[Psychiatric Emergency Admissions and Inpatient Length of Stay Before and During the COVID-19 Pandemic in Germany]. / Psychiatrische Notfallaufnahmen und stationäre Aufenthaltsdauer vor und während der COVID-19-Pandemie in Deutschland.

OBJECTIVE: The impact of the COVID-19 year on the number of daily psychiatric emergency admissions and length of stay was compared with previous years. METHODS: In a retrospective study, the four quarters of 2020 of several psychiatric hospitals in Germany were statistically compared with the respective quarters of 2018 and 2019. RESULTS: A total of 73,412 cases was analyzed. In the 2nd quarter of 2020, the number of daily admissions was significantly lower as compared to the control period (59.1 vs. 70.7; incidence rate ratio [95 % confidence interval] 0.81 [0.69; 0.96]; p = 0.012). Length of stay was numerically but not significantly different as compared to the control periods. CONCLUSION: The COVID-19 pandemic had a strong impact on inpatient psychiatric care. In the future, multimodal care structures must ensure the care of severely mentally ill people in crisis situations.

Impact of COVID-19 pandemic on involuntary and urgent inpatient admissions for psychiatric disorders in a German-wide hospital network.

The impact of COVID-19 on urgent and involuntary inpatient admissions, as well as coercive measures, has not been assessed so far. A retrospective study was performed analyzing claims data for inpatient psychiatric admissions between 2018 and 2020 (total n = 64,502) from a large German Hospital network. Whilst the total number of urgent admissions decreased in 2020 (12,383) as compared to 2019 (13,493) and 2018 (13,469), a significant increase in the percentage of urgent admissions was observed in 2020 (62.9%) as compared to 2019 (60.6%) and 2018 (59.7%). Compared to this study period, Odds ratio (OR) for proportion were 0.87 (0.84, 0.91) and 0.91 (0.87, 0.95) for 2018 and 2019, respectively (both p < 0.00001). Percentage of involuntary psychiatric admissions also significantly increased in 2020 and OR compared to this study period ranged from 0.86 (0.81, 0.93) in 2019 (p < 0.0001) to 0.88 (0.82, 0.95) in 2018 (p < 0.001). Proportion of coercive measures significantly increased in 2020 as compared to 2019 (p = 0.004). Taken together, the present study shows an increase in the proportion of involuntary and urgent psychiatric admissions during the whole pandemic year 2020 as compared to 2018 and 2019. The long-term impact of these COVID-19 pandemic-related trends on psychiatric health care needs to be assessed in further studies.

Emergency hospital admissions for psychiatric disorders in a German-wide hospital network during the COVID-19 outbreak.

PURPOSE: Psychiatric emergency hospital admissions for distinct psychiatric disorders and length of inpatient stay in the hospital during the Coronavirus disease 2019 (COVID-19) outbreak have not been thoroughly assessed. METHODS: A retrospective study was performed analyzing claims data from a large German Hospital network during the COVID-19 outbreak (study period: March 13-May 21, 2020) as compared to periods directly before the outbreak (same year control: January 1-March 12, 2020) and one year earlier (previous year control: March 13-May 21, 2019). RESULTS: A total of 13,151 emergency hospital admissions for psychiatric diagnoses were included in the analysis. For all psychiatric diagnoses combined, emergency admissions significantly decreased during the study period with mean (interquartile range) incidence rate ratios (IRRs) of 0.68 (0.65, 0.71) and 0.70 (0.67, 0.73) as compared to the same and previous year controls, respectively (both p < 0.00001). IRR ranged from 0.56 for mood affective disorders (F30-F39) to 0.75 for mental disorders due to psychoactive substance use (F10-F19; all p < 0.00001). Mean (standard deviation) length of hospital stay for all psychiatric diagnoses was significantly shorter during the study period [9.8 (11.6) days] as compared to same [14.7 (18.7) days] and previous [16.4 (23.9) days] year controls (both p < 0.00001). CONCLUSION: Both emergency hospital admissions and length of hospital stay significantly decreased for psychiatric disorders during the COVID-19 outbreak. It needs to be assessed in further studies whether healthcare systems will face increased demand for the provision of mental health care in the nearer future.

