerable than those of men to alcohol toxicity. The present follow-up study focuses on a direct comparison of sex-related differences in alcoholic brain shrinkage and its reversibility. In a prospective design, a random sample of 65 alcoholics of both sexes (51 males and 14 females) was studied. Computerized tomography brain scans before and after a 6-week inpatient treatment program with controlled abstinence revealed a significant re-expansion of the brain as assessed by linear measurements. By controlling for moderating variables such as age, mean daily alcohol consumption, liver dysfunction, etc. the degree of brain shrinkage was found to be similar in men and women despite significantly shorter ethanol expositions in the women. These findings corroborate the hypotheses of other investigators about basic biological differences between the two sexes as to the effects of alcohol. The hypothesis of an enhanced vulnerability of women to acute and chronic complications of alcoholism is supported.