[Changing care for the mentally ill in the "house of the poor insane in Lübeck" from the 17th to the early 19th century]. / Zum Wandel der Versorgung psychisch Kranker vom 17. bis zum Beginn des 19. Jahrhunderts am Beispiel des "Hauses der armen Unsinnigen" in Lübeck.

Until quite recently the history of the "House of the Poor Insane" in the Hanseatic City of Lübeck has only been studied selectively. Our study comprises an overall view of the comprehensive historical documents concerning this institution during the 17th and 18th century; the period of the following 40 years in another new constructed house is outlined likewise. Not only the journal, into which the principals of the institution wrote down the minutes, but foremost the cassa-books without omissions were used to describe the social history as well as the range of activities. Thus historical windows into the daily routine of the inmates are opened. - During the greater part of 17th century, the institution rather resembled a prison for the mentally ill, though in the end of the 17th and during the 18th century an important early phase of reform is to be recognized, followed, however, by a period of repression and "containment" towards the end of the century and in the beginning of the 19th century. Then again, this time initiated by the medical profession, the reform was revived. - The Lübeck findings are not only compared with the historical development of inpatient treatment in institutions elsewhere, but it is also discussed, which influences were the decisive factors for the public care in the city of Lübeck.

No considerable long-term weight gain after smoking cessation: evidence from a prospective study.

The aim of the study was to analyse predictors of the body mass index (BMI) after smoking cessation. The sample included 4075 residents aged 18-64 years in a northern German area (participation rate 70.2%), drawn randomly from the resident registration files, among them 1545 current and 903 former daily smokers. The current smokers were followed up 36 months after baseline. Face-to-face in-home computer-aided interviews (Composite International Diagnostic Interview) including questions about body weight and height at baseline and postal questionnaires at follow-up were employed. The data reveal that the number of cigarettes smoked at time of peak consumption in life contributed substantially, and years of abstinence from daily smoking contributed marginally to the BMI in a general linear model. It is concluded that the contribution of smoking cessation to the BMI increase was practically negligible. Efforts to prevent weight gain after smoking cessation should focus especially on heavy smoking.

Gender differences in unipolar depression: a general population survey of adults between age 18 to 64 of German nationality.

BACKGROUND: Several studies from different epidemiological backgrounds have shown that unipolar depression is more prevalent in females than in males. This study examines gender differences in depression in a sample of 4075 probands recruited representatively from the general population in the northern German epidemiological catchment area of Lübeck. METHODS: Probands were interviewed with M-CIDI by lay interviewers. RESULTS: Being married only seems to increase the female depression risk when having children, while higher education reduced female excess; both male and female risk for depression raised sharply in separated, divorced and widowed probands. Not being employed was associated with an increased risk in male depression whereas in females risk was nearly unchanged. The gender ratio increased with the minimum number of depressive symptoms. Female excess was not reduced by a higher degree of subjective impairment or melancholic features. Females also predominated in longer episode durations. Female excess in the total group emerged beginning from adolescence with a tendency for a male excess in the prepubescent ages. No birth cohort effect was observed. LIMITATIONS: The cross-sectional design of this study precluded causal analysis of reported associations and some retrospective assessments are error-prone because of recall bias. CONCLUSIONS: We support previous findings of variations in gender differences in depression, however observed social parameter influences underline the need for a more detailed analysis of subgroups and underlying psychological mechanisms.

Motivational intervention: an individual counselling vs a group treatment approach for alcohol-dependent in-patients.

AIMS: The present study aimed to evaluate whether individual counselling for alcohol-dependent patients in three sessions is as effective as a 2-week group treatment programme as part of an in-patient stay in a psychiatric hospital which was to foster motivation to seek further help and to strengthen the motivation to stay sober. Of particular importance was the external validity of the results, i.e. a 'normal' intake load of in-patients in detoxification and a wide variety of motivation to stop drinking were to be investigated. METHODS: Subjects eligible for the study were all patients with alcohol problems admitted to a psychiatric hospital, but without psychosis, as the main diagnosis, and with a maximum of 10 detoxification treatments in the past. A randomized-controlled trial was conducted with 161 alcohol-dependent in-patients who received three individual counselling sessions on their ward in addition to detoxification treatment and 161 in-patients who received 2 weeks of in-patient treatment and four out-patient group sessions in addition to detoxification. Both interventions followed the principles and strategies of motivational interviewing. RESULTS: Six months after intervention, group-treatment patients showed a higher rate of participation in self-help groups; however, this difference had disappeared 12 months after treatment. The abstinence rate among the former patients did not differ between the two intervention groups. CONCLUSION: Group treatment may lead to a higher rate of participation in self-help groups, but does not increase the abstinence rate 6 months after treatment.

