[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.

[Via internet to the psychiatrist. The internet as a first step to seek psychiatric advice]. / Via Internet zum Psychiater. Das Internet als erster Schritt bei der Suche nach psychiatrischer Hilfe.

OBJECTIVE: Consultation via Internet is becoming increasingly common for patients with psychiatric illnesses. METHODS: We report on the e-mail-correspondence with a young woman (according to her own statement), taking medical advice for depressive symptoms via Internet. RESULTS: The correspondence focuses on the difficulties of the consulter to find and accept adequate (professional) support in the "real world". CONCLUSIONS: On the basis of this case report, advantages and limitations of the communication via Internet are discussed.

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.

Typical and atypical antipsychotics--the misleading dichotomy. Results from the Working Group 'Drugs in Psychiatry' (AGATE).

OBJECTIVES: (1) To investigate the risk of extrapyramidal motor side effects (EPS) associated with the prescription of different antipsychotics under naturalistic treatment conditions; (2) to test the rationale of the terms 'typical' and 'atypical' based on EPS rates. DESIGN: Cross-sectional study in the federal state of Bavaria. SETTING: 20 psychiatric hospitals in Bavaria. PARTICIPANTS: 6,061 inpatients, aged 18-65 years, with psychotic disorders. MAIN OUTCOME MEASURES: Co-medication with the anticholinergic biperiden was used as an index of EPS. Odds ratios for EPS and numbers needed to harm [number of patients who would need to be treated to obtain one more case with an adverse outcome (i.e. EPS) as compared with the control treatment (clozapine)] were calculated to obtain risk estimates for 15 different antipsychotics. RESULTS: Groups of 'typical' and 'atypical' antipsychotics were not homogeneous in their EPS rates, and showed wide variation within each group. Nor did the frequency of EPS allow a clear distinction between the groups. There were 2 reasons for this: first, EPS rates rose continuously over the whole spectrum of drugs under study, and therefore precluded the definition of a cut-off score; second, there was considerable overlap between the 2 groups as EPS rates of various 'atypicals' (e.g. amisulpride, risperidone and zotepine) did not differ from some 'typical' substances (e.g. fluphenazine), while one 'typical' antipsychotic (perazine) even had a lower EPS risk than most 'atypicals'. CONCLUSIONS: The odds of inducing EPS are not distinguishable between 'typical' and 'atypical' antipsychotics as EPS rates rise on a continuous scale throughout both classes. We propose dropping the categorization of antipsychotics as 'typical' and 'atypical' and instead using risk estimates like number needed to harm for EPS to help in benefit/risk considerations for antipsychotic treatment.

[Patients with mental retardation in a psychiatric hospital]. / Patienten mit Intelligenzminderung in der psychiatrischen Klinik.

OBJECTIVE: Because only few data are available, inpatient care of patients with mental retardation was evaluated to get a valid data base concerning quality and quantity of care and to reveal their deficits. METHODS: All patients with first admission to a psychiatric hospital between 1996 and 2002 were included in te cohort study (n=9727). The analyses were based on the psychiatric basis documentation system (DGPPN-BADO). 192 patients (2%) had the diagnosis of a mental retardation according to ICD-10. RESULTS: 62% of patients suffered from a mild (F70), 26% from a moderate (F71) and 9% from a severe mental retardation (F72). The most frequent comorbid disorders were disruptive behaviour disorders, adjustment disorders, alcohol-related disorders, Schizophrenia and mood disorders. Mean length of stay was 34.8 days, rate of rehospitalisation within one year was 0.3. GAF improved on 11.8, CGI (improvement scale) was 3.4. Some predictors for these outcome criteria could be revealed. CONCLUSIONS: The data allow a depth insight into inpatient care of patients with mental retardation. They deliver important clues for quality improvement in psychiatric hospital and for collaboration with outpatient services.

Quantitative analysis of motor disturbances in schizophrenic patients.

The presence of neurological signs and disturbed psychomotor performance have been consistently confirmed by clinical studies in schizophrenic patients. These parameters are mainly assessed by using clinical rating scales. In recent years, new approaches such as ultrasonic movement analysis systems have been introduced in order to objectively evaluate motor disturbances in schizophrenic patients. Ultrasonic movement analysis systems calculate the three-dimensional positions of tiny markers, which are attached to moving body parts, with high spatial and temporal resolution. Thus, key parameters of gait and hand movements can be determined precisely. This article summarizes and discusses several studies using these new methods. Results indicate that schizophrenia causes a specific motor deficit pattern, with a predominant disturbance of spatial parameters. Conventional antipsychotic treatment usually worsens these deficits, whereas the effects of atypical antipsychotic treatments are less pronounced. Disturbed motor performance can be normalized by external sensory stimuli, but only when no major attentional processes are required, and it can be enhanced by an attentional strategy, but not to the extent that motor parameters are normalized.

