[Documentation, Application and Efforts to Reduce Involuntary Admissions and Coercive Measures - Results from a Nationwide Study on Acute Psychiatric Hospitals in Germany]. / Dokumentation, Anwendung und Ansätze zur Reduktion von unfreiwilligen Unterbringungen und Zwangsmaßnahmen ­ Ergebnisse einer bundesweiten Befragung akutpsychiatrischer Krankenhäuser in Deutschland.

OBJECTIVE: This nationwide full census survey investigated the documentation status regarding involuntary admissions and coercive measures in psychiatric hospitals in Germany. METHODS: As part of the ZIPHER study, a questionnaire survey on the documentation, application and reduction of coercion was conducted (N = 147, response rate = 34.4 %). RESULTS: The majority of participating hospitals reported a comprehensive documentation of the use of coercion. However, substantial regional differences could be found in this regard as well as for the use of guidelines. The involuntary admission quote was M = 13.4 % (±â€Š10.9). Of those, 33.9 % (±â€Š22.2) were affected by mechanical restraint, 8.9 % (±â€Š17.2) by seclusion, and 11.8 % (±â€Š18.0) by compulsory medication. CONCLUSION: The regional differences plead for a unification of legal bases and applied practice as well as for a merge of respective data on a nationwide level of the relevant stakeholders.

Homelessness among psychiatric inpatients in North Rhine-Westphalia: a retrospective routine data analysis.

BACKGROUND: Within the last five years the number of homeless persons in Germany has more than doubled, with many suffering from mental illnesses that require treatment. Whether the mental illness itself led to losing shelter or whether the state of being homeless increased the likelihood of developing symptoms of a mental disorder remains unclear. The current study assessed the interaction of homelessness and mental illness from a care provider perspective. METHODS: We conducted a retrospective analysis of inpatient routine data from 20 psychiatric hospitals in North Rhine-Westphalia (NRW), Germany, over a period of four years (N = 366,767 inpatient treatment cases). Patients were considered "homeless" if they had no fixed unique address. RESULTS: About 2.4% of the analyzed cohort was classified as homeless, with increasing tendency over the study period (+14% from 2016 to 2019). The percentage of homeless patients varied broadly between the hospitals (0.2-6.3%). Homeless patients were more often male and on average eight years younger than patients with a fixed address. Homeless patients experienced more involuntary measures (admission and restraint), had a shorter course of treatment and were more often discharged within one day. Every second homeless case was diagnosed with a substance use disorder and every third homeless case with a psychotic disorder, whereas affective disorders were diagnosed less frequently in this group. Psychiatric comorbidity occurred more often in homeless patients whereas somatic diseases did not. CONCLUSIONS: Multiple patient-related sociodemographic and local factors are associated with homelessness of psychiatric inpatients. In addition, clinical factors differ between homeless and non-homeless patients, pointing to more severe mental illness and treatment complications (e.g., coercive measures) in homeless persons. Thus, homelessness of psychiatric inpatients can imply special challenges that need to be considered by healthcare providers and politicians, with the goal of optimizing mental and social care and the mental health outcomes of homeless persons.

Clinical manifestations and immunomodulatory treatment experiences in psychiatric patients with suspected autoimmune encephalitis: a case series of 91 patients from Germany.

