Increased Treatment Complexity for Major Depressive Disorder for Inpatients With Comorbid Personality Disorder.

OBJECTIVE: The study examined inpatient treatment for major depressive disorder (MDD) when it is complicated by comorbid personality disorder. METHODS: In this descriptive analysis of a large data sample from 2013 (German VIPP data set) of 58,913 cases from 75 hospitals, three groups were compared: patients with MDD, patients with MDD and a comorbid personality disorder, and patients with a main diagnosis of personality disorder. RESULTS: Compared with MDD patients, those with comorbid personality disorder had higher rates of recurrent depression and nearly twice as many readmissions within one year, despite longer mean length of stay. Records of patients with comorbidities more often indicated accounting codes for "complex diagnostic procedures," "crisis intervention," and "constant observation." Patients with comorbid disorders differed from patients with a main diagnosis of personality disorder in treatment indicator characteristics and distribution of personality disorder diagnoses. CONCLUSIONS: Personality disorder comorbidity made MDD treatment more complex, and recurrence of MDD episodes and hospital readmission occurred more often than if patients had a sole MDD diagnosis.

Major depression treatment in Germany-descriptive analysis of health insurance fund routine data and assessment of guideline-adherence.

BACKGROUND: Guideline oriented treatment strategies of Major depressive disorder (MDD) improve treatment outcomes and reduce risks of chronicity and recurrence. AIMS: Description of routine treatment reality and analysis of guideline fidelity in first episode MDD in Germany. Indicators: patients with severe or psychotic depression or severe psychiatric comorbidities' treatment by specialists, adequate antidepressant pharmacotherapy, permanent treatment with more than one antidepressant, long-term benzodiazepine treatment and provision of psychotherapy. METHOD: Descriptive analysis of routine data of the German statutory health insurance fund Barmer GEK in the index year 2011 that covers a population of 7,501,110. RESULTS: 236,843 patients were diagnosed a depressive episode. 53.0% of the patients with severe depression, 34.4% with psychotic depression and 50.9% with severe psychiatric comorbidities were treated by specialists; of the patients treated by a general practitioner 48.1% with severe and 47.3% with psychotic depression received an antidepressant; 9.7% of all patients with MDD got two antidepressants simultaneously; 8.3% received longterm benzodiazepine prescriptions; 26.1% got psychotherapy. LIMITATIONS: the analyses depends on the indicators definitions that cannot cope with the variety of individual treatment path; comparison with guidelines was complicated by a large fraction of patients with recurrent MDD that was wrongly diagnosed with first episode depression; due to the data structure, not all guideline recommendations could be examined CONCLUSIONS: Routine practice was oriented upon the guidelines recommendations. However some aspects could be identified that bear potential for improvements.

[Diagnosis of Metabolic Risk Factors in Psychiatric Inpatients]. / Diagnostik metabolischer Risikofaktoren bei stationär-psychiatrischen Patienten.

OBJECTIVE: Individuals suffering from mental illness have one to two decades reduced life expectancy. The increased morbidity and mortality is mainly due to cardiometabolic disorders. Despite these numbers, international studies give evidence that diagnoses and treatment of metabolic risk factors in psychiatric patients is insufficient. We assume that in Germany metabolic risk factors are also underdiagnosed and insufficiently treated. METHODS: We tested for the frequency of diagnoses of the metabolic risk factors obesity, nicotine dependence and abuse, disorders of lipid metabolism, hypertension and diabetes in 139 307 cases of residential treatment and semi-residential care in 47 psychiatric hospitals in Germany in the year 2012. Data were derived from the VIPP(indicators of treatment quality in psychiatry and psychosomatic medicine)-project, a project that comprises the routine data of psychiatric hospitals, that are sent to the InEK (institute for the lump sum payment system for hospitals). Frequencies were compared with prevalence of metabolic risk factors in the German population and prevalences of metabolic risk factors found in psychiatric patients in international studies. RESULTS: In particular obesity (2.8 %), disorders of lipid metabolism (2.8 %) and nicotin dependence (4.2 %) were underdiagnosed. We assume that also diabetes (6.8 %) and hypertension (17.7 %) were underdiagnosed. CONCLUSION: The results give evidence that metabolic risk factors are underdiagnosed and possibly insufficiently treated in German psychiatric hospitals. We cannot exclude that the results might also be due to poor documentation. It remains to be seen if the introduction of the PEPP (the new lump sum payment system in German psychiatry) will heighten the level of attention for metabolic risk factors and their treatment.

[Incidence and Costs of 1:1 Care in Psychiatric Hospitals in Germany - A Descriptive Analysis Based on the VIPP Project Data Set]. / Häufigkeit und Kosten der 1:1-Betreuung in der Erwachsenenpsychiatrie in Deutschland - Eine deskriptive Analyse anhand des VIPP-Datensatzes.

