[A review of the update of the German S3-guideline on diagnostics and therapy of bipolar disorders 2019]. / Überblick über Neuerungen der überarbeiteten und aktualisierten Leitlinie zur Diagnostik und Therapie bipolarer Störungen 2019.

Since the first publication of the guideline in 2012, which included critically reviewed evidence up to 2010, several hundred articles with new evidence were published and some topics of the clinical consensus needed to be reconsidered. Therefore, it was urgently necessary to revise the guideline to bring them up to date. In this article important revisions and updates are presented and the chances and limitations of the development of the guidelines and their implementation are discussed.

[Disulfiram in outpatient treatment of alcohol dependency]. / Disulfiram in der ambulanten Therapie alkoholabhängiger Menschen.

AIM: The alcohol deterrent drug disulfiram plays a minor role in the treatment of alcohol dependency in Germany. The study looks at the efficacy, tolerability and feasibility of a disulfiram outpatient treatment program in a German psychiatric hospital. METHOD: Data from 190 outpatients with alcohol dependency, who had participated in a disulfiram therapy program at the psychiatric outpatient department over a period of 10 years, were analyzed with respect to efficacy and tolerability. To test for predictors, independent variables and treatment success as a dependent variable a logistic regression was carried out. RESULTS: After 1 year 24.2 % of the patients maintained alcohol abstinence while 55 % had had an alcohol relapse despite being in the disulfiram program. No severe complications were observed under disulfiram treatment. Therapy success was largely related to participating in treatment-specific group therapy. CONCLUSION: Disulfiram proved to be a well-tolerated medication as part of multimodal therapy of alcohol dependency. The disulfiram program was easily integrated into other health service treatment. Approximately one quarter of patients who had had an unfavorable course before, achieved abstinence, while participation in group therapy was a major predictor of treatment success. Disulfiram is a medication, which in the context of a psychosocial treatment concept, should receive a wider distribution in Germany.

[Involuntary psychiatric hospital admissions: a comparison between five hospitals in three German federal states]. / Psychiatrische Unterbringungspraxis : Ein Vergleich von fünf Kliniken in drei Bundesländern.

BACKGROUND: There is considerable variance in involuntary psychiatric hospital admission rates both in Europe and Germany. In a prospective comparison between five hospitals in three German federal states we assessed and analyzed involuntary psychiatric hospital admissions, including the patient's perspective. MATERIAL AND METHOD: All involuntarily admitted patients were assessed by an independent researcher. Clinical data, patient and psychiatrist views were documented with different instruments including the McArthur admission experience survey. RESULTS: In this study 104 out of 244 involuntarily admitted patients gave informed consent. We found considerable differences between study centres concerning involuntary admission quotas (3.2-25.8% of all hospital admissions) and involuntary admission rates (16.6-97.6 per year per 100,000 inhabitants). Hospitals in the state of Baden-Württemberg had the lowest involuntary admission rates while they were highest in Bavaria. In Baden-Württemberg involuntarily admitted patients were more likely to suffer from chronic schizophrenia, they were more severely ill and experienced the involuntary hospital admission as more strenuous. There were no differences between centres concerning frequency of dangerous behavior or self-harm. CONCLUSION: We found a high variance across regions concerning the reasons for, frequencies and legal basis of involuntary hospital admissions. Regional differences of legal frameworks and service organization can explain this only to a limited amount. Transparency, legal certainty and reflection of stakeholder roles are a future necessity. Furthermore, there is a need for stringent compliance with legal regulations and coherent documentation.

[Predictors of success of long-term treatment in alcohol dependency]. / Zugangsvariablen als Prädiktoren für das Therapieergebnis bei Alkohollangzeitentwöhnungsmaßnahmen.

OBJECTIVE: There is a lack of positive predictors for long-term treatment of subjects with alcohol addiction. We analyzed the relation between motivation and other external variables of access to treatment as well as treatment outcome. METHOD: 434 persons with alcohol addiction, treated in 2004 in the Diakonie-Krankenhaus Harz (DHK), Elbingerode, as part of a long-term therapy, were followed-up one year after treatment. Access variables were defined and examined in relation to outcome variables with multiple linear and logistic regressions. RESULT: Ways of accessing treatment had no effect on later treatment outcome, while motiva­tion at the start of therapy was relevant: Patients with ambivalent motivation had the most negative outcome. CONCLUSION: Therapy motivation was the main predictor for the outcome of a long-term anti-addiction treatment. To improve the quality of the treatment system, interventions to strengthen motivation should be promoted.

