[The assessment of free volitional competence in cases of suicide with life insurance]. / Begutachtung der "freien Willensbestimmung" bei Suizid in der Lebensversicherung.

The German insurance law stipulates that in cases of suicide, life insurance providers are not obligated to pay within a restriction period of 3 years, except if it can be proven that the suicide was committed in a state that precludes the insured's ability to make free choices. The relevant psychiatric assessment criteria are identical with those of mental and volitional competence in general. However, a different profile of patients and other disorders are involved, mainly depressive syndromes, but also chronic alcoholism as well as schizophrenic and paranoid syndromes. The assessment has to be based on the legal concept of mental disorder, which is different from the current diagnostic classifications in psychiatry. Decisive psychopathological symptoms are impairment of reality control, of volition and/or of judgement. These posthumous assessments are particularly difficult and require a thorough knowledge of psychopathology as well as of the relevant jurisdiction. The latter is summarised in this article.

[Documentation in psychiatry and psychotherapy: prerequisites and clinical practice]. / Dokumentation in der Psychiatrie und Psychotherapie: Rechtliche Grundlagen und klinische Praxis.

BACKGROUND: As a result of changes to the legal and economic framework over the past years, medical documentation has changed substantially. METHODS: Based on a literature search of important medicolegal studies and appeal decisions, an overview is given of legal principles and their practical consequences, especially for the fields of psychiatry and psychotherapy. RESULTS: Documentation is a contractual and crime-related duty arising from the professional code for doctors and the legal obligation to provide documentation. In addition to being a memory aide for the doctor, its purposes are to safeguard and justify the treatment and to provide legal evidence. The documentation should be provided in a format that is sufficiently clear for specialist staff, using keywords, possibly handwritten, and use contemporary terminology. All important diagnostic and therapeutic measures must be documented. This is particularly important when the treatment deviates from standard treatment and in medical procedures aiming to protect the patient. CONCLUSIONS: The legal requirements for documentation are becoming more stringent. The time spent on such activities has so far not been reimbursed by the financing bodies.

[The situation of caregivers of inpatients with bipolar affective disorders]. / Die Situation von Angehörigen von Patienten mit bipolaren affektiven Störungen.

OBJECTIVE: Research on the situation of caregivers of patients with bipolar affective disorders has been mostly neglected in German-speaking countries. METHODS: In the sense of a bottom-up approach, a content analysis of problem-oriented interviews with 32 caregivers of patients with bipolar disorder was carried out. Additionally, the relevant literature identified by means of a computerized MEDLINE research on the years 1997 - 2007 with the key words "caregiver"/"relative", "burden" and "bipolar disorder", was analysed to describe the situation of the caregivers comprehensively. Related articles in the MEDLINE search were also viewed. RESULTS: The burden of relatives of bipolar patients are manifold and partially specific. On the top of the list caregivers mentioned emotional burdens like: "lack of understanding, helplessness and hopelessness" (90,6 %) and "own concernment" (81,2 %). Specific burdens of these caregivers are "repulsing and uncooperative behaviour of the patient" (78,1 %) and "burdens due to the alternation between manic and depressive symptoms" (71,9 %). The manic and depressive symptomatic complex were assessed as burden with equal frequency (75,0 %). CONCLUSIONS: An effective support should consider the necessity of helping the caregivers in handling the symptoms of the illness and imparting coping strategies for emotional relief of caregivers.

[The psychiatrist and the psychiatric hospital--an analysis of referral and aftercare]. / Der niedergelassene Psychiater und die psychiatrische Klinik.

