[Personnel assessment in psychiatry and psychotherapy : Results of a feasibility study on the platform model]. / Personalbemessung in der Psychiatrie und Psychotherapie : Ergebnisse einer Machbarkeitsstudie zum Plattform-Modell.

The topic of personnel assessment in psychiatry, psychotherapy and psychosomatics is currently of great importance in terms of health policy. Sufficient empirical evidence for the development of a comprehensive system for staffing is not yet available. The platform model developed by the psychiatric psychosomatic societies and associations pursues a combined empirical normative approach for a future-oriented assessment instrument for the various professional groups. The concept presented has been proven in the health policy discussion as a sensible system of comprehensive personnel assessment; however, an empirically sound control is still lacking as to whether this system can be used practically for the task described and thus can withstand the task of a resilient and future-proof measurement instrument for the necessary personnel. The task of the present study was to examine the extent to which the assumptions of the platform model are confirmed, whether methodological indications can be identified and whether there are limitations of the study that can be used in the validation and foundation of the model. The study confirmed the feasibility of the model and refers to a number of methodological findings and limitations that can be used for the further development of the model. The developed model allows the necessary staffing to be derived and justified, regardless of diagnoses and settings. It is future-oriented and dynamic.

[After the reform is before the reform : Results of the amendment processes of mental health law in German federal states]. / Nach der Reform ist vor der Reform : Ergebnisse der Novellierungsprozesse der Psychisch-Kranken-Hilfe-Gesetze der Bundesländer.

BACKGROUND: On the basis of mental health law, which differs between the federal states in Germany, courts can order the involuntary commitment of people with severe mental disorders in psychiatric hospitals, if they present a danger to themselves or to others. Due to decisions of the highest courts, these laws have been subject to revision since 2011. The aim of this paper is to analyze and compare the results of the revision processes in order to define the need for action for federal and state legislature. MATERIAL AND METHODS: Research of the current status of the revision processes in the federal states and a comparative analysis. The state laws were compared on the basis of selected particularly relevant areas with respect to human rights and treatment. RESULTS: In spite of the revisions the state laws are extremely heterogeneous and in many states do not fully comply with the requirements of the United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD) or the highest courts' decisions. CONCLUSION: The state laws should be harmonized, particularly where they restrict basic and human rights, e. g. regarding prerequisites and objectives of involuntary commitment and coercive measures.

[The German Association for Psychiatry, Psychotherapy and Psychosomatics participation compass II : Implementation of social participation for people with mental illnesses]. / Der DGPPN-Teilhabekompass II : Umsetzung sozialer Teilhabe für Menschen mit psychischen Erkrankungen.

For most people living with mental illnesses, participating in society is of existential importance; however, psychosocial care often fails to recognize its significance and therefore rarely includes the patient's interaction with society in the course of treatment. The reasons for this are both substantial and organizational in nature. The endless opportunities for participating in society, current areas as well as ways of taking part in social life even beyond the terms of the social legislative definition are, in addition to institutional variety and regional differences, all too often barriers to providing the very urgently needed support. Further aspects are insufficient knowledge of therapists about established options of rehabilitative treatment and about responsibilities related to participation in specialized training and further education for professional caregivers. The presented compass of participation for social integration of persons with mental illnesses starts at this point: it provides guidelines for psychiatric and psychotherapeutic practitioners, general practitioners as well as for physicians working in residential or day care institutions with a psychiatric and psychotherapeutic background. Both this article and planned online versions should help professionals to timely and successfully assist people, particularly those with severe mental illnesses, to navigate the broad spectrum of services for social and vocational integration in Germany.

[DGPPN recommendations on quality indicators for schizophrenia]. / Aktuelle Empfehlungen der DGPPN für Schizophrenie-Qualitätsindikatoren.