[How can the mentally ill achieve sustained employment? Supported employment versus pre-vocational training]. / Was bringt psychisch Kranke nachhaltig in Arbeit? : "Supported employment" vs. "pre-vocational training"

People with severe mental disorders are often without work, although work may have a positive effect on their health. The paper presents some results in this field from the German S3 guidelines on psychosocial therapies. In terms of evidence-based medicine supported employment (SE - first place then train) has proven to be most effective. Nevertheless, SE is still rare in Germany. Pre-vocational training, however, follows the concept first train then place and is offered in rehabilitation of the mentally ill (RPK) centres in Germany. There is some evidence that the programs are beneficial for users. The UN Convention for the Rights of Persons with Disabilities outlines an obligation for work on an equal basis with others and for vocational training. So far, the German mental health system only partly meets these requirements.

[S3 guidelines on diagnostics and therapy of bipolar disorders: development process and essential recommendations]. / S3-Leitlinie zur Diagnostik und Therapie bipolarer Störungen: Entwicklungsprozess und wesentliche Empfehlungen.

Bipolar disorders are severe psychiatric disorders with extensive individual and health economic consequences. Starting in 2007 the first German evidence and consensus based guideline for diagnostics and treatment of bipolar disorders was developed which holds the potential of increasing confidence of therapists, patients and relatives in the decision-making process and improving healthcare service experiences of patients and relatives. Apart from recommendations for diagnostics and treatment the guidelines provide those for trialogue action, knowledge transfer and self-help and for strategies for healthcare provision of this complex disorder. In the present article the methodology and essential recommendations are outlined and complemented in specific topics by corresponding articles in this special issue. Due to restrictions of the length of this presentation there is the need to refer to the comprehensive version of the guidelines at several points also regarding a detailed discussion of the limitations.

[Psychiatric care for subjects with bipolar disorder: results of the new German S3 guidelines]. / Versorgung von Menschen mit bipolar affektiven Störungen in Deutschland : Welche Relevanz hat die S3-Leitlinie?

Bipolar affective disorders are frequent and have severe consequences. The German S3 guidelines outline the principles of evidence-based treatment of this condition. Based on a partnership with service users and their families accessibility to illness-specific therapy including psychotherapy/psychoeducation, self-help groups for family members and for users are important. Other significant service aspects include assertive outreach and specific rehabilitation (including work). Psychiatric services in Germany remain scattered; therefore there is a need for more coordination.

The validity of self-rated psychotic symptoms in depressed inpatients.

BACKGROUND: Self-ratings of psychotic experiences might be biased by depressive symptoms. METHOD: Data from a large naturalistic multicentre trial on depressed inpatients (n=488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale. RESULTS: At discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P<0.001) and with the BDI total score (0.64, P<0.001). Moderate correlations were found for the MADRS (0.34, P<0.001), HAMD (0.37, P<0.001) and AMDP depression score (0.33, P<0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P<0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P<0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P=0.02). CONCLUSIONS: In depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.

Relationship between baseline severity of depression and antidepressant treatment outcome.

INTRODUCTION: Assessment of depression severity is of key importance, since several clinical guidelines recommend choice of treatment dependent on the depression severity grade. Using different tools to assess baseline severity may result in different outcomes. METHODS: This paper describes the results of a multicentre, naturalistic study investigating the relationship between depression symptom severity (using 4 different measures of symptom severity) and clinical outcome among patients hospitalised for depression (N=1 014). Moreover, the impact of differences between methods of measuring depression severity has been investigated. Statistical analyses (univariate measurements, logistic regression models) were conducted to detect coherences and differences between the various methods of severity categorisation. RESULTS: Results revealed different associations between outcome and classification methods. Response or remission rates varied if baseline severity was assessed by different instruments. Moreover, the number of responders increased with higher baseline severity grades of depression, whereas the number of remitters decreased. Additional analyses dependent on outcome criteria using continuous instead of categorical data revealed similar results. DISCUSSION: Baseline severity may be only one of many other important clinical variables that mediate clinical outcome, but it is surely an important one deserving further research and consideration.

[Predicting improvement in work status of patients with chronic mental illness after vocational and integrative rehabilitation measurements]. / Vorhersage einer Verbesserung des beruflichen Status chronisch psychisch Kranker nach rehabilitativen bzw. integrativen Massnahmen.