OBJECTIVE: Against the background of the problematic interface between outpatient and inpatient care in the German psychiatric health care system, the role of psychiatrists in private practice concerning the pathways of psychiatric inpatients before and after their hospital stay should be evaluated. METHODS: Based on data of the psychiatric basic documentation (DGPPN-BADO) of 4905 patients admitted to the psychiatric hospital in 2003, predictors of the type of referral as well as the outpatient aftercare were analysed by means of logistic regression analyses. RESULTS: 9.8 % of patients were referred by psychiatrists in private practice. Patients sent by psychiatrists more seldom had an addiction disorder, more often were residents of sheltered homes, showed a present episode lasting more than three months and had a psychopharmacological pre-treatment with an atypical antipsychotic or SSRI. At discharge, outpatient aftercare by psychiatrists in private practice was recommended to 32.1 % of inpatients. Referral by a psychiatrist in private practice as well as the diagnosis of schizophrenia or affective disorder led more often to an outpatient aftercare by a psychiatrist. CONCLUSIONS: Due to the small number of patients referred by psychiatrists, the cooperation between psychiatric hospital and psychiatrists in private practice has to be focused by the quality management of the hospital.

[Depressive patients in primary care]. / Zögerliche antidepressive Therapie in der Hausarztpraxis. So behandeln Sie richtig.

The study aimed at investigating out-patient treatment of patients with depressive disorders referred to a psychiatric hospital by general practitioners (GP) and psychiatrists in private practice (PP). Data of the German psychiatric basic documentation system (DGPPN-BADO) of all depressive inpatients admitted to a psychiatric hospital in 2003 were analysed (n = 360). GP-patients had significantly less often a psychopharmalogical treatment before admission than PP-patients (59.4% vs. 89.7%). GP give significantly less often antidepressive drugs than PP do (53.1% vs. 87.9%). 4,7% of GP-patients and 17.9% of PP-patients received supportive psychotherapy, special psychotherapeutic treatment regimes were seldom in use during outpatient care (4,7% vs. 5,4%).

[The situation of siblings of mentally ill people]. / Die Situation von Geschwistern psychisch Kranker.

OBJECTIVE: The purpose of this article is to provide an overview of the current research regarding the situation of mentally ill persons. METHODS: The relevant literature was identified by means of a computerized MEDLINE search on the years 1996 - 2004 with the key words "sibling" and "mentally ill"/"chronically ill"/"psychiatric disorder" (631 articles). Also the related articles in the MEDLINE search were viewed. Finally 170 articles of journals and books were included in the review. RESULTS: The situation of siblings of psychiatric ill has manifold aspects, which can be classified into the following categories: Burdens due to the relationship to the ill sibling, burdens because of the relations to the shared parents and other family members, and burdens in the daily life of the siblings due to the illness of his/her sibling. On the other side there are rewards and positive developments in their life because of the illness of the sibling. Personal variables like sex, family size and age at onset of the illness are an influence on the experience of the sibling. CONCLUSION: The revealed burdens of the affected siblings require necessary answers by political representatives, professionals in and outside a clinic, and the involved families.

Treatment of schizophrenia: implications derived from an intercultural hospital comparison between Germany and Japan.

OBJECTIVES: The study was aimed at evaluating facets of psychiatric inpatient care of patients with schizophrenia in a German and a Japanese hospital. METHODS: Based upon a sample of 865 inpatients of the Psychiatric State Hospital Regensburg (BKR) and 50 inpatients of the Tokyo Women's Medical University (TWMU) admitted in 1997, data of a psychiatric basic documentation system (BADO) were analysed with regard to essential process and outcome indicators. RESULTS: Despite dissimilarities between both patient groups with respect to schizophrenic subtype, duration of illness as well as severity of illness and psychosocial functioning, the differences regarding therapeutic treatment and outcome were marked. In 1997, the rate of atypical neuroleptics was 18% at the BKR and 12% at the TWMU. Inpatients of the TWMU were given benzodiazepines and anticholinergic drugs significantly more frequently. Male patients of the TWMU showed more severe side-effects. Psychotherapy and sociotherapy were less frequently applied at the TWMU. Although the patient groups did not differ with regard to suicidal behaviour and overt aggressions during hospitalisation, we found a higher rate of mechanical restraints at the TWMU. In 1997, the average length of stay was significantly higher at the TWMU (153 days) than at the BKR (52 days), but inpatients of the TWMU improved only slightly better with regard to global psychosocial functioning (GAF) and severity of illness (CGI). CONCLUSIONS: The revealed differences in treatment are likely due to differences in service provision and national practices in Germany and Japan and provide clues for quality improvements. The BADO is a useful tool for continuous quality management and an ongoing international exchange concerning psychiatric inpatient care.

