[Community-based crisis home programme. Cost-efficient alternative to psychiatric hospitalization]. / Gemeindenahe psychiatrische Akutbehandlung in Gastfamilien. Kostengünstige Alternative zum Klinikaufenthalt bei hoher Patientenzufriedenheit.

BACKGROUND: Over recent decades, institutional psychiatric care has shifted its focus from traditional inpatient treatment to a variety of more advanced outpatient services. Within this context, a new "crisis home" programme (CHP) was launched in Zurich on 1 January 2005. With this programme, mentally ill patients can avoid hospitalization by living with a host family for a certain time period while receiving standard outpatient care. In this study we addressed the question of whether the quite substantial financial advantages of the Zurich CHP over traditional inpatient care are achieved at the expense of a reduced quality of care. SAMPLE AND METHODS: Between 1 January 2005 and 30 June 2007, a total of 33 patients enrolled in the Zurich CHP with an average stay of 19 days at host families. The vast majority of the patients (85%) were moderately to severely ill at study entry. Of these patients data were collected in a standardized way on the basis of five rating instruments. The statistical data analysis included cross-comparisons with corresponding inpatient data. RESULTS: Results showed that (1) the CHP works well in a routine setting and provides cost-efficient interventions for patients in acute crises; (2) the financial advantages of the Zurich host family programme over traditional inpatient care do not lead to a reduced quality in patient care; (3) patients suffering from severe mental illnesses clearly benefit from this programme, thus avoiding hospitalization. CONCLUSIONS: The Zurich CHP is a cost-efficient alternative to traditional inpatient treatment. Specifically, our results suggest that this type of acute crisis intervention should be established as a standard psychiatric care service.

Determinants of voluntary vs. involuntary admission in bipolar disorder and the impact of adherence.

INTRODUCTION: Treatment adherence plays a pivotal role in hospitalisation in bipolar disorder (BD). We examined the impact of adherence and pharmacological variables on involuntary vs. voluntary admission on a sample of inpatients from the European Mania in Bipolar Longitudinal Evaluation of Medication study (EMBLEM). METHODS: 1374 inpatients with an acute manic or mixed episode of BD participated in this observational study on clinical, functional and economic outcomes of pharmacological treatment. We analysed data at the time of study inclusion, and the primary outcome measure was admission status (voluntary vs. involuntary admission). RESULTS: The strongest baseline factor of admission status was adherence whereby patients' adherence was significantly associated with admission when treated with atypical antipsychotics or lithium as monotherapy. Adherence with typical antipsychotics was not significantly associated with admission status. DISCUSSION: These results emphasise the crucial role of treatment adherence for admission status and, within the context of a naturalistic study, some advantage of atypical over typical antipsychotics on admission in acute mania of BD.

[CERAD and NOSGER. Comparing predictive scales for dementia in a Swiss gerontopsychiatric patient population]. / CERAD und NOSGER. Der prädiktive Wert dieser Verfahren in der Demenzdiagnostik einer Schweizer gerontopsychiatrischen Patientenpopulation.

BACKGROUND: The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) is an established screening instrument for the diagnosis of Alzheimer's disease. The Nurses Observation Scale for Geriatric Patients (NOSGER), actually developed for rating the frequency of behavioral disturbances, appears suitable for dementia screening as well. MATERIAL AND METHOD: In this retrospective study we analyze the neuropsychological data of 400 consecutive patients at our hospital with several psychiatric diagnoses and cognitive deficits. By means of logistic calculation in single and multivariable models, the predictive value of CERAD and NOSGER for dementia diagnosis was studied. RESULTS: All CERAD subtests were significant single predictors for dementia. The multivariable model with the highest prediction for probability of dementia diagnosis contained the subtests Verbal Fluency Test, Word List Recall, Constructional Practice Recall, and the Mini-Mental State Examination. However, NOSGER could not differentiate between demented and nondemented patients. CONCLUSION: In our gerontopsychiatric population, CERAD separates demented patients from nondemented ones with high predictive potency. The NOSGER does not reveal any predictive value for the diagnosis of dementia.

Specific alterations of cerebral hemodynamics during a planning task: a transcranial Doppler sonography study.