Adjunctive lithium treatment in the prevention of suicidal behavior in patients with depression and comorbid personality disorders.

OBJECTIVE: Patients with both major depression and personality disorders have a high risk of suicidal behavior. Lithium is meant to have anti-suicidal properties in patients with affective disorders. The anti-suicidal effect of lithium in patients with affective disorders and comorbid personality disorders has not been investigated yet. METHODS: A post-hoc analysis of a subsample of patients with depression and comorbid personality disorder (PD) and a recent suicide attempt (n = 19) from the prospective, placebo-controlled lithium intervention study (N = 167), was conducted. RESULTS: Three patients in the lithium group (n = 8) and two patients in the placebo group (n = 11) presented a suicide attempt throughout the course of the study. No differences related to suicidal behavior could be detected between the placebo group and the group with lithium intervention. CONCLUSIONS: On the basis of the small sample size, among patients with comorbid PD, lithium does not seem to have an effect on suicidal behavior in contrast to patients with affective disorders without comorbid PD.

A randomized, controlled trial of aerobic exercise in combination with paroxetine in the treatment of panic disorder.

OBJECTIVES: Regular aerobic exercise (running) has been shown to be superior to a pill placebo in the treatment of panic disorder. Combined drug and exercise treatment has not been investigated in randomized controlled studies to date. METHODS: This is a randomized, 10-week, controlled, parallel group, pilot study. A total of 75 outpatients with panic disorder with or without agoraphobia (DSM-IV and ICD-10) received either (1) exercise plus paroxetine 40 mg/day (n=21), (2) relaxation plus paroxetine (n=17), (3) exercise plus pill placebo (n=20), or (4) relaxation plus pill placebo (n=17). Changes in the Panic and Agoraphobia Scale (P&A), and the Clinical Global Impression Scale (CGI) underwent repeated measure analysis. RESULTS: Effects sizes were large for all groups (d=1.53-3.87), however not significantly different. Paroxetine-treated patients were significantly more improved than placebo-treated patients. On the CGI, patients in the exercise groups (plus paroxetine or placebo) had a trend toward better improvement compared to relaxation (P=0.06). Response and remission rates were higher in the paroxetine compared to pill placebo groups. CONCLUSIONS: While paroxetine was superior to placebo, aerobic exercise did not differ from relaxation training in most efficacy measures.

Quetiapine addition to serotonin reuptake inhibitors in patients with severe obsessive-compulsive disorder: a double-blind, randomized, placebo-controlled study.

OBJECTIVE: Although many patients with obsessive-compulsive disorder (OCD) benefit from treatment with serotonin reuptake inhibitors (SRIs), it is estimated that 40% to 60% of them do not respond. The objective of the present study was to evaluate the efficacy of quetiapine added to baseline treatment with SRIs for the treatment of OCD in severely ill adult subjects. METHOD: Forty patients (21 men, 19 women) with primary OCD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria participated in a 12-week, double-blind, placebo-controlled trial. They were randomly assigned to dosages of quetiapine titrated up to 400 mg/d (n = 20) or to placebo (n = 20) in addition to their SRI treatment. During the continuation phase (weeks 6-12), subjects received different dosages between 400 and 600 mg/d depending on clinical response. At entry, all patients were unresponsive to at least 1 course of at least 12 weeks of treatment with SRIs at defined doses. The total Yale-Brown Obsessive-Compulsive Scale score was the primary efficacy parameter. RESULTS: Intention-to-treat, last-observation-carried-forward analysis demonstrated a mean +/- SD decrease in Yale-Brown Obsessive-Compulsive Scale score of 5.2 +/- 5.4 in the quetiapine group and 3.9 +/- 4.9 in the placebo group. The analysis of treatment effects between the 2 groups showed no significant difference. There were no significant group differences in any of the other self-rating scales or clinician-administered rating scales. CONCLUSIONS: In this study, augmentation of SRI treatment with quetiapine in severe OCD had no additional effect.