BACKGROUND: In Germany, several quality indicators have been proposed for the measurement of quality of mental healthcare. Some of these quality indicators have been tested in feasibility studies. The German Association for Psychiatry and Psychotherapy (DGPPN) established the "Task Force Quality Indicators (QI)" that, based on previous experience in the development and pilot testing of indicators, considered the further development and practical realization of QI for schizophrenia. AIM: The aim was to select a set of QI for schizophrenia that can also be applied to other diagnoses or used in generic measurements. Another goal was to focus on high feasibility of indicators. METHODS: In a multistage selection process, the DGPPN Task Force selected QI that focus on essential quality aspects from an inventory of 161 existing QI developed by national and international research groups. Indicators were adapted in consultation with the "trialogic forum" of the DGPPN. RESULTS: The DGPPN proposes the following ten indicators for quality measurement in mental healthcare for schizophrenia: QI1 Long-term treatment/Monitoring of side effects, QI2 Seclusion and restraint, QI3 Number of suicides, QI4 Psychoeducational-oriented intervention for significant others, QI5 Timely beginning of outpatient treatment after discharge from inpatient treatment, QI6 Aggression management - inpatient treatment, QI7 Diagnostic procedures/Physical examination, QI8 Antipsychotic polypharmacy, QI9 Rehabilitation/Vocational rehabilitation, QI10 Diagnostic procedures/Psychosocial functioning. DISCUSSION: Most of our proposed QI have to be measured by means of additional data documentation. Based on prior experience in the pilot testing of QI, the DGPPN estimates that the additional efforts in data documentation would be manageable, but have to be refinanced. The indicators will be tested in feasibility studies in different mental healthcare hospitals in Germany.

[Coercive measures in German hospitals for psychiatry and psychotherapy : A pilot study by the DGPPN to evaluate a uniform assessment instrument]. / Zwangsmaßnahmen in deutschen Kliniken für Psychiatrie und Psychotherapie : Eine Pilotstudie der DGPPN zur Erprobung eines einheitlichen Erfassungsinstrumentes.

STUDY OBJECTIVE: A simple instrument to record case-related coercive measures was tested as part of a pilot project of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN). METHODS: To assess coercive measures data were collected for 3 months in 8 German hospitals for psychiatry and psychotherapy. The type of measures used, the main diagnosis and the legal basis for the coercive measures were documented. RESULTS: In the sample studied, coercive measures were applied in 8% of cases. Coercive measures were most commonly used in patients with a schizophrenic disorder. The principle of justifiable necessity according to § 34 of the German Penal Code was used particularly often as the legal basis for justifying the coercive measures. CONCLUSION: Suitable measurement instruments and reliable data that enable the learning of best practices represent the basis for a reduction of coercive measures.

[Structural quality in psychiatric and psychotherapeutic hospitals]. / Strukturqualität in psychiatrischen und psychotherapeutischen Kliniken.

BACKGROUND: The new German flat rate reimbursement system for psychiatry and psychosomatics (PEPP) is primarily based on the diagnostic classification and the costs of therapeutic processes. In 2019 the current normative standard for calculating the therapeutic staff in psychiatric clinics (Psych-PV) will be substituted by a stepwise adaptation process over 5 years. Using regionally calculated remuneration factors, all clinic budgets should eventually converge to comparable values. AIM: Major factors influencing the structural quality of therapy in psychiatric clinics are identified and recommendations are given to support the work of the Federal Joint Committee (G-BA) which has been appointed to develop new recommendations for the minimum setting of personnel requirements. RESULTS: The full reimbursement of the necessary staff and of the costs resulting from outsourcing of day clinics and outpatient departments in the community, including the obligation to treat psychiatric emergency patients is mandatory and currently not sufficiently guaranteed in the new PEPP system. A workflow which opens the possibility to finance therapeutic innovations (e.g. psychotherapy) and helps to overcome the financial sectorial boundaries between inpatient and outpatient treatment is also missing. DISCUSSION: A mandatory recommendation for minimum staff settings needs a guaranteed full financing from the political side. Additionally, important would be an option for financing of therapeutic innovations and increased costs because of changed patient structures with respect to diagnosis and severity. Moreover, a sufficient remuneration for regional treatment responsibilities and for additional financial outlay resulting from structural costs for regionally outsourced departments is needed to avoid supplementary financing by reducing the budget for the therapeutic staff.