PURPOSE: Chronically mentally ill patients often need special rehabilitation to be able to re-enter competitive employment. We know only very little about predicting favourable or unfavourable rehabilitation courses. The present study seeks to examine the relationship between successful rehabilitation -- as defined by a progress in professional ability -- and individual parameters obtained at initiation off-take. METHOD: Data of 101 subjects who had completed a rehabilitation programme serve as the basis. At the beginning of rehabilitation, sociodemographic, intellectual, psychopathological and quality of life measures were obtained. Each participant was assigned to one of two rehabilitation outcome groups: progress vs. stagnation, determined by the vocational status after programme termination. Both groups were then compared regarding the aforementioned parameters at programme onset to identify substantial predictors for rehabilitation success via regression analysis. RESULTS: High level of functioning, fewer periods of unemployment, a high level of work-related adaptation, and young age at programme onset were found to be predictive of progress in vocational status. CONCLUSIONS: Objective parameters have a higher predictive potential regarding vocational reintegration of psychologically ill people compared to subjective criteria. Psychiatric diagnoses as defined by DSM-IV do not reveal relevant connections with subsequent vocational successful reintegration, whereas the initial level of functioning has a definite predictive value.

[Bipolar affective and schizoaffective disorders of older age -- classification, symptoms and course]. / Bipolare affektive und schizoaffektive Störungen des höheren Lebensalters.

Bipolar affective and schizoaffective disorders of older age are underdiagnosed, although they are of growing importance for psychiatric services. In this review article, we present and discuss results concerning classification, psychopathology, epidemiology, course, prognosis, neuroimaging, family studies and therapy. Bipolar (schizo)affective disorders of older age are a diagnostic heterogeneous group, especially as secondary manias must be separated from "endogenous" bipolar disorders nosologically. Bipolar (schizo)affective disorders of older age show some peculiarities: Gender ratio, age at onset, mortality and comorbidity with neurological disease are amongst them. Nevertheless, in many other aspects bipolar (schizo)affective disorders of older age do not differ from bipolar disorders of younger patients. For the acute and maintenance treatment there is a dearth of controlled studies. Lithium is of great importance. Other substances, as well as psychoeducation and ECT may be used analogously as in younger patients, if age specific factors are taken into account (as for example the danger of falls).

[A study of persons living in neglect, filth and squalor or who have a tendency to hoard]. / Eine Studie über Personen mit Verwahrlosung, Vermüllung oder Horten.

PURPOSE: Who develops neglect, lives in filth and squalor or tends to hoard? What happens to people with such tendencies, after heaving been discovered by community mental health services? MATERIALS AND METHODS: During a two-year observation period it was attempted to study all such persons in the city of Halle/Saale. Life history as well as medical, social and psychiatric variables were assessed. After a mean period of 11 months these persons were re-assessed. RESULTS: 35 persons who lived in squalor and filth or in a neglected condition or who were known to hoard were assessed (60 % male, mean age: 63 years). 17 persons (49 %) suffered from an organic brain disease, 14 (40 %) fulfilled criteria of psychotic illness (mainly schizophrenia). In 9 cases a comorbid physical disorder contributed to the prevailing living conditions. After 11 months, for 21 persons (60 %) no amelioration of neglect, squalor or hoarding was observed, which was especially true for persons suffering from a psychotic illness. The results yielded some evidence that interventions, which aimed at living conditions (such as moving to sheltered accommodation), had positive effects, while this was not true for standard mental health care within community services and hospital treatment. CONCLUSION: Neglect, living in squalor and hoarding are frequently symptoms of an underlying psychiatric or somatic illness. In this respect the results suggest that "standard care" proved to be of limited effect -- especially for subjects with a psychotic illness.

[Anxiety disorders comorbid with unipolar depression. Clinical diagnoses versus standardized diagnostic interview]. / Angststörungen bei unipolaren Depressionen. Klinische Diagnosen vs. standardisiertes Interview.

Anxiety disorders frequently co-occur with affective disorders. It is well-known that such comorbid anxiety disorders are more frequently diagnosed with standardized interviews than during the "daily routine." In 117 consecutive inpatients with major depression we assessed the frequency of DSM-IV anxiety disorders and compared it to the routine diagnoses of the discharge letters to analyze underlying principles of such diagnostic strategies. According to SCID-I (DSM-IV) 36 patients fulfilled criteria for a comorbid anxiety disorder, while this was only true for 17 patients according to discharge letters. Logistic regression revealed that clinically recognized cases had higher anxiety levels (higher diagnostic threshold). At the same time, in patients with higher depression scores anxiety syndromes tended not to be seen as separate disorders. This strategy is in line with "classic psychopathology," where severe depression (or melancholia) "included" anxiety symptoms. The borderline between depressive disorders and anxiety disorders is not as clear-cut as DSM-IV and ICD-10 try to indicate.

[Neuropsychological testing in vocational rehabilitation for subjects with schizophrenia]. / Neuropsychologische Diagnostik in der beruflichen Rehabilitation schizophrener Menschen.

