Treatment of refractory chronic depression and dysthymia with high-dose thyroxine.

BACKGROUND: An 8-week open trial was conducted to investigate whether patients with treatment-resistant, chronic depression and/or dysthymia could profit from high-dose thyroxine (T4) augmentation. METHODS: Nine patients whose current depressive episode had lasted for a mean of 15.5 +/- 8.6 months (range: 2-30 months) received T4 in addition to their current medication. RESULTS: Two patients dropped out of the study owing to side effects. The remaining 7 patients received a final mean dose of T4 of 235 +/- 58 micrograms/day (range: 150-300 micrograms/day). Their scores on the Hamilton Depression Rating Scale had fallen from a mean of 21.1 +/- 4.1 before inclusion in the study to a mean of 8.0 +/- 2.8 at the end of the 8th week. Five patients were full responders, 1 a partial responder, and 1 a nonresponder. CONCLUSIONS: Augmentation with high-dose T4 proved to have an antidepressant effect in more than 50% of the previously treatment-resistant patients with chronic depression and/or dysthymia.

Disrupted melatonin-secretion during alcohol withdrawal.

1. The synthesis of the pineal hormone, melatonin, is under adrenergic control. The brain's rhythm generating system (suprachiasmatic nucleus and associated systems) which is synchronised by the light-dark cycle controls norepinephrine release from the sympathetic nerve terminal resulting in cAMP accumulation. Increased cAMP leads to induction of the rate-limiting enzyme, N-acetyltransferase and synthesis of melatonin. The pineal exhibits a circadian rhythm with highest blood levels of the hormone being present during the night. The circadian rhythm of melatonin production provides important time-of-day and time-of-year information and, as a result, this hormonal cycle drives other 24-hour rhythms as well as seasonal cycles of reproduction, at least in photoperiodic mammals. 2. Chronic alcoholics were withdrawn from alcohol during a continued period of 4 days and nights. Blood samples were drawn from an indwelling venous catheter and sleep was monitored with polysomnography. No medication was used. No alcohol intake was allowed after admission. Bright light treatment was applied during day 3 of the study. 3. During the 4 days of alcohol-withdrawal the night time melatonin-secretion was disrupted. More than 50% of the patients had a very low secretion (< 30 pg/ml) which did not normalize during the study period. Psychopathology, sleep quality and sleep architecture improved significantly. The melatonin secretion pattern showed low values throughout the study. This low melatonin secretion might reflect the long lasting toxic influence of alcohol on the biological clock and/or a direct inhibitory effect on pineal function. These are different effects, although interrelated. 4. Ethanol has a direct inhibitory effect on pineal melatonin synthesis. A well-recognized action of ethanol is its ability to permeate and perturb the structure of cell membranes and may be related to its lipophilic properties. The changes in membrane fluidity seem to last longer than the study period of 4 days.

Sleep quality during alcohol withdrawal with bright light therapy.

1. Alcohol withdrawal is a complex syndrome that ranges from anxiety, insomnia to delirium tremens. Common treatment is the application of sedative medication. Exposure to bright light in the daytime should advance the normal sleep/wake cycle and moreover it should improve the availability of man's adaptive behavior during alcohol withdrawal. 2. This pilot study describes bright light therapy (BL) during alcohol withdrawal in ten alcohol dependent patients (DSM-III-R: 291.80) without any sedative medication. BL (3000 Lux) was administered on day 3 of abstinence between 7.00-9.00 a.m. and 5.00-9.00 p.m. Total-sleep-polysomnography (recordings between 10.30 p.m.-6.00 a.m.) and self-rating scale were performed to compare intraindividual changes during three nights. After one adaptation night (immediately after alcohol withdrawal), one baseline night and one "BL-night" and one "post-BL night" were analysed. 3. At baseline, total sleep time and sleep efficiency were severely deteriorated, but tended to improve in the following nights after BL. Sleep onset latency showed a significant decline after BL. Stages 3 and 4 were reduced at baseline. Latencies to slow wave sleep were significantly shortened after BL. REM increased in the nights after BL. Subjective sleep quality improved after BL. Although the present results, bright light having a possible stabilizing effect on sleep maintenance and sleep architecture during acute alcohol withdrawal, the authors could only derive hypotheses for further ongoing controlled investigations using placebo light, to receive final verification.