Comparison of psychiatric ICD-10 diagnoses in Denmark and Germany.

A dataset of psychiatric ICD-10 diagnoses from the Danish case register concerning psychiatric hospitals was compared with a sample of psychiatric diagnoses from 27 psychiatric hospitals in Germany. The comparison shows a higher proportion of F1 diagnoses in the German dataset and a difference in the coding of alcohol dependence and harmful use. Some further differences in the groups F0-F6 are demonstrated and some of them are discussed. The most frequent diagnoses found in both datasets but in different sequence are alcohol dependence syndrome and paranoid schizophrenia and, in third place, adjustment disorder. Various aspects of the problem of rarely used diagnoses are discussed.

Lifetime-comorbidity of obsessive-compulsive disorder and subclinical obsessive-compulsive disorder in Northern Germany.

OBJECTIVE: Inspite of the worldwide relevance of obsessive-compulsive disorder (OCD), there is a substantial lack of data on comorbidity in OCD and subclinical OCD in the general population. METHODS: German versions of the DSM-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4075 persons aged 18-64 years, living in a northern German region. RESULTS: In both genders, high rates of comorbid depressive disorders were found in OCD and subclinical OCD, whereas somatoform pain disorder was only associated with OCD. In female subjects, OCD was additionally associated with social and specific phobias, alcohol, nicotine and sedative dependence, PTSD and atypical eating disorder. CONCLUSION: Due to low comorbidity rates, subclinical OCD seems to represent an independent syndrome not restricted to the presence of other axis-I diagnoses. Comorbidity patterns show a disposition to anxiety and to depressive disorders in OCD and subclinical OCD. A broad association with obsessive-compulsive spectrum disorders could not be confirmed in our general population sample.

Evaluation of the multiaxial system of ICD-10 (preliminary praft): correlations between multiaxial assessment and clinical judgements of aetiology, treatment indication and prognosis.

Forty-five raters in 7 German centres took part in a multicentric field trial of the multiaxial system of ICD-10, delivering a total of 488 multiaxial assessments of 12 written case summaries. In addition to the multi-axial ratings (including main and subsidiary psychiatry diagnoses, level of social dysfunctioning and psychosocial stressors), assessments were made by the raters of the aetiology, treatment indications and prognosis of the main psychiatric disorder. There were significant correlations between these judgements and the measures of the multiaxial ratings: 62% of the cases diagnosed as endogenous were assessed as having a high level of social dysfunctioning (the proportion for all cases being 50.4%) and 63.4% as having a low number of stressors (vs. 52.8% in all cases). In contrast, cases diagnosed as reactive were assessed as having a lower level of social dysfunctioning and more social stressors. Cases whose prognosis was poor showed a higher rate of comorbidity and a high level of social dysfunctioning. The results demonstrate that the multiaxial approach reflects factors important to the process of clinical treatment and decision making and delivers preliminary evidence of this system's treatment and prognostic validity.

Efficacy and safety of tianeptine in the treatment of depressive disorders in comparison with fluoxetine*

Depression is treated by a great variety of antidepressant treatments. SSRIs (such as fluoxetine) are well known: it is, however, sure that further progress is needed and the search for antidepressants with other mechanisms of action (such as tianeptine) or different efficacy is still of interest. A multinational study compared tianeptine with fluoxetine in 387 patients with Depressive Episode, or Recurrent Depressive Disorder, or Bipolar Affective Disorder (ICD-10), in a double-blind parallel group design. They were treated for six weeks. At inclusion, no significant difference between groups was shown. Final MADRS scores were 15.7 and 15.8 with tianeptine and fluoxetine, respectively (ITT population) (p = 0.944). MADRS responders were 58% and 56% with tianeptine and fluoxetine, respectively (p = 0.710). No statistical difference was observed for the other efficacy parameters. Thirty-six withdrawals occurred in each group, without any difference for the reasons of discontinuation. There was no major difference between groups for the other safety parameters. In this study, both tianeptine and fluoxetine exhibited a good efficacy and safety. Copyright 1999 Elsevier Science B. V. All rights reserved.

Prevalence, quality of life and psychosocial function in obsessive-compulsive disorder and subclinical obsessive-compulsive disorder in northern Germany.