Until now it is difficult to predict the success of vocational rehabilitation programs for subjects with severe mental illnesses. The growing knowledge about the neuropsychological mechanisms of psychiatric disorders has not been fully integrated into psychiatric rehabilitation research. We reviewed the literature how to use neuropsychological parameters for predicting outcome of vocational rehabilitation programs in subjects with schizophrenia and schizoaffective disorders. Twenty studies were reviewed, which evaluated neuropsychological variables to predict dimensions of rehabilitation success. As a result of this review, we suggest implementing neurocognitive tests, which assess executive functions, working memory, and attention deficits in routine rehabilitation to better plan and coordinate rehabilitation, and to predict rehabilitation outcome.

[Temperament and affective disorders--historical basis of current discussion]. / Temperament und affektive Erkrankungen--geschichtliche Grundlagen einer aktuellen Diskussion.

The history of the temperament concept begins in ancient Greece. The humoral theory remained influential over the centuries. At the beginning of the 20 th century, both Wilhelm Wundt and his pupil Emil Kraepelin formulated new aspects. Wundt described two dimensions: "speed of variability of emotions" and "intensity of emotions". Kraepelin observed four fundamental states (depressive, manic, irritable and cyclothymic), which he linked to manic-depressive illness. Since then different lines of temperament research have evolved: (1) psychiatric-psychopathological theories (e. g. Ewald, Kretschmer and Sheldon), which tend to see temperament as a dilution of full-blown affective disorders; (2) neurobiological theories (e. g. Pavlov, Eysenck and Gray), which understand temperament as determined by underlying neurobiological processes - especially levels of arousal; and (3) developmental theories (e. g. Chess & Thomas, Rothbart and Kagan), which derived their temperament concept from early childhood observations. Recent theories (e. g. those of Cloninger or Akiskal) combine different aspects. After reviewing the historical temperament concepts we present underlying factors which are linked to affective disorders (such as emotional reactivity, cyclicity or trait affectivity). Finally, we illustrate the importance of temperament concepts for research in affective disorders.

Personality features of patients with mixed and pure manic episodes.

OBJECTIVE: To test the hypothesis that patients with a mixed manic episode show different personality features than patients with a pure manic episode. METHOD: Sixteen patients with a mixed manic episode (broad criteria) and 26 patients with a pure manic episode were assessed with diagnostic interviews (SCID I/II) as well as instruments for depression, mania and personality. RESULTS: Even after controlling for age as well as depression and mania score at assessment, no differences between the two groups emerged concerning either personality features as assessed with the NEO-five-factor inventory (NEO-FFI) or personality disorders. CONCLUSION: We found no difference between patients with mixed mania and patients with pure mania concerning their personality features. Possible reasons for this are being discussed.

[Temperament and affective disorders. The TEMPS-A Scale as a convergence of European and US-American concepts]. / Temperament und affektive Störungen. Die TEMPS-A-Skala als Konvergenz europäischer und US-amerikanischer Konzepte.

In temperament research, three traditions can be found: (1) in psychiatry or psychopathology, (2) in neurobiology, and (3) in developmental psychology. After giving an overview, we present results and theories concerning the relation between temperament and affective disorders. Based on Kraepelin's concept of the fundamental states ("Grundszustände"), we describe four types of temperament: hyperthymic (manic), depressive, irritable, and cyclothymic. A fifth anxious temperament is added. Clinical description and scientific implications are described in the light of recent work by Akiskal and the German version of the TEMPS-A scale, a self-report questionnaire for assessing temperament.

[The concept of hyperthymia]. / Zum Konzept der Hyperthymie - Historische Entwicklung und aktuelle Aspekte -

The article reviews the conceptual history of "hyperthymia". Since K. W. Stark had used this term in the early 19(th) century, it has developed in two different directions: (1) to delineate a psychopathological syndrome and (2) to define a type of personality disorder (psychopathy). As Kurt Schneider's personality disorder (psychopathy) concept was easily understood and highly practicable, it became influential during the 20(th) century. Earlier before, psychiatrists such as E. Mendel, C. Wernicke and C. G. Jung had described entities such as "chronic mania", "hypomania" or "sanguinic degeneration", which were rather similar to each other. We analyze the historical development of such concepts. Emil Kraepelin was highly influential, as he introduced "constitutional excitation" into a broad concept of manic-depressive illness and saw it as a very mild form. After Kraepelin such spectrum concept was first forgotten. Only in recent years these historical considerations were confirmed by empirical observations, although a separate hyperthymic disorder is neither part of DSM-IV nor ICD-10. The concept of a hyperthymic temperament or a hyperthymic personality is a trait-marker and should be differentiated from hypomania as a state-marker. Nowadays, the importance of hyperthymia is not so much one of a disorder requiring treatment; rather the concept has interesting genetic, diagnostic and conceptual consequences.