Planning plays an important role in daily activities, and several experimental paradigms have been investigated with brain imaging methods showing activity in putative brain regions such as dorsolateral prefrontal cortex and other frontal and non-frontal regions. The Stockings of Cambridge (SOC), a related procedure to the Tower of London task, was introduced to 21 healthy subjects while they underwent bilateral transcranial Doppler sonography (TCD) of the middle (MCA) and anterior (ACA) cerebral arteries. Different levels of difficulty were applied during continuous registration of peak mean cerebral blood flow velocity (CBFV). A specific test procedure allowed separating the actual planning from the execution phase. There was also a similar control task, which did not involve planning. CBFV differed among the planning, execution, and control conditions (MCA: P < 0.01; ACA: P < 0.001), but did not show a significant difference between the MCA and ACA (P > 0.1). Easy tasks yielded a more rapid increase of CBFV in the MCA compared to difficult problems during planning (P < 0.05). In conclusion, our findings of specific CBFV patterns support the idea of different cognitive challenges for planning and control and between easy and difficult conditions.

Brain areas and time course of emotional processing.

The aims of the present study were to identify brain regions involved in emotional processing as well as to follow the time sequence of these processes in the millisecond-range resolution using low resolution brain electromagnetic tomography (LORETA). Different emotional (happy, sad, angry, fearful, and disgust) and neutral faces were presented to 17 healthy, right-handed volunteers on a computer screen while 25-channel EEG data were recorded. Subjects were instructed to generate the same emotion as shown in the presented faces. Event-related potentials (ERPs) were computed for each emotion and neutral condition, and analyzed as sequences of potential distribution maps. Paired topographic analysis of variance tests of the ERP maps identified time segments of significant differences between responses to emotional and neutral faces. For these significant segments, statistical analyses of functional LORETA images were performed to identify active brain regions for the different emotions. Significant differences occurred in different time segments within the first 500 ms after stimulus onset. Each emotional condition showed specific activation patterns in different brain regions, changing over time. In the majority of significant time segments, activation was highest in the right frontal areas. Strongest activation was found in the happy, sad, and disgust conditions in extended fronto-temporal areas. Happy, sad, and disgust conditions also produced earlier and more widely distributed differences than anger and fear. Our findings are in good agreement with other brain-imaging studies (PET/fMRI). But unlike other imaging techniques, LORETA allows to follow the time sequence in the millisecond-range resolution.

Nongenetic pathologic developments of brain-wave patterns in monozygotic twins discordant and concordant for schizophrenia.

Evidence from previous studies has suggested that the inter-individual differences in human brain-wave patterns (EEG) are predominantly determined by genetic factors. In particular, the within-pair EEG concordance of monozygotic (mz) twins was found to be typically as high as r = 0.81 across channels and frequency bands, thus being comparable to that between repeated assessments on the same individual with typically r = 0.83. Yet our investigations into mz twins discordant and concordant for schizophrenia yielded a significantly reduced within-pair EEG concordance for both, the pairs discordant for schizophrenia and the pairs concordant for schizophrenia (with concordance for schizophrenia assessed through a syndrome-oriented approach). A multivariate discriminant function of EEG parameters distinguished in a reproducible way between affected and unaffected subjects at an overall performance of >75% correctly classified subjects, while the severity of illness, as derived from EEG-differences between affected and unaffected subjects, was closely related to the severity of illness as provided by psychopathology syndrome scores. Consequently, EEG anomalies associated with schizophrenia and manifested differently in the mz co-twins concordant for schizophrenia are likely the effect of nongenetic, pathologic processes that evolved independently in the co-twins' genetically identical brains once the illness began to progress. The existence of such nongenetic processes would suggest a modification of the standard phenotype-to-genotype search strategies of molecular-genetic studies that aim to link the schizophrenia phenotype to genetic vulnerability factors.

Ethnicity-independent genetic basis of functional psychoses: a genotype-to-phenotype approach.

