Predictors of Functional Outcome in Patients With Bipolar Disorder: Effects of Cognitive Psychoeducational Group Therapy After 12 Months.

Background: Cognitive deficits are known as a core feature in bipolar disorder. Persisting neurocognitive impairment is associated with low psychosocial functioning. The aim of this study was to identify potential cognitive, clinical and treatment-dependent predictors for functional impairment, symptom severity and early recurrence in bipolar patients, as well as to analyze neurocognitive performance compared to healthy controls. Methods: Forty three remitted bipolar patients and 40 healthy controls were assessed with a neurocognitive battery testing specifically attention, memory, verbal fluency and executive functions. In a randomized controlled trial, remitted patients were assigned to two treatment conditions as add-on to state-of-the-art pharmacotherapy: cognitive psychoeducational group therapy over 14 weeks or treatment-as-usual. At 12 months after therapy, functional impairment and severity of symptoms were assessed. Results: Compared to healthy controls, bipolar patients showed lower performance in executive function (perseverative errors p < 0.01, categories correct p < 0.001), sustained attention (total hits p < 0.001), verbal learning (delayed recall p < 0.001) and verbal fluency (p-words p < 0.002). Cognitive psychoeducational group therapy and attention predicted occupational functioning with a hit ratio of 87.5%. Verbal memory recall was found to be a predictor for symptom severity (hit ratio 86.8%). Recurrence in the follow-up period was predicted by premorbid IQ and by years of education (hit ratio 77.8%). Limitations: Limitations of the present study result mainly from a small sample size. The extent of cognitive impairment appears to impact occupational disability, clinical outcome as well as recurrence rate. This result must be interpreted with caution because statistical analysis failed to show higher significance. Conclusions: Bipolar patients benefit from cognitive psychoeducational group therapy in the domain of occupational life. Deficits in sustained attention have an impact on occupational impairment. Implications for treatment strategies are discussed. Further evaluation in larger studies is needed.

Discontinuous patterns of brain activation in the psychotherapy process of obsessive-compulsive disorder: converging results from repeated FMRI and daily self-reports.

This study investigates neuronal activation patterns during the psychotherapeutic process, assuming that change dynamics undergo critical instabilities and discontinuous transitions. An internet-based system was used to collect daily self-assessments during inpatient therapies. A dynamic complexity measure was applied to the resulting time series. Critical phases of the change process were indicated by the maxima of the varying complexity. Repeated functional magnetic resonance imaging (fMRI) measurements were conducted over the course of the therapy. The study was realized with 9 patients suffering from obsessive-compulsive disorder (subtype: washing/contamination fear) and 9 matched healthy controls. For symptom-provocative stimulation individualized pictures from patients' personal environments were used. The neuronal responses to these disease-specific pictures were compared to the responses during standardized disgust-provoking and neutral pictures. Considerably larger neuronal changes in therapy-relevant brain areas (cingulate cortex/supplementary motor cortex, bilateral dorsolateral prefrontal cortex, bilateral insula, bilateral parietal cortex, cuneus) were observed during critical phases (order transitions), as compared to non-critical phases, and also compared to healthy controls. The data indicate that non-stationary changes play a crucial role in the psychotherapeutic process supporting self-organization and complexity models of therapeutic change.

[Effect of the degree of instability during therapy on the treatment outcome of in-patient psychotherapy of obsessive-compulsive disorder]. / Beeinflussung des Behandlungsergebnisses einer stationären Psychotherapie von Zwangsstörungen durch den Ausprägungsgrad der Instabilität im Therapieverlauf.

BACKGROUND: The present study evaluates a central hypothesis of synergetic psychotherapy research according to which a marked instability in the psychotherapeutic process is associated with high response rates. METHODS: 14 patients with obsessive-compulsive disorder (OCD) completed an eight-week in-patient course of multimodal behavior therapy with exposure exercises. The instability during the course of the therapy was recorded by daily selfassessment by the patient using the Synergetic Navigation System (SNS), an Internet-based real-time monitoring procedure. RESULTS: There was a negative correlation between the degree of the instability and the percentage reduction in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) (r = -0.395; P = 0.199), the "Global Severity Index" (GSI) of the symptom check-list (SCL-90-R) (r = -0.718; P = 0.013), the scale value for obsessive-compulsiveness in the SCL-90-R (r = -0.782; P = 0.004) and the remaining sub-scales of this data-gathering instrument. CONCLUSIONS: An unstable progress of the psychotherapy causes a smaller reduction in symptoms than a stable one. The contradiction relative to the study hypothesis is possibly based on the special features of OCD, with a high level of patient insecurity when anticipating new, non-obsessive-compulsive ways of thought and behavior. The relationships between instability and reduction in symptoms appear to be diagnosis-specific.