Satisfaction of inpatients and outpatients with staff, environment, and other patients.

The study described here compared levels of satisfaction with staff, environment, and other patients among 420 first-time and long-term patients in psychiatric outpatient and inpatient settings. The demographic, clinical, and outcome variables associated with satisfaction were explored. Patient satisfaction was related to quality of life, social functioning, treatment expectations, and one-year psychological and physical prognoses. Perceptions of other patients were significantly more positive among long-term patients than among first-time patients. The concerns of first-time patients about other patients are of special importance, and they should be addressed during initial treatment.

[Occupational rehabilitation of psychiatric patients in an occupation-specific facility--results of a study]. / Berufliche Rehabilitation psychisch Kranker in einer fachspezifischen Einrichtung--Ergebnisse einer Studie.

The day structure of persons with acute or chronic mental illness is a central problem field in the design of helping and supportive programmes. The specifics involved in chronic mental illness must therefore be taken into account to a sufficient degree. A specialized vocational rehabilitation centre has been established in Vienna in the process of reorganization of psychiatric care. The study presented, which comprised the 441 persons who had participated in programmes at the Centre during the initial six years of its operation, shows that rehabilitative intervention in particular has positive effects when taking place before premature pensioning. A follow-up study of 294 former programme participants found that a total of 132 persons (i.e., 44.9%) had been working permanently or at least occasionally after programme completion. Given the fact that the majority of rehabilitation interventions provided had occurred in cases deemed prognostically unfavourable, the findings clearly show the importance of specialized facilities. No significant influence on the course of rehabilitation was found to be related to age, sex, psychiatric diagnosis and frequency/duration of previous hospitalizations. The rehabilitative process took a more favourable course in persons whose stay in the Centre had extended beyond six months.

[Evaluation of a changed psychiatric treatment system--contributions to treatment research exemplified by Vienna]. / Evaluation sich verändernder psychiatrischer Versorgungssysteme--Beiträge zur Versorgungsforschung am Beispiel Wiens.

On the basis of changes that occurred in Vienna, the implications of planned interventions into the total structure of the institutional psychiatric care is being investigated. By a simultaneous and concerted action in that 1.5 million city, the in-patient and out-patient areas have, with the aid of predefined goals, been regionalized and much improved in terms of equipment. The number of patients in the large mental hospitals dropped by 68.5 percent between 1976 and 1988. The new out-patient facilities were made use of by 1.09 percent of the population from 1980 to 1987. No serious negative developments have been recorded. The study shows that the defined goals have to a large extent been achieved. In spite of the evident backlog demand, the total costs of the institutional psychiatric care did not rise as much as the costs of the general in-patient medical care over the same period of time. Changes in psychiatric care are measurable, the influence of the institutions on "patient carriers" justifies the interest in care research.

Comprehensive mental health services: who needs them?

In 1980 the agency "Psychosocial Services" was founded in Vienna, Austria to set up and to operate comprehensive outpatient services, with responsibility to the total population of the city of 1.53 millions. Vienna has been divided into eight catchment areas. 11.076 patients have been in contact with the eight outpatient departments until the end of 1984 (0.72% of the total population). Data show high numbers of alcoholic, neurotic and schizophrenic patients. Number of patients indicates a need of some minimum equipment of the city with regionalized outpatient services. 50% of all the patients have never been under inpatient precare when they contact the outpatient departments.

[Gerontopsychiatric patients in psychiatric facilities]. / Gerontopsychiatrische Patienten in psychiatrischen Einrichtungen.