The functional psychoses schizophrenia, schizoaffective disorder, and bipolar illness represent complex clinical syndromes that are characterized by phenotypic heterogeneity. Yet evidence from numerous studies suggests that (1) the prevalence of schizophrenia and bipolar illness is with 1% very similar across ethnicities, and (2) a strong genetic component is involved in the disorders' pathogenesis. Using data from different US-American ethnicities (77 families with a total of 17 unaffected and 170 affected sib pairs; 276 marker loci), we searched for ethnicity-independent oligogenic susceptibility loci for which the between-sib genetic similarity in affected sib pairs deviated from the expected values. Specifically, we addressed the question of the extent to which genetic risk factors and their interactions constitute multigenic inheritance of functional psychoses across populations and might constitute universal targets for treatment. Our novel multivariate genotype-to-phenotype search strategy was based on a genetic similarity function that allowed us to quantify the inter-individual genetic distances d(x(i), x(j)) between the allelic genotype patterns x(i), x(j) of any two subjects i, j with respect to n loci l(1), l(2), em leader l(n). Thus, we were able to assess the between-ethnicity, the within-ethnicity, and the within-family genetic similarities. The problem of ethnicity-independent vulnerability was addressed by treating the Afro-American families as "training" samples, while the non-Afro-American families served as independent "test" samples. We evaluated the between-sib similarities, which were expected to deviate from "0.5" in affected sib pairs if the region of interest contained markers close to vulnerability genes. The reference value "0.5" was derived from the parent-offspring similarities that are always 0.5, irrespective of the affection status of parents and offspring. We found 12 vulnerability loci on chromosomes 1, 4, 5, 6, 13, 14, 18, and 20, that were reproducible across the two samples under comparison and therefore, likely to constitute an ethnicity-independent, oligogenic vulnerability model of functional psychoses. The elevated vulnerability appeared to be unspecific and to act in such a way that exogenous factors become more likely to trigger the onset of psychiatric illnesses.

Occupation, social support and quality of life in persons with schizophrenic or affective disorders.

BACKGROUND: Most people suffering from severe mental illness (SMI) lack paid employment. This study investigates the relationship between work status and objective as well as subjective quality of life (QoL) in people with SMI. METHODS: The sample consists of 261 subjects (102 women, 159 men) aged 35 (men) and 38 (women) years on average, of whom 158 suffer from a schizophrenic disorder (ICD-10: F2) and 103 were diagnosed as having an affective disorder (ICD-10: F3). Subjective QoL was assessed with the WHOQOL-BREF scale. RESULTS: Subjects with an occupation in general have a larger social network at their disposal and receive more social support. With regard to income, few (12%) of the subjects with a job on the open labour market live below the poverty level, but many (28-38%) of those engaged in sheltered or other work-like activities do. Occupation ameliorates satisfaction with life domains referring to social integration (social relationships, environment), whereas the individual's well-being (psychological, physical) is hardly affected. Social support is an important mediator of the relationship between occupation and subjective QoL. Income is weakly and negatively related to subjective QoL. CONCLUSIONS: Supportive relationships to colleagues at the workplace mainly explain the better subjective QoL of SMI people with an occupation. When designing specific employment possibilities for people with SMI, we should take notice of the social support dimension at the workplace. Mentally ill people have a substantial poverty risk, even when they are working. In particular, payment for sheltered work should be ameliorated.

[The social understanding of Eugen Bleuler - his viewpoint outside of the psychiatric clinic]. / Das Gesellschaftsbild von Eugen Bleuler - Anschauungen jenseits der psychiatrischen Klinik.

Based on writings from different periods in the life of Eugen Bleuler, the present work represents a consistent recognizable concept of ethics, social order and race hygiene in his scientific work. These subjects are set by Bleuler in a more general connection of nature and culture; it can be shown that the scientific understanding of social and cultural phenomena is founded on principles which can be easily identified by looking at nature. Bleuler's position is a clear-cut deterministic and materialistic one; the crisis of the post-world-war era can be solved only by rational reasonable ethics rules of a science applied on social questions. Bleuler outlines the general importance of race hygiene; practical consequences of this position remain unaffected. Euthanasia is to be planed in certain cases of difficult and incurable disease - including also mental illness; mental deficiency as such does not legitimize a such step yet.

[A risk profile of the aggressive psychiatric inpatient: can it be identified?]. / Gibt es ein Täterprofil des aggressiven Psychiatrie-Patienten?