OBJECTIVE: 1:1 care is applied for patients requiring close psychiatric monitoring and care like patients with acute suicidality. The article describes the frequency of 1:1 care across different diagnoses and age groups in German psychiatric hospitals. METHODS: The analysis was based on the VIPP Project from the years 2011 and 2012. A total of 47 hospitals with more than 120,000 cases were included. Object of the analysis was the OPS code 9-640.0 1:1 care. The evaluation was performed on case level. RESULTS: Data of 47 hospitals were included. Of the 121,454 cases evaluated in 2011 3.8 % documented a 1:1 care within the meaning of OPS 9-640.0 additional code. Of the 66 245 male cases a 1:1 care was documented in 3.5 % and the 55 207 female cases was 4.1 %. Compared to 2011, the proportion of 1:1 care in 2012 rose to 4.8 %. CONCLUSION: The results show that 1:1 care is frequently applied in German psychiatric hospitals. The Data of the VIPP project have proven to be a useful tool to gain information on the frequency of cost-intensive interventions in German psychiatric hospitals. Further analyses should create the possibility of evaluation at the level of the individual codes.

[The Quality of Inpatient Treatment of Elderly with Major Depression]. / Die Qualität der stationären Versorgung von Menschen mit Depressionen im Alter.

OBJECTIVE: There are highly effective treatments either in inpatient or day hospital settings available for elderly with major depression. It is important to consider some specific needs of elderly people (e. g. higher somatic comorbidities). METHODS: On the base of a large routine data set (139 307 patients in hospital treatment) differences between elderly and younger people with major depression are investigated. RESULTS: Elderly with major depression receive significantly less day hospital treatment and psychotherapy. Surprisingly, the mean length of hospital stay was significantly longer in younger patients with major depression. CONCLUSION: The results from such routine data should be interpreted with caution. Never the less our results suggest that there is still room for improvement for elderly people with major depression.

[Gerontopsychiatry versus general psychiatry in the inpatient treatment in late-life depression]. / Gerontopsychiatrie versus Allgemeinpsychiatrie bei stationärer Behandlung von Depressionen im höheren Lebensalter.

OBJECTIVE: Is the integrated treatment of depressed elderly patients on a geriatric psychiatry unit superior to the treatment on a general psychiatry unit? METHOD: Retrospective comparison of treatment outcomes of depression in elderly patients on geriatric and general psychiatry units. RESULTS: The clinical outcome showed comparable results. Somatic examinations turned out to be more comprehensive on a geriatric psychiatry unit, which also showed better results in pharmacotherapeutic safety. CONCLUSIONS: Regarding risk management, geriatric psychiatry units proved superior to general psychiatry units.

The differentiation between 'lack of insight' and 'dysfunctional health beliefs' in schizophrenia.

BACKGROUND: 'Lack of insight' into one's own illness is a frequent symptom in schizophrenic disorders. 'Health beliefs' are psychological explanations of one's own health status and are held by all individuals. The question is how they relate to each other. METHODS: Lack of insight (according to the definition of the AMDP System) and health beliefs (measured with the Illness Concept Scale) were assessed in 364 schizophrenic outpatients who participated in a study on neuroleptic long-term treatment. RESULTS: 'Insight into illness' and 'health beliefs' are independent of each other. Insight is related to the current psychopathological status as measured by the Brief Psychiatric Rating Scale, whereas health beliefs are related to personal life experiences. Lack of insight and dysfunctional health beliefs are both associated with patient noncompliance. CONCLUSION: Poor insight and dysfunctional health beliefs are separate clinical phenomena. Making this distinction is important for guiding research and patient care.

The acute antipanic activity of aerobic exercise.

OBJECTIVE: Regular physical activity is anxiolytic for both healthy subjects and patients with panic disorder. However, the acute antipanic activity of exercise has not yet been studied systematically. METHOD: The effects of quiet rest or aerobic treadmill exercise (30 minutes at 70% of maximum oxygen consumption) on cholecystokinin tetrapeptide (CCK-4)-induced panic attacks were studied in a crossover design in 15 healthy subjects. The effects were measured with the Acute Panic Inventory. RESULTS: Panic attacks occurred in 12 subjects after rest but in only six subjects after exercise. In both conditions, CCK-4 administration was followed by a significant increase in Acute Panic Inventory scores; however, prior exercise resulted in significantly lower scores than quiet rest. CONCLUSIONS: Aerobic exercise has an acute antipanic activity in healthy subjects. If the authors' results are confirmed in patients, the optimum intensity and duration of acute exercise for achieving antipanic effects will have to be characterized.

Cognitive function over the treatment course of depression in middle-aged patients: correlation with brain MRI signal hyperintensities.