Youth suicide risk factors and attitudes in New York and Vienna: a cross-cultural comparison.

The prevalence of suicide risk factors and attitudes about suicide and help-seeking among New York and Viennese adolescents were compared in order to explore possible cross-cultural differences. Viennese adolescents exhibited higher rates of depressive symptomatology than their New York counterparts and had more first-hand experience with suicidal peers. More attribution of suicide to mental illness was reported in Vienna; yet Viennese youth were less likely than New York adolescents to recognize the seriousness of suicide threats. Help-seeking patterns of Viennese adolescents were influenced by their setting a high value on confidentiality. These cross-cultural differences may reflect the limited exposure of Austrian youth to school-based suicide prevention programs. The findings highlight the need of taking the sociocultural context into consideration in the planning of youth suicide prevention strategies.

Suicide among Viennese minors, 1946-2002.

OBJECTIVES: The first documented conference on suicide among school pupils was held by the Viennese Psychoanalytical Society in 1910, yet since then research on youth suicide in Vienna and Austria has been sparse. We investigated cases of suicide among Viennese minors over a period of 57 years in terms of prevalence, gender differences, suicide methods and monthly distribution. METHODS: We studied registered suicides among Viennese youths aged 19 or younger occurring between 1946 and 2002 (n = 683). RESULTS: The total suicide rate and the rates for male and female suicides among Viennese minors decreased over the period studied. The mean suicide rate was 6.2 per 100,000 (statistics on suicides per 100,000 were available only for the period 1953-2002), with a male-female ratio of 2.1:1. The predominant suicide method was domestic gas until its detoxification in Vienna. From 1976 jumping from a height became the most common suicide method of Viennese minors; it was also the predominant method among females, whereas hanging was the predominant method among males. Since 1996 the percentage of firearm suicides among males has doubled, and jumping suicides among females have tripled. A greater number of suicides among minors took place during the months of January, June, October and December. CONCLUSIONS: Suicide rates of Viennese minors are on the decline, corresponding to a reported decrease in the general suicide rate in Austria. In view of an observed recent increase in firearm suicides among males and jumping suicides among females aged 19 and younger, further monitoring as well as legal and environmental prevention measures are needed.

St. John's wort (Hypericum perforatum) and breastfeeding: plasma and breast milk concentrations of hyperforin for 5 mothers and 2 infants.

BACKGROUND: Herbal preparations for depression, such as St. John's wort, are often preferred over pharmaceutical preparations by mothers and midwives after childbirth because these preparations are available to patients as over-the-counter "natural" treatments and are popularly assumed to be safe. The only existing report on St. John's wort excretion into human milk showed that only 1 active component (hyperforin) was detectable in breast milk, but was not detectable in the infants' plasma. Another report found more cases of minor problems in infants breast-fed by women taking St. John's wort. However, significance was reached only in comparison with disease-matched women (p<.01), not healthy controls (p=.20). METHOD: Five mothers who were taking 300 mg of St. John's wort 3 times daily (LI 160 [Jarsin], Lichtwer Pharma GmbH; Berlin, Germany) and their breastfed infants were assessed. Thirty-six breast milk samples (foremilk and hindmilk collected during an 18-hour period) and 5 mothers' and 2 infants' plasma samples were analyzed for hyperforin levels by tandem mass spectrometry (LC/MS/MS; limit of quantification=0.1 ng/mL). Data were gathered from January 2001 to February 2002. RESULTS: Hyperforin is excreted into breast milk at low levels. However, the compound was at the limit of quantification in the 2 infants' plasma samples (0.1 ng/mL). Milk/plasma ratios ranged from 0.04 to 0.13. The relative infant doses of 0.9% to 2.5% indicate that infant exposure to hyperforin through milk is comparable to levels reported in most studies assessing anti-depressants or neuroleptics. No side effects were seen in the mothers or infants. CONCLUSION: These results add to the evidence of the relative safety of St. John's wort while breast-feeding found in previous observational studies.

Magnetic resonance imaging in patients with obsessive-compulsive disorder with good versus poor insight.