[Physical training in the treatment of depressive disorders]. / Körperliches Training in der Behandlung depressiver Erkrankungen.

Therapeutic exercise programs have become an obligatory component in the modern treatment of many internal and orthopaedic conditions. In the field of psychiatry, the interaction of physical fitness and mental well-being has been increasingly recognized. In the meanwhile, solid evidence has emerged that regular exercise is associated with therapeutic effects in psychiatric patients suffering from depressive and possibly other psychiatric disorders. The present article reviews the relevant literature and summarizes neurobiological effects of exercise which might play a role in the effectiveness of therapeutic exercise. For instance, there is experimental evidence, that regular exercise induces a downregulation of central 5-HT(2C) receptors which play an important role in the pathogenesis of anxiety and depression. The production of brain-derived neurotrophic factor (BDNF)is stimulated in several brain regions. In conclusion, practical aspects and motivational factors have to be regarded in order to successfully establish exercise programs in the treatment of psychiatric disorders.

Onset and maintenance of psychiatric disorders after serious accidents.

The purpose of this study was to prospectively investigate the onset, course, and remission of psychiatric disorders in the first 6 months after a serious accident for consecutive patients in a hospital emergency department. Participants were 58 patients aged 18-65 who were assessed shortly after attending a hospital emergency department and were followed up 6 months afterwards. Patients were interviewed with regard to past and current psychiatric history using different instruments (e.g. SCID for DSM-IV). Prior to their accidents, 35% of all subjects had experienced one or more psychiatric disorders (lifetime prevalence). Shortly after the accident, the incidence of Acute Stress Disorder (7%), subsyndromal Acute Stress Disorder (12%), and adjustment disorder (1.5%) was increased as a reaction to the accident. At this time, 29% of all patients suffered from an acute psychiatric disorder. Six-months after the accident, 10% of the subjects met criteria for Major Depression, 6% for PTSD, 4% for subsyndromal PTSD, and 1.5% for Specific Phobia as newly developed disorders. The course of the psychiatric disorders shows that those patients who met criteria for any psychiatric diagnosis shortly after the accident ran a much higher risk for developing new or comorbid psychiatric disorders in the future.

The reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a German general practice population sample.

OBJECTIVE: Our goal was to analyze the retest reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a primary-care setting and recommend a cut-off value for the different alcohol-related diagnoses. METHOD: Participants recruited from general practices (GPs) in two northern German cities received the AUDIT, which was embedded in a health-risk questionnaire. In total, 10,803 screenings were conducted. The retest reliability was tested on a subsample of 99 patients, with an intertest interval of 30 days. Sensitivity and specificity at a number of different cut-off values were estimated for the sample of alcohol consumers (n=8237). For this study, 1109 screen-positive patients received a diagnostic interview. Individuals who scored less than five points in the AUDIT and also tested negative in a second alcohol-related screen were defined as "negative" (n=6003). This definition was supported by diagnostic interviews of 99 screen-negative patients from which no false negatives could be detected. As the gold standard for detection of an alcohol-use disorder (AUD), we used the Munich-Composite International Diagnostic Interview (MCIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. RESULTS: On the item level, the reliability, measured by the intraclass correlation coefficient (ICC), ranged between .39 (Item 9) and .98 (Item 10). For the total score, the ICC was .95. For cut-off values of eight points and five points, 87.5% and 88.9%, respectively, of the AUDIT-positives, and 98.9% and 95.1%, respectively, of the AUDIT-negatives were identically identified at retest, with kappa = .86 and kappa = .81. At the cut-off value of five points, we determined good combinations of sensitivity and specificity for the following diagnoses: alcohol dependence (sensitivity and specificity of .97 and .88, respectively), AUD (.97 and .92), and AUD and/or at-risk consumption (.97 and .91). CONCLUSIONS: Embedded in a health-risk questionnaire in primary-care settings, the AUDIT is a reliable and valid screening instrument to identify at-risk drinkers and patients with an AUD. Our findings strongly suggest a lowering of the recommended cut-off value of eight points.