[Indicators of patient care in Psychiatric and Psychosomatic Facilities (VIPP project)--a database project]. / Versorgungsindikatoren in der Psychiatrie und Psychosomatik (VIPP)--Ein Datenbank-Projekt.

INTRODUCTION: In Germany a new and unique remuneration system for psychiatric and psychosomatic stationary treatments (PEPP system) was introduced in 2013 on an optional basis. From 2015 it will be mandatory for psychiatric and psychosomatic facilities. The introduction of the PEPP system brings up different questions regarding the possible incentives of the new remuneration system and its effects on the supply of psychiatric and psychosomatic treatments. To conduct these necessary analyses a reliable database is needed. MATERIAL AND METHODS: The goal of the project "Indicators of patient care in Psychiatric and Psychosomatic Facilities" (VIPP project) is to gather a representative database which reflects the situation of day-to-day patient care performed by German psychiatric and psychosomatic facilities. The §â€Š21 data set represents the basis of this database which will be complemented by other data sources (i. e., financial statements and other economic data). A number of more than 100 ,000 cases per year has already been exceeded. These case data were provided by a wide range of psychiatric hospitals, departments and universities that participate in this project. The dataset is anonymised and by pooling the data it is not possible to identify the cases of a specific clinic. Participants receive a web-based access and have the possibility to analyse the data independently. RESULTS: Using the examples of coding accuracy and rehospitalisation rates the variety as well as the enormous potential of this database can be demonstrated. DISCUSSION: On the base of the VIPP database valid patient care indicators can be identified and cross-sectional analyses can be conducted. From such results key data on health economic strategies can be derived and the incentives, strengths and limitations of this constantly changing system can be identified.

[Changes in mental health care by a regional budget--results of a pilot project in schleswig-holstein (Germany)]. / Vom Fall zum Menschen--Erfahrungen aus einem Regionalen Psychiatrie-Budget.

OBJECTIVES: In a region of Schleswig-Holstein, a regional budget was used to investigate which structural changes could be brought about by a financial plan which enables (clinical) treatment that defies rigid financial limits and makes flexible treatment in various settings possible. METHODS: Since 2003 in a region in Schleswig-Holstein (Steinburg) a financing system has been tested in cooperation with all health insurances. It is no longer based on days of treatment or individual treated cases, instead a budget has been made available for the setting of interdisciplinary psychiatric and pyschotherapeutic management. RESULTS: In 5 years, the number of inpatient treatment places in the care region was reduced considerably. The length of stay per patient and year decreased by 25%. Day care and outpatient treatment offers were expanded substantially and new treatment concepts were established. The quality of treatment remained safeguarded. CONCLUSIONS: A regional budget is suitable for bringing about fundamental changes in terms of content and structure in psychiatric care. The result is clearly improved flexibility as compared to previous care structures; incentives for disorders are reduced. The principle "outpatient before inpatient" is strengthened. The financial plan can be transposed onto other regions, whereby modifications according to the structure of the care region may be necessary.

Upregulation of the platelet Serotonin2A receptor and low blood serotonin in suicidal psychiatric patients.

Suicidality has been found to be associated with low pre- and postsynaptic serotonin functioning. The purpose of this study was to examine whether in acutely suicidal psychiatric inpatients, the blood serotonin concentration was related to the underlying psychiatric disorder and whether it was associated with changes in the affinity (dissociation constant, KD) or in the maximal binding capacity (Bmax) of the platelet serotonin2A receptor. We therefore determined the blood serotonin concentrations and the platelet serotonin2A receptor activities of 45 suicidal psychiatric patients and 20 healthy subjects. We found that the blood serotonin concentrations were significantly lower in suicidal patients compared to healthy subjects. In all diagnostic categories (affective disorder, schizophrenia and adjustment disorder) we noted a significantly higher maximal binding capacity of the platelet serotonin2A receptor. These findings support the notion that a reduction in the availability of serotonin and an upregulation of the serotonin2A receptors in psychiatric patients are associated with a loss of control over suicidal impulses.