BACKGROUND: Despite the worldwide relevance of obsessive-compulsive disorder (OCD) there are considerable differences in prevalence rates and gender ratios between the studies and a substantial lack of prevalence data on subclinical OCD. Moreover, data on quality of life and on psychosocial function of subjects with OCD and subclinical OCD in the general population are missing to date. METHODS: German versions of the DSM-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4075 persons aged 18-64 years living in a northern German region. Specific DSM-IV based criteria for subclinical OCD were used. RESULTS: The life-time prevalence rates for OCD and subclinical OCD were 0.5% and 2%, respectively. Twelve month prevalence rates were 0.39% and 1.6%, respectively. The gender female:male ratio was 5.7 in OCD and 1.2 in subclinical OCD. In various measures of psychosocial function and quality of life, OCD and subclinical OCD were significantly impaired. However, subclinical OCD subjects did not visit mental health professionals more often than controls. CONCLUSION: Due to different epidemiological characteristics subclinical OCD might represent a syndrome distinct from OCD which is also associated with significant impairments in personal and interpersonal functions and in quality of life.

[Lifetime prevalence of mental disorders in general adult population. Results of TACOS study]. / Lebenszeitprävalenz psychischer Störungen in der erwachsenen Allgemeinbevölkerung. Ergebnisse der TACOS-Studie.

The present paper reports lifetime prevalence rates of mental disorders in the 18- to 64-year-old general population of a northern German region. A representative random sample from registration office files of 4,075 individuals was examined in personal interviews using the fully standardized and computerised "Munich Composite International Diagnostic Interview" (M-CIDI). The response rate was 70.2%. Individuals were classified according to the DSM-IV. Substance use disorders were most frequent with 25.8% followed by anxiety (15.1%), somatoform (12.9%), affective (12.3%), and eating disorders (0.7%). Disorders other than substance use were more frequent in women and less frequent in men. A trend toward less psychiatric morbidity exists in individuals with higher educational level, higher income, and those who are married or reside in rural communities. Of all individuals affected by mental disorders, 42% fulfilled the criteria for at least one additional disorder. The results are discussed against the background of selected previous studies.

Use of the ICD-10 classification in psychiatry: an international survey.

On the background of some years of experience with ICD-10 psychiatric diagnoses in many countries of the world, an international comparison was performed to evaluate the frequency and use of the ICD-10 psychiatric diagnoses. For future revision of the ICD-10, it is important to know which diagnostic categories are either not used or are used possibly in an unspecific manner. Nineteen departments of psychiatry in 10 different countries took part in the study, presenting data on 33,857 treatment cases leading to a total of 25,470 ICD-10 main diagnoses. The analysis of data reveals that on a four-character level (Fxx.x), the 10 most often used diagnostic categories represent 40% of all main diagnoses, and 70% on a three-character level (Fxx.-). There are 32 specific diagnostic categories on a four-character level which are not used at all and 121 which are used less frequently than 0.1% in inpatient and outpatient treatment. The study shows that the ICD-10 classification is in use in a variety of treatment settings worldwide. Further results and limitations of this study are discussed against the background of transcultural differences.

Prevalence of alcohol consumption, abuse and dependence in a country with high per capita consumption: findings from the German TACOS study. Transitions in Alcohol Consumption and Smoking.

BACKGROUND: The aim of the Transitions in Alcohol Consumption and Smoking (TACOS) project is to investigate substance use and use disorders in the adult general population in a region of the under-researched north of Germany, focussing on smoking and alcohol consumption. In this study, the design and quality assurance provisions of the baseline cross-section of the longitudinal project are described. Prevalence rates of alcohol use disorders, consumption pattern, and the nature of their association are also analysed with regard to preventive strategies. METHOD: A random sample of 4075 participants, aged 18 to 64 and drawn from residents registration office files, was interviewed with a DSM-IV adapted version of WHO CIDI. Fieldwork resulted in a response rate of 70.2% and an unbiased database with regard to demographic characteristics. RESULTS: Low lifetime prevalence of alcohol use disorders (4.5% abuse, 3.8% dependence) and hazardous consumption (13.2% lifetime; 6.0% 12-month) was found compared to southern regions of Germany and US American data. In contrast, we found a comparatively high percentage of moderate alcohol uses. Male subjects are more affected by lifetime alcohol use disorders (abuse OR 8.3, 95% CI 5.3-13.2; dependence OR 4.3, 95% CI 2.8-6.4). The association between alcohol use disorders and alcohol consumption pattern revealed a weaker relation for alcohol abuse compared to dependence. CONCLUSION: National and regional drinking habits and norms have to be considered as a significant source of variance, supporting the need for European epidemiological research on substance use in addition to US American activities, and emphasising the advantages of community-based preventive measures. An evaluation of public recommendations for safe limits of alcohol consumption and prevention targets referring to average consumption is indicated. There is also a need for a clear distinction between alcohol abuse and dependence.