Panic disorder during pregnancy and postpartum period.

BACKGROUND: Earlier studies on the influence of pregnancy and postpartum period on the course of panic disorder have been inconsistent. The present study aims to quantify panic manifestations in these periods in large sample of women. METHOD: Panic manifestations, including exacerbations and new manifestations of panic disorder, were assessed retrospectively in a sample of 128 women with panic disorder with or without agoraphobia, 93 of whom had had 195 pregnancies. RESULTS: Panic manifestations were fewer during pregnancy and more frequent in the postpartum period when compared with the control period. Women who had never been pregnant had significantly more panic manifestations than women with prior pregnancies. Breastfeeding and miscarriages did not have a significant effect. Women with postpartum panic reported more psychosocial stress events during this period. CONCLUSIONS: Possible reasons for postpartum panic and the protective effects of pregnancy are discussed, including psychosocial or hormonal factors and other neurobiological changes. Postpartum panic coincides with a sudden drop of hormones after delivery.

A multicenter study about Neurobiology of Suicidal Behavior: design, development, and preliminary results.

The subproject 1.5 "Neurobiology of Suicidal Behavior" is a multicenter study assessing peripheral parameters of the serotonergic, noradrenergic, and dopaminergic transmitter systems. Additionally, stress hormones and the lipid system as well as inhibitory and excitatory amino acids will be investigated. The different parameters are collected in cerebral spinal fluid (CSF), blood, and saliva. Patients with a depressive spectrum disorder with and without a suicide attempt (during the last three weeks) and being medication free for two weeks are included in the study. So far, 103 patients and controls have been recruited. The design and development of this project as well as interconnections with the others subprojects are described. Preliminary results about the stress hormone system and suicidality are presented.

Suicide prevention by lithium SUPLI--challenges of a multi-center prospective study.

Several studies have shown that there is a significantly increased risk of suicide related mortality in patients with a positive history of suicide attempts. The SUPLI-Study is the first prospective, randomized, double blind, placebo controlled multi-center trial focusing on the proposed suicide preventive effects of lithium in patients with suicidal behavior but not suffering from bipolar disorder or recurrent major depressive disorder. Patients with a recent history of a suicide attempt are treated with lithium versus placebo during a 12 month period. The hypothesis is that lithium treatment will lead to a 50% reduction of suicidal behavior. The protocol of the study and preliminary results are presented.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls.

Patients with borderline personality disorder (BPD) were compared with a healthy control group with regard to traumatic life events during childhood. The patients (n=66) and controls (n=109) were investigated using a comprehensive retrospective interview with 203 questions about childhood traumatic life events, parental attitudes, family history of psychiatric disorders and birth risk factors. The frequency of reports of traumatic childhood experiences was significantly higher in patients than in controls, including sexual abuse, violence, separation from parents, childhood illness, and other factors. On a 0- to 10-point "severe trauma scale," patients had significantly more severe traumatic events (mean score=3.86, SD=1.77) than control subjects (0.61, SD=0.93). Only four (6.1%) of the BPD patients, but 67 (61.5%) of the controls did not report any severe traumatic events at all. Compared with controls, patients described the attitude of their parents as significantly more unfavorable in all aspects. Patients reported significantly higher rates of psychiatric disorders in their families in general, especially anxiety disorders, depression, and suicidality. Among birth risk factors, premature birth was reported more often in BPD subjects. In a logistic regression model of all possible etiological factors examined, the following factors showed a significant influence: familial neurotic spectrum disorders, childhood sexual abuse, separation from parents and unfavorable parental rearing styles. The present data support the hypothesis that the etiology of BPD is multifactorial and that familial psychiatric disorders and sexual abuse are contributing factors.