[The role of the general practitioner in inpatient psychiatric care]. / Die Rolle des Hausarztes im Rahmen der stationären Versorgung psychiatrischer Patienten.

OBJECTIVE: In the light of the increasing importance of the general practitioner as a gatekeeper within the German psychiatric health care system, his/her role needs to be evaluated. METHOD: On the basis of the psychiatric documentation (DGPPN-BADO) of 4066 patients predictors for referral to inpatient psychiatric care by the general practitioner together with outpatient aftercare were analysed by means of logistic regression models. RESULTS: 18.4% of the patients were referred by a general practitioner, mostly those with an affective disorder (Odds Ratio 4.0) or schizophrenia (OR 3.3), and residents of old people's or nursing homes (OR 3.5). In 49.9% of the patients, aftercare by a general practitioner was recommended - more frequently patients with addictive disease (OR 2.0), pensioners (OR = 1.7) and elderly patients (OR 1.03), more rarely patients with schizophrenia (OR 0.4) or affective disorders (OR 0.7). CONCLUSION: In view of the relatively low referral rate, in-hospital quality management should focus on improving cooperation between psychiatric hospital and GP.

[Who comes from where and who goes where? Treatment methods for psychiatric inpatients]. / Wer kommt woher, wer geht wohin? Behandlungswege stationär-psychiatrischer Patienten.

Based on data of the psychiatric basic documentation of 4066 patients, predictors of type of referral as well as outpatient aftercare were analyzed by means of logistic regression analyses. Of the patients, 25.7% were admitted without any referral, 18.4% were referred by a general practitioner, and 9.8% by a psychiatrist in private practice. Patients referred by a general practitioner suffered more frequently from an affective disorder or schizophrenia and were residents of senior citizen homes. Inpatients sent by a psychiatrist were more often residents of sheltered homes, showed a present episode lasting more than 3 months, and had undergone psychopharmacological pretreatment with an atypical antipsychotic or SSRI. Outpatient aftercare was recommended to 83.1% of inpatients: 49.4% by a general practitioner and 32.1% by a psychiatrist in private practice. Outpatient aftercare by a general practitioner was more frequent in the elderly and patients with addiction disorders. Referral by a psychiatrist in private practice as well as schizophrenia or an affective disorder led more often to outpatient aftercare by a psychiatrist. The small number of patients referred by general practitioners and psychiatrists in private practice has to become the focus of quality management.

[Expectations and satisfaction from relatives of psychiatric patients in inpatient treatment]. / Erwartungen und Zufriedenheit von Angehöringen psychiatrischer Patienten in stationärer Behandlung.

Based upon a content analysis of interviews(n=32), a questionnaire evaluating expectations and satisfaction with psychiatric inpatient care was developed and sent to all caregivers whose ill family members gave their agreement to the survey (n=1 39). The response rate was 41.7% (n=58). Successful treatment of the patient by competent physicians and psychologists, understandable and sincere explanations to caregivers regarding the patient's disease, support of the patient's self-confidence and gains in confidence, psychotherapy for the patient, and by no means psychopharmacological treatment were assessed as most important by caregivers. From their point of view, gaps between expectations and satisfaction with inpatient care exist, especially regard-ing the following aspects: patient psychotherapy, information to caregivers about therapies, medication, side effects and treatment progress, understandable and sincere explanation to care-givers, support in dealing with the patients, and information about the possibilities of rehabilitation after inpatient care.

[The assessment of (in)competence to make a will]. / Die Begutachtung der Testier(un)fähigkeit.