Autoimmune encephalitis (AE) can rarely manifest as a predominantly psychiatric syndrome without overt neurological symptoms. This study's aim was to characterize psychiatric patients with AE; therefore, anonymized data on patients with suspected AE with predominantly or isolated psychiatric syndromes were retrospectively collected. Patients with readily detectable neurological symptoms suggestive of AE (e.g., epileptic seizures) were excluded. Patients were classified as "probable psychiatric AE (pAE)," if well-characterized neuronal IgG autoantibodies were detected or "possible pAE" (e.g., with detection of nonclassical neuronal autoantibodies or compatible cerebrospinal fluid (CSF) changes). Of the 91 patients included, 21 (23%) fulfilled our criteria for probable (autoantibody-defined) pAE and 70 (77%) those for possible pAE. Among patients with probable pAE, 90% had anti-NMDA receptor (NMDA-R) autoantibodies. Overall, most patients suffered from paranoid-hallucinatory syndromes (53%). Patients with probable pAE suffered more often from disorientation (p < 0.001) and impaired memory (p = 0.001) than patients with possible pAE. Immunotherapies were performed in 69% of all cases, mostly with high-dose corticosteroids. Altogether, 93% of the patients with probable pAE and 80% of patients with possible pAE reportedly benefited from immunotherapies (p = 0.251). In summary, this explorative, cross-sectional evaluation confirms that autoantibody-associated AE syndromes can predominantly manifest as psychiatric syndromes, especially in anti-NMDA-R encephalitis. However, in three out of four patients, diagnosis of possible pAE was based on nonspecific findings (e.g., slight CSF pleocytosis), and well-characterized neuronal autoantibodies were absent. As such, the spectrum of psychiatric syndromes potentially responding to immunotherapies seems not to be limited to currently known autoantibody-associated AE. Further trials are needed.

The social-psychiatric service and its role in compulsory hospitalization.

Coercive measures are a sensitive, much-discussed ethical and legal issue in the psychiatric context. Hence, the identification of their predictors and ways of prevention are of utmost importance. The present study aimed to determine the impact of the social-psychiatric services (SPS) in North Rhine Westphalia (NRW) on involuntary admissions according to the German Mental Health Act and to identify predictors for the reduction of these involuntary admissions. A dataset including details from 31 districts and 23 towns in NRW over a time period of 10 years (2005-2014) was analysed regarding the number of involuntary admissions, gender and age of admitted patients, and person/institution initiating the compulsory act. All 56 SPS in NRW were contacted for information on the number of clients/contacts, home visits, areas of responsibility and their involvement in involuntary admissions. Thirty SPS participated in the survey. We found a significant increase of involuntary admissions over time with significantly higher proportions of male patients and patients younger than 60 years in every year. Regarding the characteristics of SPS, a negative correlation between the number of clients contacting the SPS on their own initiative and low-income households was observed. Additionally, the number of clients contacting the SPS on their own initiative was significantly higher in districts/towns associated with lower involuntary admission rates. These data suggest that patient-based factors were of great importance in the context of involuntary admissions. Furthermore, the SPS and home treatment should be strengthened and intensified to achieve lower involuntary admission rates.

Antidepressive response of inpatients with major depression to adjuvant occupational therapy: a case-control study.

BACKGROUND: Despite marked costs and limited evidence regarding effectiveness, occupational therapy (OT) is widely applied in psychiatric settings and financed by health insurance companies in European countries. This pilot study investigated the antidepressive effects of adjuvant OT for patients with major depression in a 6-week inpatient setting, stratified for females and males. METHODS: A total of 114 inpatients with major depression were assigned to either a standard OT group (using basic handcraft) or an active control group that played board games (2 h daily, 5 days a week). HAMD-21 scores were assessed as the primary outcome parameter after 3-6 weeks. RESULTS: The OT intervention was not superior to "board game" (BG) activities in reducing depressive symptoms. However, significant interaction effects were found in favor of the OT group regarding anxiety measures and other variables. Male participants displayed more significant interaction effects than female participants. CONCLUSIONS: OT as an adjuvant short-term treatment for inpatients with major depression may be more efficacious than game interventions in terms of reducing anxiety and other symptoms, particularly in males. Trial registration The study was registered in the EU Clinical Trials Register as a multicenter trial (EudraCT Number 2009-016463-10; https://www.clinicaltrialsregister.eu/ctr-search/trial/2009-016463-10/DE#A) However, because of the elaborate setting requirements, the original study design with four centers was transformed into a solution with those two centers facilitating the pertinent resources. Furthermore, "mono-therapy with mirtazapine" was changed into "preferably mono-therapy with any antidepressant drug".