Violent behavior of psychiatric inpatients has grown in interest. Within the scope of a prospective study,patient assaults in six psychiatric hospitals of the Swiss Canton of Zurich were assessed during a period of 6 months, from November 1999 until May 2000. Three hundred eighty-eight of 5,251 inpatients (7.4%) were reported to act aggressively. The following risk factors for aggressive behavior were identified: male gender, younger age, unemployment, severity of mental illness, and rehospitalization. Psychiatric diagnosis was not related to aggressiveness. In spite of the detection of risk factors, a characteristic profile of aggressive psychiatric inpatients cannot be stated. Research should pay more attention to situation-specific cues for the aggressive behavior of such individuals.

[The "Psychopathologic laboratory" at Burghölzli. Development and termination of the working relationship of C.G. Jung and Eugen Bleuler]. / Das "psychopathologische Laboratorium" am "Burghölzli". Entwicklung und Abbruch der Arbeitsbeziehung C.G. Jung/E.Bleuler.

C.G. Jung was on the staff of the University Psychiatric Clinic in Zurich ("Burghölzli"), headed by Eugen Bleuler, from 1900 to 1909; he became a senior physician in 1905. In correspondence with Sigmund Freud, Jung claimed that he had informed Bleuler about the subject of psychoanalysis and had recruited him for the movement. In fact, it can be shown that Bleuler was familiar with Freud's publications even before Jung came to Burghölzli and that he had written a very positive review of the hysteria study. Jung received his doctorate (1902) and postdoctoral qualification as university lecturer based on Bleuler's reports to the Department of Medicine and continued to give lectures on certain recurring topics, such as the theory of hysteria, until the summer semester of 1914, well after his resignation. Minutes of department meetings that have not previously been evaluated appear to indicate that the department's rejection of the founding of a "psychopathologic research laboratory," expected by Jung,was a major factor leading to his resignation on March 7, 1909. The importance of other events for Bleuler's relationship with Jung--the unsuccessful attempt at an analytical treatment of Otto Gross or Jung's relationship with Sabina Spielrein--cannot be demonstrated based on current sources.

Affective disorder and 'psychopathy' in a sample of younger male delinquents.

OBJECTIVE: The authors' goal was to determine the prevalence of affective disorder, a history of traumatic events and the prevalence of post-traumatic stress disorder (PTSD) diagnosis in their relationship to 'psychopathy' in a sample of younger male delinquents admitted to a correctional institution. METHOD: As part of routine mental health screening, the SCID-1 and Psychopathy Checklist (PCL-R) were administered to 102 inmates aged 17-27 years. RESULTS: Affective disorder was found in 28% and 29% had a history of suicidal attempts. The PCL-R-score was significantly correlated with the number of prior threatening events, but PTSD could not be diagnosed in the 'psychopathic' group. The prevalence of affective disorder was significantly higher in the 'non-psychopathic' group. CONCLUSION: The inverse relationship between threatening events and the PTSD diagnosis seems to indicate other coping modalities than those found in 'non-psychopaths'. That finding is discussed against the background of psychophysiological data and psychosocial learning models.

Prepulse inhibition deficits in patients with panic disorder.

Prepulse inhibition (PPI) is an operational measure of sensorimotor gating that is reduced in several neuropsychiatric disorders that are characterized by deficits in inhibition or gating of intrusive or irrelevant stimuli. Clinically, panic disorder (PD) patients have been described as having difficulties in inhibition of responding to sensory and cognitive events. Because such difficulties may be due to failures in early stages of information processing, we examined PPI in patients with PD. Acoustic startle reactivity, habituation, and PPI (30-, 60-, 120-, 240-, and 2,000-ms interstimulus intervals) were assessed in patients with panic disorder (m/f = 10, 10) and age- and gender-matched healthy controls (m/f = 11, 10). PD patients were assessed with structured clinical interview for DSM-IV criteria with benzodiazepine treatment as an exclusion criterion. Panic disorder patients exhibited normal startle reactivity, reduced habituation, and significantly reduced PPI in the 30-, 60-, and 240-ms prepulse conditions. Within the PD group, the patients with high trait and state anxiety exhibited less PPI than patients with low trait and state anxiety. Furthermore, in PD patients, decreased PPI correlated significantly with high trait but not state anxiety. These data indicate that early stages of sensory information processing are abnormal in patients with PD. These observed deficits in PPI could reflect a more generalized difficulty in suppressing or gating information in panic disorder. The correlation between high trait anxiety and deficient PPI supports the hypothesis that sensorimotor gating abnormalities are an enduring feature of subjects with PD.