Based upon German law and jurisdiction, psychiatric literature as well as the author's experiences, essential criteria for the assessment of testamentary capacity are presented, peculiarities of the posthumous assessment of psychopathology are explained and the anachronistic idea of the "lucid interval" is critically discussed. The legal term "freedom to determine one's will", decisive for the competence to contract and to make a will, corresponds to the psychopathological dimension of judgement. In the practice of experts' assessments, this criterion is most likely to be impaired by delusional misinterpretation of reality, lack of insight in being ill, pathological dominance of affects or suggestibility, while cognitive deficits are less often decisive. Using knowledgeably all available sources of information, a posthumous expert's statement on the legal ability to make a will is possible with the reliability legally required in more than 90 % of cases.

[Burden of relatives and their expectations towards psychiatric institutions. A review of the literature and own results]. / Belastungen von Angehörigen und ihre Erwartungen an psychiatrische Institutionen. Literaturübersicht und eigene Ergebnisse.

OBJECTIVE: This article aimed to provide an overview regarding the burden of relatives of mentally ill patients and their expectations towards psychiatric institutions. METHODS: The literature was selected from Medline covering the years 1996 - 2002. 342 articles were reviewed, 145 of which were described in this review. RESULTS: The burden of relatives are manifold and can be classified into the following categories: time spent on caring, financial difficulties, occupational restrictions, detrimental effects on relatives own physical and psychological well-being, reduction in leisure activities, negative effects on social relationships, experiences of discrimination and refusal, deficiencies in information about illness, feelings of not being taken seriously, insufficient service support, long distance to mental health service, emotional burdens of caregivers and difficulties with the patients behaviour. The expectations of the relatives mainly refer to the categories "relationship between staff and relatives", "information about illness" and "establishing of institutions required". CONCLUSION: The various burdens of relatives and their expectations towards psychiatric services point to necessary improvements of mental health services in the sense of a consumer-oriented psychiatric care.

[Fair hospital comparisons -- does the method contracted in Germany enable unbiased results?]. / "Fair ist, Gleiches mit Gleichem zu vergleichen" -- Eine Simulationsstudie zu den Krankenhausvergleichen nach section 5 Bundespflegesatzverordnung?

AIM: To evaluate the method for comparison of average length of stay in hospitals as defined in a contract between German health insurance companies and the "Deutsche Krankenhausgesellschaft" (German Hospital Association). METHOD: Simulation study executing the algorithm agreed upon in different scenarios, which varied the number of hospitals to be compared, the dispersion of diagnostic specialization over hospitals, and the distribution of hospitals' sizes. Scenarios were constructed to realistically reflect the situation in German inpatient treatment of mentally ill patients. RESULTS: By fixing casemix adjustments only on diagnoses of patients and by doing so aggregated on the level of hospitals, the method for comparison yielded artificial differences between hospitals even in a situation where each patient is treated with exactly the same amount of resource allocation (given the individual needs defined for all scenarios). Results of artificial differences were heavily biased against or in favour of the reference hospitals according to the specific condition of the scenario parameters. CONCLUSION: The contracted method is not capable of achieving fair hospital comparisons, at least not for psychiatric hospitals.

[Psychotherapy in a psychiatric hospital]. / Psychotherapie in der psychiatrischen Klinik.

This study was aimed to evaluate the role of psychotherapy in psychiatric in-patient care at the example of the Bezirksklinikum Regensburg (BKR) (Community Clinic in Regensburg, Germany). Based on a sample of 6,719 patients suffering from F2-F6 ICD-10 diagnoses, the data of the psychiatric basic documentation (BADO) from January 1995 until April 1999 was retrospectively analysed regarding type and frequency of psychotherapy, influencing factors on indication, and effects of psychotherapy on treatment success. In 33% of cases, specific psychotherapy was in use. A client-centered therapy was carried out in 20% of patients. Other techniques of psychotherapy such as behaviour therapy, cognitive therapy, IPT for schizophrenics, or psychodynamic psychotherapy were applied to 2-6% of patients. Inpatients with eating disorders, personality disorders, neurotic disorders, somatization disorders, and depression were more likely to receive a specific psychotherapy. A significantly positive effect on treatment success was only documented in affective disorders, whereas a significantly negative influence was found in personality disorders.