Clustering and switching on verbal and figural fluency functions in adults with attention deficit hyperactivity disorder.

INTRODUCTION: Neuropsychological studies of adult patients with ADHD have revealed marked disturbances of executive functions including impairments of attention, working memory, impulsivity, shifting, and divergent thinking. Phonemic fluency tasks, in particular, have been shown to be sensitive measures for the assessment of executive functions of adults with ADHD. METHODS: The present study has examined figural fluency and both phonemic and semantic verbal fluency in 34 adult patients with ADHD and 34 healthy participants. For evaluation of fluency performance the number of words or designs, the number of repetitions and the number of deviations from test rules were calculated. Furthermore, clustering strategies and switching responses were analysed. In comparison with healthy participants, patients with ADHD produced significantly fewer words or designs, but they did not differ from healthy participants in the number of repetitions or rule violations. RESULTS: Analysis of switching and clustering showed that patients produced significantly fewer switching responses on both verbal fluency tasks, although patients tended to generate smaller clusters. Switching on the figural fluency task was unimpaired. CONCLUSIONS: The results of the present study suggest that adult patients with ADHD may suffer from a dysfunction that may affect retrieval processes and the categorisation of knowledge.

[Evidence-based hospital management considering data from the psychiatric basic documentation system]. / Evidenzbasiertes Klinikmanagement auf Grundlage der psychiatrischen Basisdokumentation.

OBJECTIVE: The study aimed to demonstrate how data from the psychiatric basic documentation system (DGPPN-BADO) are able to support the hospital management in making evidence-based decisions. METHODS: Data from 14 327 psychiatric in-patients in the years 1997, 1999 and 2001 were analysed. RESULTS: About 40 % of patients were admitted without any medical sending, 20 % were referred by a general practitioner and 10 % by a psychiatrist in private practice. Between 1997 and 2001 an increase of patients with affective disorders and personality disorders was found. Comparing 1999 to 2001, patients showed greater deficits in their psychosocial capability (measured with GAF) at admission, but also at discharge. Outpatient aftercare was recommended to more than 80 % of in-patients, about 50 % by a general practitioner and about 33 % by a psychiatrist in private practice. 10 % of patients were cared by the own outpatient clinic. CONCLUSIONS: Data from the psychiatric basic documentation system could be shown as being relevant for evidence-based hospital management ensuring an effective and efficient in-patient treatment.

[Familial plaque-only Alzheimer's disease in the Rottal-Inn and Passau counties]. / Familiäre Plaque-only-Alzheimer-Krankheit in den Landkreisen Rottal-Inn und Passau--Genetisch-genealogische Alzheimer-Forschung.

We describe the kindred of Alois Alzheimer's second patient, who died from plaque-only Alzheimer's disease (AD) in 1910. There is a neuropathologically defined subtype of AD without or only few tangles. This plaque-only form is found in about 6 % of autopsied cases of AD. We recruited of AD patients with age of onset before 70 years from the Rottal-Inn and Passau counties in Bavaria and extended a kindred with familial dementia using genealogies deduced from historic parish records. 1247 individuals were documented genealogically. In the maternal branch of the kindred we documented 40 deceased individuals with possible Alzheimer's disease, whereas other branches of the family had no suspicious entries. We conclude, that there is a familial predisposition to dementia with variable age of onset between 36 and 80 years of age in the kindred of Johann F.

[Changes in the emotional processing in depressive patients: a study with functional magnetoresonance tomography under the employment of pictures with affective contents]. / Veränderungen in der Emotionsverarbeitung bei Depressiven: eine Studie mit funktioneller Magnetresonanztomographie unter der Verwendung von Bildmaterial affektiven Inhalts.

OBJECTIVE: The influence of emotional contents on brain activation was examined using functional magnetic resonance tomography (fMRT). METHOD: Aquiring 100 EPI-measurements of the whole brain, series of positive and negative pictures from the International Affective Picture System (IAPS) were shown to eight depressed males and to healthy controls. RESULTS: In depression, there was an overactivation in hippocampal area during positive stimulation, whereas an overactivation of amygdala, orbital and prefrontal regions was seen during negative stimulation. CONCLUSIONS: These results emphasize the importance of functional interaction between the neural network associated with emotion. We could show that depression is connected to dysregulation and disturbed functional connectivity during emotional processing.

[Psychotherapy units in Bavarian state mental hospitals]. / Psychotherapiestationen in den bayerischen Bezirkskrankenhäusern.