INTRODUCTION: It has been proposed that the often found hyperintensities on MRI representing vascular changes might be correlated with a worse outcome of cognitive malfunction in depression. The purpose of this study was to evaluate neuropsychological status in the acute depressed state and following remission and to investigate the potential relationship between MRI hyperintensities and neuropsychological functioning through the treatment course in a group of middle-aged depressed patients. MATERIALS AND METHODS: Twenty-seven depressed patients were assessed by a series of neuropsychological tests at the beginning of the depressive episode and again after an euthymic phase of 6 months following treatment. Thirty healthy controls were tested at comparable intervals. In all patients and controls a MRI was performed to identify hyperintensities representing a possible correlation with test performance during treatment course. RESULTS: At the onset of a depressive episode patients performed significantly worse than the controls in all tests. After sustained remission the patient group still performed significantly worse in verbal memory and verbal fluency compared to controls. There were no significant correlations between number of presence of vascular risk factors, or presence of hyperintensities on MRI, and cognitive abilities at either time point. DISCUSSION: These findings favor the hypothesis that some neuropsychological deficits might persist following treatment for depression, even in middle-aged patients. We found, however, that any residual cognitive deficit is not associated with MRI-hyperintensities in this age-group.

Why does vertigo become chronic after neuropathia vestibularis?

OBJECTIVE: Vertigo is one of the most frequent complaints in general medical practice and is often linked to psychiatric disorders. A longitudinal study of 67 patients with an acute vestibular disorder was undertaken to clarify if, after experiencing acute vestibular vertigo, certain patients have a higher likelihood of developing chronic, debilitating dizziness despite no evidence of a damaged peripheral vestibular system. METHOD: The severity of dizziness was determined in 67 patients with vestibular neuronitis, 6 months after their release from hospital, using the Vertigo Symptom Scale from Yardley et al. The intensity of anxiety directly after vertigo was experienced, body-related cognitions, illness coping, personality structure, and the recovery of the organ of equilibrium were recorded in order to explain the severity of vertigo that occurred after 6 months. The function of the organ of equilibrium was assessed by using a caloric test. RESULTS: Over a period of 6 months, 13 of the 67 patients (19.4%) reported continuing dizziness after neuropathia vestibularis. Eleven of the 13 patients showed high scores on a scale for measuring vertigo-related symptoms, which can be interpreted as being equivalent to anxiety. The variables of gender, catastrophic thoughts and a dependent personality accounted for 35% of why vertigo became chronic. CONCLUSION: Neuropathia vestibularis represents a risk factor for the development of chronic vertigo. Chronic vertigo after neuropathia vestibularis appears to be equivalent to anxiety and is partly conditional on catastrophic thoughts at the beginning.

Panic disorders and agoraphobia: side effects of treatment with an implantable cardioverter/defibrillator.

BACKGROUND: Implantable cardioverter/defibrillator (ICD) treatment has reduced the mortality of patients with a high risk of sudden cardiac death. However, ICD discharges may cause anxiety with respect to new discharges and lead to preventive, for example, phobic, behavior. This study evaluated the frequency of panic disorders and agoraphobia in patients with ICD and assessed the risk factors in their development. HYPOTHESIS: Treatment with ICD represents a risk factor in the development of anxiety disorders. METHODS: Ninety patients with ICD were examined using a standardized lifetime Diagnostic Interview of Psychiatric Syndromes (DIPS). This interview makes it possible to estimate the incidence of panic disorders and agoraphobia. The impact of the severity of the underlying cardiac disease, the number of ICD discharges, and the subjective appraisal of the shock experience on the development of panic disorders and agoraphobia was assessed. RESULTS: Fifteen patients (16.7%) developed anxiety disorders after ICD implantation. The incidence was 21% in patients with and 6.9% in patients without ICD discharge. In patients with two or more ICD discharges annually, the incidence of panic disorders and agoraphobia was higher than that in patients with a single ICD discharge annually (62 vs. 10%, p<0.01). The intensity of self-observation of their body was significantly related to the development of anxiety disorders (p<0.001). CONCLUSION: Panic disorders and agoraphobia are frequent side effects of ICD treatment. Risk factors in the development of these disorders are two or more ICD discharges annually and a negative cognitive appraisal of ICD discharges. Therapeutic efforts should aim at reducing the number of ICD discharges and provide early psychological treatment.

A prospective study on the course of anxiety after vestibular neuronitis.

OBJECTIVE: Critical life events trigger intense emotions. Anxiety is one of the most frequent of these emotions. It is unclear which factors determine the intensity and course of anxiety after a critical life event. METHOD: Anxiety levels of 92 patients in the 6 weeks after experiencing an acute vestibular disorder were examined. The influence of cognitive, personality and illness variables on the course of their anxiety was analyzed. RESULTS: Acute vestibular disorder is accompanied by intensive anxiety. In most patients, anxiety decreased as vertigo regressed. Catastrophizing and dysfunctional cognitions and different personality styles predicted 17.6% of the anxiety 6 weeks after the functional loss of vestibular equilibrium. CONCLUSIONS: Acute vestibular disorder is a critical life event. Most individuals cope successfully with acute vestibular disorder. However, dysfunctional cognitions are risk factors for the persistence of anxiety.