[Differences between unipolar and bipolar affective disorders. Review and results from a clinical population]. / Unterschiede zwischen unipolaren und bipolaren affektiven Störungen - Ubersicht und eigene Ergebnisse bei einer klinischen Klientel.

OBJECTIVE: On account of the different therapeutic options in mood disorders, differences between unipolar and bipolar disorders are described by reviewing the literature and evaluating data of a psychiatric basic documentation system (DGPPN-BADO). METHODS: Based upon a sample of 18 846 psychiatric in-patients of the Bezirksklinikum Regensburg between 1989 and 1999, data of 2644 patients with unipolar depression (UD) and bipolar affective disorders (BAS) were analysed and compared with findings from previous studies. RESULTS: 77,8 % suffer from unipolar depression, 22,2 % from bipolar affective disorders. Patients with BAS fall ill 10 years earlier than patients with UD, they have a 50 percent higher number of hospital stays and longer cumulative length of stay, and they are significantly more ill at admission. In both patient groups we found a mean duration of hospital stay of about 45 days and a clinical improvement of nearly 25 points in GAF. Patients with BAS attempt suicide more often and have comorbid alcoholism more frequently. At discharge they show greater deficits in their psychosocial capability (measured with GAF) than patients with UD do. CONCLUSION: Patients with BAS, which had to be hospitalised, have a more severe course of illness, but they can be treated equally as effective and efficient as patients with UD.

Suicidal behaviour of psychiatric in-patients.

OBJECTIVE: The study aimed to examine suicidal behaviour before and during in-patient care in a psychiatric state hospital. METHOD: Based upon a psychiatric basic documentation system prevalence and risk factors of in-patient suicides, suicide attempts and suicidal thoughts were investigated over an 11-year period from 1989 until 1999. RESULTS: A total of 30 in-patient suicides were found among 21 062 patients. According to the multivariate logistic regression analysis the risk of hospital suicide increases for patients with schizophrenia, higher cumulative length of stay, previous suicide attempt, part-time employment and training/retraining. Predictors of suicide attempt during hospitalization are suicide attempt on admission, personality disorder, suicidal thoughts on admission, schizophrenia and affective disorder. CONCLUSION: As Schizophrenics represent the high-risk group of in-patient suicide, suicide prevention should be a major goal in their treatment. More frequent suicide risk assessment is recommended particularly before granting a leave or an outing.

[Referral into the psychiatric clinic. What information must the admitting document contain?]. / Uberweisung in die psychiatrische Klinik. Was müssen Sie auf dem Einweisungsschein angeben?

The importance of certain items of information on a referral in the eyes of the clinicians was determined. Indispensable information was considered to be that on current medication, suicidality/aggressiveness towards others, the present problem, the reasons for referral, drug intolerance, and somatic pathologies. Also considered to be very important items were care provision, prior treatment, history of drug addiction, telephone number of relatives, prior diagnostic measures, psychiatric diagnosis and previous findings.

[Referral to psychiatric hospital - which informations are necessary?]. / Einweisung in die psychiatrische Klinik - Welche Informationen sind wichtig?

OBJECTIVE: The study aimed to investigate the relative importance of information provided by referral letters to in-patient psychiatric care from the clinicians' point of view. METHODS: The estimation of psychiatric hospital physicians (n = 32) was assessed by questionnaire comprising 21 Items in 4-step Likert-type scales. RESULTS: As indispensable information are valued details about actual medications, suicidality/aggression, presenting problem, reason for referral, drug intolerance, and somatic disorders. Details concerning guardianship, previous therapy, substance misuse, relatives' telephone number, prior investigations, psychiatric diagnosis, and previous examination findings are assessed very important. CONCLUSIONS: The mentioned details of referral letter are important within all medicine disciplines to ensure continuous care and to avoid time- and cost-intensive double diagnostics and therapy.