Needs-oriented discharge planning for high utilisers of psychiatric services: multicentre randomised controlled trial.

AIMS: Attempts to reduce high utilisation of mental health inpatient care by targeting the critical time of hospital discharge are rare. In this study, we test the effect of a needs-oriented discharge planning intervention on number and duration of psychiatric inpatient treatment episodes (primary), as well as on outpatient service use, needs, psychopathology, depression and quality of life (secondary). METHODS: Four hundred and ninety-one adults with a defined high utilisation of mental health care gave informed consent to participate in a multicentre RCT carried out at five psychiatric hospitals in Germany (Düsseldorf, Greifswald, Regensburg, Ravensburg and Günzburg). Subjects allocated to the intervention group were offered a manualised needs-led discharge planning and monitoring intervention with two intertwined sessions administered at hospital discharge and 3 months thereafter. Outcomes were assessed at four measurement points during a period of 18 months following discharge. RESULTS: Intention-to-treat analyses showed no effect of the intervention on primary or secondary outcomes. CONCLUSIONS: Process evaluation pending, the intervention cannot be recommended for implementation in routine care. Other approaches, e.g. team-based community care, might be more beneficial for people with persistent and severe mental illness.

Neuropsychological assessment of attention in adults with different subtypes of attention-deficit/hyperactivity disorder.

There is only little information about varying attention functions of adults with different DSM-IV subtypes of attention-deficit/hyperactivity disorder (ADHD). In the present study groups of adult patients with ADHD - predominantly inattentive type, ADHD - predominantly hyperactive-impulsive type or ADHD - combined type and three healthy control groups were compared regarding multiple components of attention. Assessment of attention was performed using a computerized neuropsychological test battery for attentional functions. In comparison with healthy subjects, the three patient groups displayed impairments of vigilance, selective attention, divided attention, and flexibility. These impairments of attention of ADHD subgroups were primarily observed with regard to reaction time. With regard to tonic and phasic alertness no differences between patient and control groups could be found. Comparison between ADHD subgroups revealed that DSM-IV subtypes of ADHD differ in measures of divided attention, selective attention and flexibility. Differences between ADHD subgroups were primarily observed with regard to task accuracy. The results suggest that while distinct profiles of attentional functioning were observed between adult patients with ADHD and healthy adults indicating gross disturbances of various attention functions in patients with ADHD, differences between ADHD subgroups were only weak.

Methylphenidate-induced improvements of various measures of attention in adults with attention deficit hyperactivity disorder.

The present study examined the effect of the stimulant medication methylphenidate (MPH) on attentional functioning of adults with ADHD. Sixteen adults with a diagnosed ADHD without comorbidity were assessed twice, at baseline off MPH and following MPH treatment. The assessment battery consisted of reaction time tasks of low complexity, including measures of alertness--subdivided into tonic and phasic alertness, vigilance, divided attention, flexibility and such aspects of selective attention as including focused attention, inhibition and integration of sensory information. In addition, 16 healthy participants who were matched to adults with ADHD according to sex, age, education level and intellectual functions were also assessed twice using the same test battery. The results of the present study suggest that adults with ADHD off stimulant medication are seriously impaired in various components of attention including vigilance, divided attention, selective attention and flexibility. These impairments of attention were observed primarily in regard to reaction time and its variability. Treatment of adults with ADHD using individually tailored doses of MPH has a positive effect on measures of alertness, vigilance, selective attention, divided attention and flexibility. However, even on MPH adults with ADHD displayed considerable deficits in vigilance and integration of sensory information. The present findings indicate that adults with ADHD are not differentially impaired in attentional processes but may suffer from a more global deficit of attention. Although MPH treatment has been found to be effective in the treatment of the attention deficit of adults with ADHD, additional treatment appears to be necessary.

[The work of medical doctors on psychiatric wards: an analysis of everyday activities]. / Der Arbeitsalltag von Arzten im Stationsdienst: Eine Tätigkeitsanalyse in psychiatrischen Versorgungskliniken.