Development and termination of the working relationship of C. G. Jung and Eugen Bleuler 1900-1909.

From 1900 to 1909, C. G. Jung was on the staff of the University Psychiatric Clinic in Zurich ('Burghölzli'), headed by Eugen Bleuler, where he became a senior physician (Sekundararzt) in 1905. Jung received his doctorate (1902) and postdoctoral qualification as a university lecturer (Habilitation) based on Bleuler's reports to the department of medicine, and he continued to give lectures on certain recurring topics, such as the theory of hysteria, until summer semester 1914, well after his resignation. Minutes of department meetings that have not previously been evaluated appear to indicate that a major factor leading to Jung's resignation on 7 March 1909 was the department's rejection of the founding of the 'psychopathologic research laboratory' that he had expected. The importance of other events for Bleuler's relationship with Jung - the unsuccessful attempt at an analytical treatment of Otto Gross, and Jung's relationship with Sabina Spielrein - cannot be determined from current sources.

[Psychopathy in forensic psychiatry]. / Das gegenwärtige Verständnis des Psychopathiebegriffes in der forensischen Psychiatrie - Literaturübersicht und eigene Befunde -

The review refers to the construct of psychopathy which is of increasing relevance for forensic psychiatry and psychology, especially empiric studies on legal prognosis and predictors of therapeutic efficacy. Psychopathy is related to early-onset delinquency, number and severeness of violent crimes, number of sexual victims in rapists, and unfavorable legal prognosis. Recent research has also indicated that the treatment of psychopaths is complicated by low levels of motivation and high rates of attrition. In psychiatric-diagnostic terms, psychopathy is related to substance abuse and dependency and to cluster A and B personality disorders (PD), especially to antisocial and borderline PD. In juvenile with "psychopathic tendencies", a relationship to impulsivity, emotional and behavioral difficulties, and learning behavior (card sorting test) had been shown and interpreted by reference to an anatomical level. In connection with these findings, the relevance of psychopathic disorder for testimonies on legal responsibility should also be discussed again. Further research on psychopathy, especially psychiatric morbidity and psychosocial functioning in non-forensic groups, is needed.

Localization of MDMA-induced brain activity in healthy volunteers using low resolution brain electromagnetic tomography (LORETA).

3,4-Methylenedioxymethamphetamine (MDMA; 'Ecstasy') is a psychostimulant drug producing heightened mood and facilitated social communication. In animal studies, MDMA effects are primarily mediated by serotonin (5-HT), but also by dopamine (DA) and possibly noradrenaline (NA). In humans, however, the neurochemical and neurophysiological basis of acute MDMA effects remains unknown. The distribution of active neuronal populations after administration of a single dose of MDMA (1.7 mg/kg) or placebo was studied in 16 healthy, MDMA-naïve volunteers. Thirty-one-channel scalp EEGs during resting with open and closed eyes was analyzed in the different EEG frequency bands. Scalp maps of power showed significant, global differences between MDMA and placebo in both eye conditions and all frequency bands. Low resolution brain electromagnetic tomography (LORETA) was used to compute 3D, functional images of electric neuronal activity from the scalp EEG data. MDMA produced a widespread decrease of slow and medium frequency activity and an increase of fast frequency activity in the anterior temporal and posterior orbital cortex, concomitant with a marked enhancement of mood, emotional arousal and increased extraversion. This activation of frontotemporal areas indicates that the observed enhancement of mood and possibly the increased extroversion rely on modulation of limbic orbitofrontal and anterotemporal structures known to be involved in emotional processes. Comparison of the MDMA-specific EEG pattern with that of various 5-HT, DA, and NA agonists indicates that serotonin, noradrenaline, and, to a lesser degree, dopamine, contribute to the effects of MDMA on EEG, and possibly also on mood and behavior.

[Diagnostic principles for differential therapy of psychoses]. / Diagnostische Grundlagen für eine differenzielle Therapie der Psychosen.

The pharmacotherapy of psychotic disturbances is not limited on neuroleptics, but includes Clomethiazol and Benzodiazepines (e.g. to treat delirium) or antidepressants (e.g. to treat psychotic depression) too. Even more divergent is the psychosocial treatment of different psychotic states. In this overview the diagnostic principles, needed for a differential therapy of psychotic disorders, are described.