The DSM-IV provides two subtypes of obsessive-compulsive disorder (OCD), labelled as OCD with insight and OCD with poor insight. For the latter, patients generally fail to recognize that the obsessions or compulsions are excessive or unreasonable. Several studies have shown significant brain abnormalities in OCD patients. However, at present, it remains unclear whether a specific pattern of structural brain abnormalities is related to poor insight in OCD. In the present study, magnetic resonance imaging (MRI) findings were compared in OCD patients with insight versus those with poor insight. Outpatients with diagnoses of OCD according to DSM-IV (300.30) and ICD-10 (F42) (n = 84; mean age 38+/-13; 35 females, 49 males) were dichotomized into the two subtypes. All subjects underwent an MRI examination. MRI findings were rated as "MRI abnormality" and "normal MRI." In our sample, 48% of the patients had MRI abnormalities. There was a highly significant difference between the two groups according to frequencies of MRI abnormalities, with 83% of the patients with poor insight showing MRI abnormalities compared with only 21% of the patients with insight. The specifier "poor insight" helps to identify a subgroup of OCD with a higher frequency of brain abnormalities of various types. This distinction should be taken into account in future studies concerning the course and therapeutic outcome of OCD.

Mental distress and quality of life in a deaf population.

BACKGROUND: High risks of mental illness within the deaf community are reported. The assessment of the level of mental distress and quality of life in the deaf community is difficult due to communication problems in spoken and written language. The deaf community is characterized by the use of sign language. METHODS: A new measure of acceptable reliability using sign language is described. The interactive computerised package including special versions of the World Health Organisation's Brief Quality of Life questionnaire (WHOQOL-BREF), the 12-Item General Health Questionnaire (GHQ-12) and five subscales of the Brief Symptom Inventory (BSI) was administered to a large community sample of deaf people (n = 236), and results were compared with normative data for German-speaking hearing people. RESULTS: The deaf sample has a significantly poorer quality of life than the general population for the physical and psychological domains (p < 0.01) as measured by the WHOQOL-BREF. However, in the domain of social relationships, no significant difference (p = 0.19) was demonstrated. All findings with the GHQ-12 and the BSI show much higher levels (p = 0.01) of emotional distress among the deaf. CONCLUSION: Although a poorer quality of life and a higher level of mental distress are demonstrated, the similarity to the general population in the domain social relationships shows that this does not affect all domains. These findings show the need for easily accessible health services for the deaf which offer sensitive communication with them.

An innovative and reliable way of measuring health-related quality of life and mental distress in the deaf community.

BACKGROUND: Structured assessment of quality of life and mental distress in deaf people is difficult for various reasons. This paper describes the development and reliability of an interactive computer-based assessment package for measuring quality of life and psychological distress in the deaf population. METHODS: The Brief version of the WHO Quality of Life (WHOQOL) Questionnaire, the 12-item General Health Questionnaire (GHQ-12) and the Brief Symptom Inventory (BSI) had been translated into sign-language and videotaped. A total of 236 members of the deaf community in Upper Austria participated by responding to a programme consisting of self-administered written and videotaped test-items presented to them on a notebook computer. The reliability of the various assessments was established on this large community sample. RESULTS: When reliability of the versions for the deaf was compared with that of written versions of the same measures in general population samples, it was found to be somewhat lower, although still in an acceptable range, for the WHO-QOL and the GHQ-12. For the BSI, the reliability was even higher than that of the general population. CONCLUSIONS: For deaf individuals whose preferred communication is sign language, quality of life and mental distress can be effectively and reliably assessed with the use of carefully translated and adapted common instruments.

The new concept of the monitoring and appraisal of bone union inflexibility of fractures treated by Dynastab DK external fixator.

Background. This work focuses on problems of heuristic techniques based on artificial intelligence. Mainly about artificial non-linear and multilayer neurons, which were used to estimate the bone union fractures treatment process using orthopaedic stabilizers Dynastab DK. Material and methods. The author utilizes computer software based on multilayer neuronal network systems, which allows to predict the curve of the bone union at early stages of therapy. The training of the neural net has been made on fifty six cases of bone fracture which has been cured by the Dynastab stabilizers DK. Using such trained net, seventeen fractures of long bones shafts were being examined on strength and prediction of the bone union as well. Results. Analyzing results, it should be underlined that mechanical properties of the bone union in the slot of fracture are changing in nonlinear way in function of time. Especially, major changes were observed during the forth month of the fracture treatment. There is strong correlation between measure number two and measure number six. Measure number two is more strict and in the matter of fact it refers to flexion, as well as the measure number six, to compression of the bone in the fracture slot. Conclusions. Consequently, deflection loads are especially hazardous for healing bone. The very strong correlation between real curves and predicted curves shows the correctness of the neuronal model.