Frequency and phenomenology of persisting alterations in affective, schizoaffective and schizophrenic disorders: a comparison.

Investigating the long-term outcome of affective, schizoaffective and schizophrenic disorders, a model that integrated the operationally gathered findings with the 'interactional atmosphere' experienced by the clinician was applied. Eight different types of phenomenological constellations of persisting alterations were delineated (depletion syndrome, apathetic-paranoid (respectively apathetic-hallucinatory) syndrome, adynamic deficiency syndrome, chronic psychosis, structural deformation, slight asthenic insufficiency syndrome, chronic subdepressive syndrome, chronic hyperthymic syndrome. Former assumptions that cross-sectionally the persisting alterations in affective disorders are usually indistinguishable from those in schizophrenia could not be confirmed.

[Coincidence of epilepsy and Asperger syndrome. Case report and review]. / Koinzidenz von Epilepsie und Asperger-Syndrom. Kasuistik und Ubersicht.

Asperger syndrome is an autistic disorder and was first described by Hans Asperger in 1944 without further acceptance in the literature over almost four decades. Following several publications in the 1980s, for the disorder became more widely known and was first introduced into ICD-10 and DSM-IV as a new diagnosis in 1988 and 1994, respectively. The etiology is unknown. We present a female patient with typical features of Asperger syndrome, suffering also from epilepsy and internal medical disorders. The associated diseases, diagnostic criteria and possible therapeutic options are discussed.

Low serum levels of tricyclic antidepressants in amitriptyline- and doxepin-treated inpatients with depressive syndromes are associated with nonresponse.

Nonresponse to tricyclic antidepressant (TCA) treatment is observed in about one-third of depressed patients. The cause(s) for nonresponse - apart from disease-specific effects - might be the failure to build up sufficiently high serum TCA levels due to noncompliance, substance abuse, rapid metabolism, or low dose. We carried out a retrospective analysis relating antidepressant serum levels to patient data obtained in the naturalistic setting of the Psychiatric Hospital of the Bonn University during the introductory phase of drug-monitoring. Case reports of 110 depressed inpatients who were treated with amitriptyline or doxepin were analyzed with respect to the following: medication and comedication, daily dose, type and duration of treatment, serum TCA concentrations (analyzed by the fluorescence polarization immunoassay), age, sex, body weight, abuse of nicotine or alcohol intake, serum transaminases (ALT, alanine aminotransferase, and AST, aspartate amino transferase), gamma-glutamyltranspeptidase (gamma-GT) and creatinine, compliance, and response. The salient findings were: 1. Serum TCA concentrations increased linearly with the daily amitriptyline dose but not with that of doxepin. 2. Interindividually, there was an eight to ten-fold difference in serum TCA concentrations at steady-state with 150 mg/day of either drug; longitudinally, we observed intraindividually a coefficient of variation of 8% and 12% for amitriptyline and doxepin respectively. 3. With amitriptyline (150 mg/day), the correlation between age and serum TCA concentrations was low (r = 0.33, p < 0.055) and no correlation was found after the administration of doxepin (150 mg/day), nor was there any correlation between age and dose-adjusted serum TCA concentrations after the administration of either drug. 4. Nonresponders had significantly lower serum levels than responders. These results suggest that patients should not qualify as nonresponders unless it can be demonstrated (and it is clinically applicable) that the steady-state serum TCA levels are stable within the upper limit of the recommended therapeutic range and serum level.

Validity of the negative/positive dichotomy of schizophrenic disorders under long-term conditions.