The population of Vienna is relatively old. The structure of care and support for aged patients is described. The relative share of aged patients in all admissions to the large mental hospital is smaller than their share in total population. Reduction in the number of in-patients also included the group of patients over 65 years. The task force "Ubergangspflege" (i.e.: transitional nursing) prepares and supports the deinstitutionalization of recently admitted and of long-stay patients. Utilization of a regionalized out-patients psychiatric department shows differences between the age group 60-80 years and the group over 80 years.

[Utilization of psychiatric treatment. Who drops out, who comes back and who stays?]. / Inanspruchnahme psychischer Behandlung. Wer bricht ab, wer kommt wieder und wer bleibt?

OBJECTIVE: The aim of this study is the prediction of specific factors associated with utilization patterns of mental health care. METHOD: Course of treatment of 272 out-patients and in-patients was observed for one year. Patients were asked five times (baseline, 1 month, 3, 6, and 12 months) about their utilization behavior. RESULTS: 71% of the patients continued treatment, 6% ended treatment in agreement with their therapists, and 23% dropped out of treatment. 24 patients of those who dropped out, i.e. 38% of this subgroup, returned to treatment during the one year period. Multivariate analyses indicate that continuity of treatment is associated with referrals from other institutions, male gender, the diagnosis of functional psychosis, high subjective well-being, and poor social functioning. First-time use of the corresponding institution, in-patient status, and living alone are predictors of treatment-dropout. Patients who ended treatment in agreement with their therapists are the best socially integrated group. Drop-outs who returned to treatment during the one year period have more unfavorable clinical premises, and are less well integrated socially than drop-outs who do not take up their treatment again. CONCLUSIONS: Therapeutic interventions, such as permanent efforts towards the maintenance of a supportive therapeutic relationship, motivate psychiatric patients to keep a continuing treatment-alliance. Well functioning communication between, or rather coordination of out-patient and in-patient treatment increases the chance of a continuous course of treatment.

[Expectations of psychiatric patients from their outpatient and inpatient treatment]. / Was erwarten sich psychisch Kranke von ambulanter und stationärer Behandlung?

OBJECTIVE: This study describes patient evaluations about treatment interventions and the subjective value of specific treatment expectations. METHOD: A random sample of 425 out-patients and in-patients was assessed to evaluate importance of treatment interventions and specific expectations of psychiatric treatment. RESULTS: Preferences regarding treatment interventions varied among diagnostic groups. Psychiatric patients ranked medication and supporting therapeutic conversations the highest. Sociodemographic characteristics, numbers of previous hospitalizations, quality of life and social abilities influenced treatment expectations. A patient's perception of dissatisfying quality of life and high social vulnerability increased the need for social assistance. CONCLUSION: Subjective treatment expectations of psychiatric patients should be the start-out for every treatment-regime. Socially vulnerable patients should be identified and specific treatment plans should be developed at treatment-start.

[Assisted living for former long-term hospitalized psychiatric patients]. / Unterstütztes Wohnen für ehemals langzeithospitalisierte psychisch Kranke.

OBJECTIVES: The aim of the study is the evaluation of essential characteristics of patients who entered the sheltered group homes of the Psychosozialen Dienst (PSD) in the city of Vienna after the establishment of sectorized psychiatric out-patient care facilities. METHOD: Eighty patients who lived in these group homes on the first key day, June 30th 1993, were investigated. Any change in their living situation and rate of hospitalization was ascertained at follow-up, 3.5 years after the first key day. RESULTS: The patients had an average period of hospitalization of 240.5 days per year before entry to a group home, which decreased to 12.4 days per year after entry to a sheltered group home. At follow-up more than half of all patients (65%) were still able to live in the community successfully. The number and the length of hospitalizations between the first key day and the follow-up were lowest for patients who had moved to private homes. CONCLUSIONS: Sheltered group homes play an essential role in the process of rehabilitation towards independent living within the community. The results demonstrate that rehabilitation in private apartments can be possible even after 5.7 years of residence in sheltered group homes.

[Ambulatory psychosocial and rehabilitation services in cerebral cognitive deficits]. / Ambulante psychosoziale und rehabilitative Hilfen bei Hirnleistungsstörungen.