[Cost-efficacy analysis of clinically evaluated therapeutic programs. An expanded withdrawal therapy in alcohol dependence]. / Kosten-Nutzen-Analyse klinisch-evaluierter Behandlungsprogramme. Erweiterte Entzugstherapie bei Alkoholabhängigkeit.

BACKGROUND: Cost-effectiveness analyses complete clinical evaluation studies and thereby support the a well based estimation of therapy efficiency. AIM: A qualified (extended) alcohol withdrawal treatment programme (II), which was previously described and evaluated by face-to-face follow-up studies, was analyzed with regard to cost-effectiveness. SAMPLE: 57 alcohol-dependent patients, which had undergone programme II, were compared with 37 patients after a medical detoxification programme (I). METHODS: Health insurance data (number and length of all hospitalizations, days of incapacity to work, days of financial substitution for incapacity to work) were assessed for the five years before and after index therapy and for each year, separately. RESULTS: While there were no substantial differences for the time before index therapy, programme II patients were hospitalized after index therapy (i) less frequently (3.5 + 4.4 vs. 7.3 + 11.3 times), (ii) for fewer days (66 + 75 vs. 136 + 167) than programme I patients, and they received financial support for fewer days (67 +/- 73 vs 220 +/- 187 days). CONCLUSION: Considering a somewhat better clinical outcome of programme II vs. programme I patients (14% greater abstinence rate within one year) the significantly lower rates and fewer days of follow-up hospitalisations support a sufficient efficiency of the extended alcohol withdrawal treatment programme.

Efficacy and safety of tianeptine in the treatment of depressive disorders in comparison with fluoxetine.

BACKGROUND: Depression is treated by a great variety of antidepressant treatments. SSRIs (such as fluoxetine) are well known: it is, however, sure that further progress is needed and the search for antidepressants with other mechanisms of action (such as tianeptine) or different efficacy is still of interest. METHODS: A multinational study compared tianeptine with fluoxetine in 387 patients with Depressive Episode, or Recurrent Depressive Disorder, or Bipolar Affective Disorder (ICD-10), in a double-blind parallel group design. They were treated for six weeks. RESULTS: At inclusion, no significant difference between groups was shown. Final MADRS scores were 15.7 and 15.8 with tianeptine and fluoxetine, respectively (ITT population) (p = 0.944). MADRS responders were 58% and 56% with tianeptine and fluoxetine, respectively (p = 0.710). No statistical difference was observed for the other efficacy parameters. Thirty-six withdrawals occurred in each group, without any difference for the reasons of discontinuation. There was no major difference between groups for the other safety parameters. CONCLUSIONS: In this study, both tianeptine and fluoxetine exhibited a good efficacy and safety.

[Stages of motivation to change in smokers of the general population]. / Stadien der Anderungsbereitschaft bei Rauchern in der Allgemeinbevölkerung.

Secondary preventive measures to reduce cigarette smoking can be effective only if the motivation to change in the target population is taken into account. A useful model to match interventions to the readiness to change differentiates five stages: precontemplation, contemplation, preparation, action, and maintenance. In the USA, general population studies showed that 40% of smokers were in the precontemplation and contemplation stage, respectively, and 20% were in the preparation stage. In Germany, no data according to the distribution of stages among smokers are available; however, such data are necessary to plan population-based interventions. Data with respect to nicotine use, nicotine dependence, and the stages of change were assessed in a representative sample of 4075 respondents in Luebeck, a northern German city, and 46 adjoining communities in a face-to-face interview. The response rate was 70.2%. In this sample, 37.3% were cigarette smokers. Of those smokers with at least one attempt to reduce or quite smoking in the past, 76.4% were in the precontemplation, 17% in the contemplation, and 6.6% in the preparation stage. Including individuals without an attempt to reduce or quit smoking, 95.3% can be allocated to the precontemplation or contemplation stage. Nicotine-dependent smokers were in higher stages compared to smokers without dependence. Severity of dependence was not related to the stages of change. Data demonstrate that common smoking cessation programmes that require the individuals' readiness to change are inappropriate for 95% of the population. Stage-matched interventions are introduced and discussed in the paper. Compared to data from the USA smokers in Germany are more likely to be in early stages of change. Policy-based public health measures are necessary to change these findings.

Psychiatric co-morbidity, suicidal behaviour and suicidal ideation in alcoholics seeking treatment.