Clinical outcome in patients with obsessive-compulsive disorder after discontinuation of SRI treatment: results from a two-year follow-up.

BACKGROUND: Combined treatment with serotonin-reuptake inhibitors (SRI) and cognitive-behavioral therapy (CBT) is a common therapy approach for obsessive-compulsive disorder (OCD). However, it is a matter of debate whether discontinuation of SRI after combined treatment leads to relapse. METHOD: Seventy-four consecutively admitted patients suffering from OCD were included in the study. Thirty-seven patients were treated with CBT alone, and 37 patients received combined CBT and SRI treatment. Of these latter patients, seventeen discontinued SRI treatment during the follow-up period (1 and 2 years after inpatient treatment). OCD symptom severity was determined by Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and mood was assessed by Hamilton Depression Rating Scale (HDRS). RESULTS: During the initial treatment, scores for Y-BOCS (p < 0.001), HDRS (p < 0.001) and the Global Assessment of Functioning Scale (GAF) (p < 0.001) improved significantly in all groups. Reassessment two years later revealed that a) OCD symptom severity and depression scores were similar between the groups and b) discontinuation of SRI did not prompt by a recurrence of symptoms. CONCLUSIONS: We interpret our results as suggesting that discontinuation of SRI treatment may be considered in formerly combined treated OCD patients after stable remission.

Early traumatic life events, parental rearing styles, family history of mental disorders, and birth risk factors in patients with social anxiety disorder.

OBJECTIVE: Childhood traumatic experiences, rearing styles, familial mental disorders and birth risk factors have been associated with the development of social anxiety disorder. METHOD: Patients with social anxiety disorder (n=50) and healthy controls (n=120) were investigated using a retrospective interview with 203 questions. RESULTS: The frequency of reports of traumatic childhood experiences was significantly higher in patients than in controls, including separation from parents, parents' marital discord, sexual abuse, familial violence, childhood illness, and other factors. On a 0-10 point 'severe trauma scale' patients had significantly higher mean scores (2.0; SD 1.28) than control subjects (0.82; SD 1.1; p<0.0001). Only 6 (12%) of the social phobic patients, but 63 (52.5%) of the controls did not report any severe traumatic events at all (chi2=24.0; p<0.0001). Compared to controls, patients described their parents' rearing styles as significantly more unfavourable. Patients reported higher rates of psychiatric disorders in their families in general, in particular anxiety disorders, depression, and suicidality. Birth risk factors did not differ between patients and controls. In a logistic regression model, the highest contribution was noted for familial anxiety disorders. Separation from parents also had a significant, but smaller influence. There was only a trend towards a significant contribution of childhood sexual abuse. Violence in the family, parental rearing styles and birth risk factors did not contribute significantly. CONCLUSIONS: The present data suggest that the aetiology of social anxiety disorder is multifactorial and that familial mental disorders and separation experiences are the most important contributing factors.

Search for atypical lymphocytes in schizophrenia.

The existence of atypical lymphocytes with specific morphological characteristics in the peripheral blood of schizophrenic patients has been suggested in several reports over the last 40 years. In our study this observation was examined not only by using the formerly applied method of light microscopy for general cell distribution and lymphocyte morphology but also by applying flow cytometry, a well established immunological method for lymphocyte patterns such as lymphocyte subgroups and lymphocyte activity. In contrast to the previously published data, our results demonstrated no differences in cell distribution (lymphocytes, polymorphonuclear cells, eosinophil and basophil granulocytes, monocytes), lymphocyte morphology ("atypical lymphocytes" vs. "normal lymphocytes"), distribution of lymphocyte-subtypes (T-cells (CD3(+)), T-helper-cells (CD3(+)/CD4(+)), cytotoxic T-cells (CD3(+)/CD8(+)), B-cells (CD19(+)), NK-cells (CD3(-)/CD56(+))) or state of T-lymphocyte activity (CD25(+) or HLA-DR(+)-cells) in schizophrenic patients compared to healthy controls. We suggest that possible immunological alterations in schizophrenia do not correlate with morphological characteristics of lymphocytes observable by light microscopy or an altered state activity of T-lymphocytes examined by flow cytometric parameters. Further studies should concentrate on intracellular and functional aspects of the different lymphocyte subgroups.