Multiplatform metabolome and proteome profiling identifies serum metabolite and protein signatures as prospective biomarkers for schizophrenia.

Schizophrenia is a severe mental illness with a biological basis. However, the search for reliable biomarkers suitable for clinical routine has been futile so far. Accordingly, there is a need for innovative approaches such as genomics and proteomics to achieve this goal. In the present study, we compared metabolomic and proteomic data from 26 schizophrenia patients as well as from unaffected controls carefully matched for age and gender in a multi-platform approach. The combined analysis identified many signatures with initially good biomarker characteristics. After statistical analysis and comparison of these identified serum metabolites (analysed by Gas Chromatography Mass Spectrometry) and hydrophobic serum proteins (analysed by matrix-assisted laser desorption ionisation mass spectrometry), several markers (e.g., 2-piperidinec carboxylic acid, 6-deoxy-mannofuranose, galactoseoxime and a serum peptide of m/z 3177) were determined as having the best discriminating value between the groups. Our findings represent a proof of principle indicating that metabolomic and proteomic approaches can be successfully used in psychiatric biomarker research, even though the results should be regarded as preliminary with a need for replication in larger samples.

Voluntary versus involuntary hospital admission in child and adolescent psychiatry: a German sample.

Involuntary psychiatric admission is a central issue in mental health care, especially in the treatment of children and adolescents. Its legal regulations do not only differ between European countries, but also on a federal level. Only few studies so far dealt with rates of involuntary admission (RIA), mainly focusing on adults, rather than children and adolescents. None of the studies analyzed this topic in a large cohort. The aim of this regional cross-sectional study was to compare voluntary and involuntary admissions in child and adolescent psychiatry (CAP) regarding personal and admission characteristics. Furthermore, risk factors and predictors of involuntary admission should be identified. A retrospective analysis of hospital admission registers from three major German CAP hospitals over a period of 6 years (2004-2009) was conducted (N = 10,547 inpatients). Group comparisons between involuntarily and voluntarily treated minors and a logistic regression to determine predictors of legal status were performed. Information on harm to self or others prior to the admission, medication and clinical outcome was not available due to data structure. 70.8 % of patients were voluntarily and 29.2 % involuntarily admitted. Both subsamples comprised more males. The RIA decreased consistently over the years, ranging from 25.7 to 32.4 %. The strongest predictor of being admitted involuntarily was suffering from mental retardation (OR = 15.74). Adolescence, substance abuse, psychotic disorders and admission on duty time were also strongly associated (OR > 3). In this first large cohort study on involuntary treatment of children and adolescents in Germany, about every fourth patient was treated involuntarily. Certain personal and disease-related factors increased the risk. Commitment laws and other legal instruments for regulating involuntary placements are inconsistent and a standardized description or systematic analysis is needed. The influence of demographic, institutional variables and care and health services aspects should also be investigated.

Impaired facial emotion recognition in a ketamine model of psychosis.

OBJECTIVE: Social cognitive disabilities are a common feature in schizophrenia. Given the role of glutamatergic neurotransmission in schizophrenia-related cognitive impairments, we investigated the effects of the glutamatergic NMDA receptor antagonist ketamine on facial emotion recognition. METHODS: Eighteen healthy male subjects were tested on two occasions, one without medication and one after administration with subanesthetic doses of intravenous ketamine. Emotion recognition was examined using the Ekman 60 Faces Test. In addition, attention was measured by the Continuous Performance Test (CPT), and psychopathology was rated using the Psychotomimetic States Inventory (PSI). RESULTS: Ketamine produced a non-significant deterioration of global emotion recognition abilities. Specifically, the ability to correctly identify the facial expression of sadness was significantly reduced in the ketamine condition. These results were independent of psychotic symptoms and selective attention. CONCLUSION: Our results point to the involvement of the glutamatergic system in the ability to recognize facial emotions.