AIMS: To estimate the impact of co-morbid disorders for suicidal ideas in alcohol-dependent subjects seeking treatment. DESIGN: Life-time psychiatric co-morbidity and previous suicidal behaviours were assessed retrospectively after detoxification (t1). In addition, suicidal behaviours were assessed 12 months after discharge (t2). SETTING: An inpatient detoxification treatment unit. PARTICIPANTS: Two hundred and fifty dependent inpatients were studied after detoxification. One hundred and forty-nine of them participated in the follow-up face-to-face interviews. MEASUREMENTS: Using two extended standardized interviews (CIDI and IPDE) psychiatric co-morbidity (DSM-III-R, Axes I and II) was assessed at t1; suicide attempts were reported at t1 and t2, and suicidal ideas were assessed at t2. FINDINGS: A history of suicide attempts was reported by 29.2% at t1, and suicidal ideas by 14.1% and suicide attempts by 5.4% at the follow-up (t2). One female patient committed suicide within 6 months of discharge from hospital. The following co-morbidity patterns were associated with the greatest risk for suicidal ideas. Anxiety and depressive disorders, Axes I and 11 disorders, and a history of suicide attempt (for suicidal ideas at (t2). CONCLUSION. Our results underline the importance of psychiatric co-morbidity for the suicidal risk in alcohol-dependent patients, while alcoholism itself appears to be only a moderate risk factor.

[Electroconvulsive therapy in therapy refractory depression in the elderly. Report of experiences]. / Elektrokrampftherapie bei therapieresistenter Altersdepression. Ein Erfahrungsbericht.

In the past 30 years electroconvulsive therapy (ECT) was rarely applied in Germany mostly due to political reasons. Now ECT gains more interest again among psychiatrist as an effective somatic treatment for severe psychoses. Non-response to antidepressive medications is considered as one of the major indications for ECT. However, there are only few reports in the literature concerning the use of ECT in the treatment of late-life depression. Here we report on our experience with ECT treatment of older depressive patients (mean age 69 +/- 5 years) not responding to different antidepressants before ECT. There was a marked clinical improvement in 9 of the 12 (75%) cases (reduction of the Hamilton Depression Score to less than 50%). The only serious complication occurring in the sample was a transient cardiac conduction delay. Our experience show that ECT is a safe treatment also for late-life depression, which should be applied more often to avoid chronification of depression.

[The future of diagnosis in psychiatry]. / Die Zukunft der Diagnostik in der Psychiatrie.

Following a brief introduction to the history of psychiatric classification, the article describes the development of the international classification of diseases as a whole, especially ICD-10 as a model of operationalised diagnosis, and reports on the corresponding development of DSM-III to DSM-IV. A future task is the foundation of a new nosology that will include aetiology in the framework of operationalised diagnosis. Atheoretical diagnosis as proposed nowadays according to ICD-10 will remain fictitious. Dimensional diagnoses and multiaxiality will gain in importance, especially in the category of neurotic and personality disorders. Psychiatry in primary health care will be much more important than it is today, as will rehabilitation in psychiatry. The paper concludes with the hope that the next generation will benefit from a single worldwide classification of diagnosis and that the schism between ICD-10 and DSM-IV will be overcome.

Axis I and axis II comorbidity in alcohol dependence and the two types of alcoholism.

BACKGROUND: Although high prevalence rates of psychiatric comorbidity were reported in alcoholism, there is a lack of studies covering the whole spectrum of DSM Axes I and II disorders. The relation of comorbid psychopathology and Cloninger's and Babor's types of alcoholism still remained unclear. METHODS: Psychiatric comorbidity in 250 hospitalized alcohol-dependent patients without additional substance-related disorders was assessed by the Composite International Diagnostic Interview and the International Personality Disorder Examination. Information about the course and severity of alcoholism was obtained from several sources. RESULTS: Additional Axis I disorders only were found in 24.0%, Axis II disorders only in 16.4%, and concurrent Axis I and Axis II disorders in 17.2% (total comorbidity rate: 57.6%). Two clusters of alcohol dependence were found that substantially overlap with Cloninger's and Babor's types of alcoholism. The majority of type A subjects were found to be either not comorbid at all, or to be Axis I comorbid only. Type B, on the other hand, was preferably associated with personality disorders (mainly Clusters A and B) and dimensional scores of personality pathology (schizoid, schizotypal, all Cluster B, and passive-aggressive). CONCLUSIONS: The entire spectrum of personality pathology should be assessed in the comorbidity research of alcoholism. The two types of alcoholism differ on a variety of alcohol-related and comorbid personality characteristics, but further research is needed to clarify the underlying psychological and biological associations.