5-HT1A responsivity in patients with panic disorder before and after treatment with aerobic exercise, clomipramine or placebo.

Blunted neuroendocrine and physiological responses to the selective 5-HT(1A) receptor agonist, ipsapirone, have been observed in patients with panic disorder and/or agoraphobia (PDA). In order to examine whether this hyporesponsiveness to ipsapirone is modified by pharmacological or non-pharmacological therapeutic interventions, challenges with an oral dose of ipsapirone (0.3 mg/kg) and placebo were performed in patients with PDA before and after 10 weeks of treatment with clomipramine, aerobic exercise and placebo. Before treatment, administration of ipsapirone was followed by significant increases of cortisol, anxiety and other psychopathological symptoms in comparison to the placebo challenge. In addition, a significant decrease of body temperature was observed. After the 10-week treatment period, the psychological responses to ipsapirone were significantly reduced in the clomipramine and the exercise group. In contrast, there was a non-significant trend towards higher cortisol responses after clomipramine and exercise treatment. The hypothermic response to ipsapirone was significantly reduced by clomipramine treatment. In conclusion, our results demonstrate that effective treatment of panic disorder has divergent effects on the psychological, neuroendocrine and temperature responses to ipsapirone.

Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia.

OBJECTIVE: Psychometric evaluation of the Pittsburgh Sleep Quality Index (PSQI) for primary insomnia. METHODS: The study sample consisted of 80 patients with primary insomnia (DSM-IV). The length of the test-retest interval was either 2 days or several weeks. Validity analyses were calculated for PSQI data and data from sleep diaries, as well as polysomnography. To evaluate the specificity of the PSQI, insomnia patients were compared with a control group of 45 healthy subjects. RESULTS: In primary insomnia patients, the overall PSQI global score correlation coefficient for test-retest reliability was .87. Validity analyses showed high correlations between PSQI and sleep log data and lower correlations with polysomnography data. A PSQI global score > 5 resulted in a sensitivity of 98.7 and specificity of 84.4 as a marker for sleep disturbances in insomnia patients versus controls. CONCLUSION: The PSQI has a high test-retest reliability and a good validity for patients with primary insomnia.

Short-term training increases diagnostic and treatment rate for insomnia in general practice.

OBJECTIVE: To evaluate the effect of short-term training of general practitioners (GPs) on their diagnosis and treatment of chronic insomnia. METHODS: A three-step randomized control group design was used: After baseline evaluation (T1) a group of 9 GPs underwent a training of half a day, while 7 GPs served as a control group. The diagnostic and therapeutic handling of insomnia patients was reevaluated under obligatory use of a structured diagnostic questionnaire (T2) and under optional use of it (T3). RESULTS: From 16 general practices, 4,754 patients were included. The frequency rate of insomnia was 19.3 %. The lowest diagnostic and treatment rate was found for insomnia patients without comorbidity (15 % at T1). Systematic non-pharmacological treatment was not offered by the GPs. At T2 the diagnosis rate increased significantly from 37.9 % (T1) to 71.5 % (T2, p = 0.038). It fell back to lower levels at T3 but remained better than at T1. At T3 non-pharmacological treatments and referral to a sleep expert were advised more often. CONCLUSION: Short-term training of GPs can significantly improve their diagnostic sensitivity and first-line treatment efforts against insomnia.