In Germany, the economic situation of psychiatric hospitals has markedly changed during the last years. Whilst the number of patients has steadily increased, many clinics considerably reduced the number of therapeutic staff due to an increasing lack of financial support. The German psychiatry personnel regulations act defines the number of therapeutic staff required for an adequate psychiatric treatment, but the requirements of this regulations act nowadays are widely missed in most of the German psychiatric hospitals. This severely affects the therapeutic work on psychiatric wards. This study analyses tasks and activities of medical doctors on psychiatric wards and compares the hours spent with various types of activities with the amount of time that should be spent according to the personnel regulations act. Results show that doctors spend much more time with documentation and administrative work than originally intended by the personnel regulations act. They compensate this mainly by a reduction of time spent in direct contact with the patients. In this context, the number of psychotherapy sessions as well as sessions with the patients' relatives has been considerably reduced, whereas the time spent for emergency intervention and basic treatment still corresponds to the calculations according to the personnel regulations act. All in all, the results show that a reduction of therapeutic staff in psychiatric hospitals directly leads to a change in treatment settings with a focus on less individual treatment options.

[How does recruit successfully recruit staff? An investigation of recruitment in the medical service]. / Wie wirbt man erfolgreich um Mitarbeiter? Eine Untersuchung zur Personalbeschaffung im ärztlichen Dienst.

In Germany, an increasing shortage of medical doctors has developed in recent years. Today, many clinics must compete to attract qualified MDs. In this study, 60 medical students, 60 doctors working in psychiatry, and 60 doctors working in somatic fields of clinical medicine were interviewed in order to analyse the importance that potential applicants place on the information and offers contained in advertisements seeking medical doctors. In this regard, good working atmosphere in the ward, excellent opportunities for further education, and assistance from nonmedical personnel in documentation and administration got the highest ratings. There were significant differences between psychiatrists and other doctors rating the items "own office" and "permission to take additional nonhospital jobs" such as providing medical opinions. The study shows how advertisements can be improved.

The genetic causes of basal ganglia calcification, dementia, and bone cysts: DAP12 and TREM2.

BACKGROUND: Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy (PLOSL), or Nasu-Hakola disease, is a presenile dementia associated with loss of myelin, basal ganglia calcification, and bone cysts. It is caused by recessively inherited mutations in two genes encoding subunits of a cell membrane-associated receptor complex: TREM2 and DAP12. The clinical course of PLOSL has not been characterized in a series of patients with TREM2 mutations. METHODS: The authors compare neurologic and neuroradiologic follow-up data of six patients carrying TREM2 mutations with PLOSL due to defective DAP12 genes. The authors review the known mutations in these two genes. RESULTS: Mutations in DAP12 and TREM2 result in a uniform disease phenotype. In Finnish and Japanese patients with PLOSL, DAP12 mutations predominate, whereas TREM2 is mutated more frequently elsewhere. CONCLUSIONS: Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy should be considered in adult patients under age 50 years with dementia and basal ganglia calcification. Radiographs of ankles and wrists, and DNA test in uncertain cases, confirm the diagnosis.

[Normal psychiatric interview]. / Der psychiatrische Normalbefund.

The documentation of the normal psychiatric interview has been omitted in the ICD 10 classification. Particularly, psychiatric consultants have to deal with the practical problem of adequate classification of patients with normal psychopathology. To use unspecific codes or to omit the coding of the findings are no suitable solutions. Future revision of the ICD 10 classification should integrate the normal psychiatric interview.

Identification of novel mutations in the NPC1 gene in German patients with Niemann-Pick C disease.

Niemann-Pick disease type C (NPC) is an inherited neuro-degenerative disorder associated with intracellular cholesterol trafficking defects. Mutations in two distinct genes, NPC1 and HE1, have recently been shown to cause this disease. We have analysed the NPC1 gene in five German patients with NPC from four unrelated families. We identified a total of five novel mutations in the coding region of the NPC1 gene (G231V, D874V, 1642M, 11094T and R116stop). All affected individuals displayed compound heterozygosity. The mutated alleles were transmitted by the nonaffected parents with the exception of one patient, in whom a de novo mutation (G231V) had occurred. Interestingly, the G231V/P237S NPC1 genotype in this individual is associated with an early-onset form of NPC. In contrast, we found that the D874V/D948N genotype, observed in another NPC patient, is characterized by a late onset of clinical symptoms that presents with a pronounced white-matter disease. Our results will contribute to defining the association between the clinical phenotypes and the genetic abnormalities in Niemann-Pick C disease.

MELAS: a neuropsychological and radiological follow-up study. Mitochondrial encephalomyopathy, lactic acidosis and stroke.

We report on a patient with long standing, full-blown mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS). In contrast to earlier publications, detailed neuropsychological assessment revealed no dementia but a pattern of distinct cognitive deficits with marked impairment of visuo-constructive and executive functions. Focal lesions and progressing atrophy mainly of the basal ganglia and the temporo-parieto-occipital area with preservation of hippocampal and entorhinal structures were present. Furthermore, a 4-year follow-up assessment revealed an increasing deterioration of distinct cognitive functions, including phasic alertness, tactile functions and the discrimination of tone pitch and rhythm. This may be because of chronic regional metabolic disturbances, as there was no further stroke-like episode in that period of time.