OBJECTIVE AND METHOD: In this paper we report about the situation of psychotherapeutic inpatient treatment in Bavarian state mental hospitals, based on data coming from surveys in those hospitals. RESULTS AND CONCLUSION: 22 State mental hospitals in Bavaria have 1217 beds for acute psychotherapy, proofed on the basis of quality criteria. More than 50 per cent of all psychotherapy beds are located in those hospitals.

Novel PS1 mutation in a Bavarian kindred with familial Alzheimer disease.

We describe a novel Leu174Arg PS1 mutation in two members of a Bavarian family which were initially diagnosed with frontotemporal dementia. Intriguingly, there is the possibility that there is an 18th century founder effect and that this family is related to original kindreds with familial Alzheimer disease described in the early 20th century.

[Single or Mixed Sex Wards in Psychiatric Hospital from the Patients' Viewpoint] / Getrennt- oder gemischtgeschlechtliche Behandlung in der psychiatrischen Klinik - was bevorzugen Patienten?*

OBJECTIVE: Preference on separate or mixed sex treatment should be evaluated from the viewpoint of patients of a psychiatric hospital. METHODS: The preference of patients were surveyed by questionnaire before and after mixing four single sex wards. The adjusted response rate was 74.5 %. RESULTS: About 75 % of psychiatric patients prefer a mixed sex ward, about 25 % prefer a single sex ward. Females more frequently confirm the type of ward to whom they were actually allocated. By contrast, males are in favour for mixed sex wards independently of the presently experienced type of ward. Younger patients, voluntarily admitted patients, and patients with substance addiction prefer mixed sex wards. After mixing the sexes of formerly single sex wards a significant increase in preference of mixed sex wards was found, due to increased affirmation by female patients. CONCLUSION: If single sex wards can be established in a psychiatric hospital considering their size, specialisation of wards, and sector of care, patients are enabled to choose between a single and mixed sex ward at admission.

[No Association of the - 141C Ins/Del Polymorphism of the Dopamine D2 Receptor with Schizophrenia] / Keine Assoziation des - 141C-Ins/Del-Polymorphismus im Gen des Dopaminrezeptor D2 mit Schizophrenie.

Recently, a putative functional polymorphism (- 141C Ins/Del) in the 5'-flanking region of the dopamine D (2) receptor was found. An association of the Ins allele with schizophrenia has been described in a Japanese sample. In the present study this association was examined in a German schizophrenia patient population. In a family based approach 190 German family trios were analyzed for the - 141C Ins/Del genotype. Using the transmission disequilibrium test (TDT) we found no evidence for an association of the Ins allele with schizophrenia (TDT = 0.152, P = 0.696). In parallel, we performed an independent case control study with 268 schizophrenic patients and 244 controls. Again, we did not detect an overrepresentation of the Ins allele in patients (P = 0.124). Thus, our data do not support the hypothesis that the - 141C Ins variant plays a major role in predisposition to schizophrenia. To confirm our conclusion further preferentially family based studies are needed.

["Acquired Psychopathy" and the Neurobiology of Emotion and Violence] / "Acquired Psychopathy" und die Neurobiologie von Emotion und Gewalt.

"Psychopathy" describes a type of personality disorder characterized by a dysregulation of emotion processing. Social behaviour, emotion regulation and competency are of particular relevance in forensic psychiatry. Structural-morphological and functional imaging studies prove that emotion regulation, aggressive-impulsive behaviour and learning from negative experiences are greatly influenced by frontal brain regions. These abilities are impaired in severe cases of dissocial personality disorders and in traumatic "pseudopsychopathy". We illustrate the importance functional neurobiological changes in patients personality disorders and "acquired psychopathy" by two case reports on patients who were admitted to a forensic-psychiatric facility for sexual crimes.

[Segregated or mixed sex treatment in the psychiatric clinic--what do patients prefer?]. / Getrennt- oder gemischtgeschlechtliche Behandlung in der psychiatrischen Klinik--was bevorzugen Patienten?

OBJECTIVE: Preference on separate or mixed sex treatment should be evaluated from the viewpoint of patients of a psychiatric hospital. METHODS: The preference of patients were surveyed by questionnaire before and after mixing four single sex wards. The adjusted response rate was 74.5%. RESULTS: About 75% of psychiatric patients prefer a mixed sex ward, about 25% prefer a single sex ward. Females more frequently confirm the type of ward to whom they were actually allocated. By contrast, males are in favour for mixed sex wards independently of the presently experienced type of ward. Younger patients, voluntarily admitted patients, and patients with substance addiction prefer mixed sex wards. After mixing the sexes of formerly single sex wards a significant increase in preference of mixed sex wards was found, due to increased affirmation by female patients. CONCLUSION: If single sex wards can be established in a psychiatric hospital considering their size, specialisation of wards, and sector of care, patients are enabled to choose between a single and mixed sex ward at admission.