Because of the well known changes in social and demographic structure of our population the availability of an integrated and coordinated attainment for psychosocial care for people with impaired cerebral function is of increasing importance. Vienna as the capital of the Federal Republic of Austria has structured psychosocial welfare services for the entire city, which consists of 8 psychosocial service regions ("catchment-areas"). 1 for every 200.00 inhabitants. For elderly psychosocially handicapped persons special supplies are provided. In this survey the methods and activities of these facilities are described. The increasing demand of psychosocial care for outpatients in the age of above 80 years is discussed; the importance of home visits is stressed.

Predictors of treatment discontinuity in outpatient mental health care.

BACKGROUND: Discontinuity of service utilisation among newly referred community outpatients is a common concern. However, knowledge about factors associated with service utilisation is inconsistent. METHOD: This study examined service utilisation of 323 newly referred patients in three community mental health centres (CMHCs) in Vienna, Austria over a 4-month period. Of this original cohort, 111 patients were interviewed at treatment start to identify factors associated with treatment discontinuity. RESULTS: After 4 months, one-third of the 323 newly referred patients had dropped out of CMHC treatment; one-third discontinued treatment at the CMHCs because of referrals or mutual agreement on treatment termination, and one-third was still in CMHC treatment. Multivariate analyses yielded a negative association between treatment discontinuity and the diagnosis of schizophrenia, availability of home care, living alone, and a high quality of life in the domains living situation and family/significant others. A positive association was found with unemployment, previous psychiatric admissions, low patient satisfaction with staff competence, and high self-assessment in global functioning. CONCLUSION: In treatment, differing perceptions of a patient's health status by the patient and by the psychiatrist should be addressed. Professionals should be aware that patients' difficulties in private social relations might affect both treatment alliance and service utilisation.

[Social vulnerability, social isolation of chronic psychiatric patients]. / Soziale Vulnerabilität, soziale Isolation bei chronisch psychisch Kranken.

Social vulnerability and social isolation as to different, light and severe grades of chronically ill psychiatric patients were evaluated. A social vulnerability index, composed out of marital status, income, health, living conditions, occupation, and risk factors in childhood was used. The vulnerability of 64 severely chronically ill patients and of 84 chronically ill patients was assessed. According to their vulnerability, the patients were divided into a group of highly vulnerable and a group of less vulnerable patients. The social isolation of the two groups (severely chronically und chronically ill patients) was compared and assessed. We used objective criteria (such as living alone, no friends, no contact to family members) and subjective criteria (feeling isolated). Social Vulnerability and social isolation are higher in severely chronically ill patients compared to chronically ill patients. The severely sick group is significantly more affected by objective and/or by subjective isolation than the less sick group. In both groups patients have more difficulties in social relationships than non-isolated patients. There is no significant correlation between objective isolation and subjective isolation.

[Quality of life of the mentally ill]. / Die Lebensqualität psychisch Kranker.

Object of this research project was to study the subjective quality of life of psychiatric patients. The vulnerability of 424 out- and inpatients was assessed. The Vulnerability Index, composed of: marital status, income, health, life conditions, occupation, and risk factors in childhood was used. According to their vulnerability, two groups of patients were differentiated: patients with high and low vulnerability. We compared these objective criteria of vulnerability with the subjective quality of life (Q-LES-Q). Quality of life was also compared with diagnosis, severity of illness, and treatment (first contact/long-term contacts). Quality of life of 250 patients was analysed after one year follow up. Patients with a low vulnerability score are more satisfied with 'social relations' than patients with a high vulnerability score. In-patients are more satisfied with 'social relations' than out-patients. Out-patients are more satisfied with their 'physical health', 'subjective feelings', 'leisure time activities', and 'overall life satisfaction' than in-patients. Patients with a mild affective disorder have a better 'life satisfaction' than patients with severe affective disorder. Quality of life of schizophrenics and of patients with anxiety and adjustment disorders has improved significantly after one year.