[Drug treatment of functional psychotic disorders]. / Medikamentöse Behandlung funktioneller psychotischer Störungen.

Psychotic symptoms occur in different psychiatric disorders. The principles of antipsychotic drug treatment of various non-organic psychotic disorders are discussed. In particular, the role of the so-called atypical antipsychotics is highlighted.

Effects of MDMA (ecstasy) on prepulse inhibition and habituation of startle in humans after pretreatment with citalopram, haloperidol, or ketanserin.

Prepulse inhibition (PPI) of the acoustic startle response is an operational measure of sensorimotor gating that can be assessed in animals and in humans. Serotonin releasers such as MDMA disrupt PPI and reduce startle habituation in rodents. These effects are prevented by pretreatment with selective serotonin uptake inhibitors, indicating that the effect of MDMA on startle plasticity is largely due to carrier-mediated release of serotonin from presynaptic terminals. In contrast, MDMA has been shown to increase PPI in humans. It is unclear, however, whether the MDMA-induced increase in PPI in humans is also dependent on carrier-mediated serotonin release and which postsynaptic receptors are involved. We investigated the effects of three different pretreatments on the MDMA-induced effects on PPI and habituation in humans. Pretreatments were: (1) the highly selective serotonin uptake inhibitor citalopram (40 mg IV) in 16 subjects, (2) the D(2) antagonist haloperidol (1.4 mg IV) in 14 subjects, and (3) the 5-HT(2A/C) antagonist ketanserin (50 mg PO) in 14 subjects. Each of the three studies used a double-blind placebo-controlled design. All healthy volunteers were examined four times at 2-4-week intervals after placebo, pretreatment, MDMA (1.5 mg/kg PO), and pretreatment plus MDMA. MDMA increased PPI. Habituation was not altered by MDMA, although MDMA-induced individual differences on habituation and psychological symptoms were inversely correlated. Citalopram attenuated the MDMA-induced increase in PPI and most of the psychological effects of MDMA. Neither haloperidol nor ketanserin had any effect on PPI increases produced by MDMA, although each partially attenuated some MDMA-induced psychological effects. Results are consistent with the view that MDMA increases PPI of the acoustic startle reflex in humans via release of presynaptic serotonin.

Ketamine-induced deficits in auditory and visual context-dependent processing in healthy volunteers: implications for models of cognitive deficits in schizophrenia.

BACKGROUND: In patients with schizophrenia, deficient generation of mismatch negativity (MMN)-an event-related potential (ERP) indexing auditory sensory ("echoic") memory-and a selective increase of "context dependent" ("BX") errors in the "A-X" version of the Continuous Performance Test (AX-CPT) indicate an impaired ability to form and use transient memory traces. Animal and human studies implicate deficient N-methyl-D-aspartate receptor (NMDAR) functioning in such abnormalities. In this study, effects of the NMDAR antagonists ketamine on MMN generation and AX-CPT performance were investigated in healthy volunteers to test the hypothesis that NMDARs are critically involved in human MMN generation, and to assess the nature of ketamine-induced deficits in AX-CPT performance. METHODS: In a single-blind placebo-controlled study, 20 healthy volunteers underwent an infusion with subanesthetic doses of ketamine. The MMN-to-pitch and MMN-to-duration deviants were obtained while subjects performed an AX-CPT. RESULTS: Ketamine significantly decreased the peak amplitudes of the MMN-to-pitch and MMN-to-duration deviants by 27% and 21%, respectively. It induced performance deficits in the AX-CPT characterized by decreased hit rates and specific increases of errors (BX errors), reflecting a failure to form and use transient memory traces of task relevant information. CONCLUSIONS: The NMDARs are critically involved in human MMN generation. Deficient MMN in schizophrenia thus suggests deficits in NMDAR-related neurotransmission. N-methyl-D-aspartate receptor dysfunction may also contribute to the impairment of patients with schizophrenia in forming and using transient memory traces in more complex tasks, such as the AX-CPT. Thus, NMDAR-related dysfunction may underlie deficits in transient memory at different levels of information processing in schizophrenia. Arch Gen Psychiatry. 2000;57:1139-1147.