Based on the phenomenological distinction of positive and negative symptoms, some authors discuss the existence of two subtypes of schizophrenia (positive vs. negative schizophrenia). Investigating the long-term course of 100 schizophrenic patients (on average 23 years after onset) it was found that only 24% of the patients had a stable monomorphous course (only once type of episode). The results of the presented longitudinal study do not support the assumption of 'purely positive' or 'purely negative' schizophrenic disorders. The relevance of positive and negative onset of illness for the long-term course and outcome is discussed with reference to the literature.

Monitoring tricyclic antidepressant concentrations in serum by fluorescence polarization immunoassay compared with gas chromatography and HPLC.

The fluorescence polarization immunoassay (FPIA) developed by Abbott to diagnose intoxication with tricyclic antidepressants was adapted for therapeutic drug monitoring and validated with chromatograpic methods to investigate its potential for this use. We compared serum concentrations of tricyclic antidepressants in vivo and in vitro obtained by FPIA with those by gas chromatography and HPLC. For amitriptyline, imipramine, clomipramine, and doxepin, the detection limit of the FPIA was 72, 71, 64, and 72 nmol/L (approximately 20 micrograms/L), respectively; that by gas chromatography was 18, 18, and 16 nmol/L (approximately 5 micrograms/L) for amitriptyline, imipramine and clomipramine, respectively; with HPLC the lower limit of detection for doxepin was 36 nmol/L (10 micrograms/L). The intra- and interassay CVs ranged from 3% to 6%. In patients being treated with amitriptyline, imipramine, clomipramine, and doxepin, at steady-state the correlation coefficients between FPIA and GC/HPLC results for split samples were 0.95, 0.92, 0.90 and 0.70, respectively. However, the slopes were close to unity only for amitriptyline and doxepin, being 0.6 for imipramine and 1.9 for clomipramine.

Prognostic value of initial subtype in schizophrenic disorders.

The prognostic value of the subtype diagnosis at the initial episode was investigated in 148 narrowly defined schizophrenic patients. Every initial episode was classified according to multiple criteria: DSM-III-R, ICD-10, the positive/negative dichotomy, and Schneider's first rank symptoms. Patients were followed up on average 23 years later (range 10-50 years). Different aspects of long-term outcome were evaluated (global functioning, social adjustment, negative social consequences). In 93% of the patients persisting alterations were found at the end of the observation time. The influence of the predominant clinical features at the initial episode on various aspects of long-term outcome was found to differ depending on which of the four diagnostic systems was used. The highest power for discrimination was found for the subtypes of DSM-III-R, while the presence of first rank symptoms had no prognostic value. It was found that patients with an initial paranoid or positive episode had a significantly better long-term outcome than patients initially having a disorganised/hebephrenic or catatonic episode. The frequency of negative social consequences was not influenced by the initial subtype, with the exception of permanent hospitalisation.

Patient acceptance of implantable cardioverter defibrillator devices: changing attitudes.

Clinical experience suggests that the implantable cardioverter defibrillator (ICD) can reduce sudden cardiac death and total mortality in patients with malignant ventricular arrhythmia who meet the selection criteria for implantation. In addition to surgical problems, patients are faced with psychological and social adjustments. Patient acceptance for such therapy is marked by perceived concerns regarding device discharge, life-style alterations, and complications. We included 57 patients with ICDs in a study of their acceptance of the device. Results of a specially designed questionnaire (state-trait personality inventory) showed that 47 of 57 patients felt that their symptoms improved with the ICD system, 32 were constantly aware of the device, and 24 patients acclimated to the ICD system within less than 2 months. With respect to the need for battery replacement, only 27 patients requested a repeat electrophysiologic evaluation, 20 patients stated fear of ICD discharges, 12 patients revealed physical discomfort from the device, and limited quality of life occurred in eight patients. Fifty-five of 57 patients answered that it was worth having an ICD device implanted, 30 (53%) patients returned to active life, and 56 (98%) would advise another patient to have an ICD implantation if necessary. In conclusion, in general, the acceptance of the ICD as a tool for management of life-threatening ventricular tachyarrhythmias is very high. Quality of life and patient acceptance are important criteria for successful ICD therapy in addition to the improved survival rate.