[Presenile dementia in polycystic lipomembranous osteodysplasia]. / Präsenile Demenz bei polyzystischer lipomembranöser Osteodysplasie.

We present a 36-year-old woman with a 3-year history of cognitive decline followed by development of a small stepped gait and urinary and fecal incontinence. Workup revealed multiple bone cysts documented by X-ray and idiopathic hyperprolactinoma. An MRI confirmed the CT finding of massive bilateral basal ganglia calcification. This is the first case of polycystic lipomembranous osteodysplasia described in Germany. We conclude that patients with presenile dementia, psychosis, or early-onset Parkinsonism associated with basal ganglia calcification should undergo X-rays of hand and feet to rule out polycystic lipomembranous osteodysplasia.

[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.

[Unruly passengers - resistance to requests by flight attendants]. / Psychisch auffällige Flugpassagiere - Widerstand gegen die Anweisungen des Flugpersonals.

Travelling by airplane is of increasing importance in modern society. Psychiatric disorders seldom cause incidents in aircrafts. Scandal sheets and serious newspapers as well report on disturbances of a flight by psychiatric patients. Up until now psychiatric research is not engaging in unruly flight passengers suffering from psychotic symptoms. We describe a passenger who became psychotic during an international flight. In addition, we provide an overview over publications dealing with unruly passengers due to psychosis and describe similar cases.

[Aphasia and dementia]. / Aphasie und Demenz.

Primary progressive aphasia (PPA) is an uncommon neurodegenerative syndrome characterized by a relatively isolated dissolution of language function at the beginning, followed by deterioration of general cognitive function and of activities of daily living after 2 or more years. On account of neuropathological and clinical findings, PPA is supposed to form part of the spectrum of frontotemporal lobar degeneration. We present a case study of a 66-year-old woman with a probable fluent progressive aphasia. She initially experienced word amnesia and developed after 2 - 3 years gradual regression of word comprehension, over-fluent speech with semantic paraphasias, and at last generalized dementia. In addition to minor bilateral cortical volume reduction on CCT, MRI showed left temporal lobe atrophy involving hippocampus, SPECT revealed reduced uptake left frontal and temporal.

[Single sex or mixed sex treatment in the psychiatric clinic from the viewpoint of patients]. / Getrennt- oder gemischtgeschlechtliche Behandlung in der psychiatrischen Klinik aus Sicht der Patienten.

Patients in a psychiatric hospital were surveyed by questionnaire to evaluate their preferences on separate or mixed-sex treatment. The adjusted response rate was 74.5%. About 75% of the responders preferred a mixed ward and about 25% preferred a single-sex ward. Females more frequently chose the type of ward to which they had been allocated. By contrast, males were in favour of mixed wards, independently of their present type of ward. Younger patients, voluntarily admitted patients, and those with substance addiction preferred mixed-sex wards. After mixing the sexes in formerly single-sex wards, a significant increase in preference of mixed-sex wards was found, due to increased affirmation by female patients. However, about 9% of women and men preferred single-sex treatment. Two open general psychiatric wards, each with 20 beds and separating females and males, could be established in psychiatric hospitals to satisfy this preference.

[Interviews with physicians in private practice as a starting point for quality improvement in hospitals]. / Befragung niedergelassener Arzte als Ausgangspunkt klinikinterner Massnahmen zur Qualitätsförderung.

Subjective criteria gain importance in care research and quality management. Therefore, psychiatrists in private practice and general practitioners working in the catchment area of a psychiatric hospital were surveyed by questionnaire evaluating expectations and satisfaction concerning their collaboration with the hospital. Psychiatrists and general practitioners rated legible interim discharge letters, good in-patient treatment, adequate diagnostics, and direct referral to the hospital as most important. Psychiatrists express dissatisfaction regarding prescription of expensive drugs, lack of involvement in planning new psychiatric institutions, delivery of discharge summaries, referring back the patient after in-patient care, and delay of hospital admission. As conclusion, quality management should pay more attention to ambulatory care physicians' points of view to reduce problems of interaction between clinicians and their colleagues in private practice and to improve the treatment continuity of psychiatric patients.

[Expectations of established neurologists and general practitioners regarding the psychiatric clinic]. / Erwartungen niedergelassener Nervenärzte und Allgemeinärzte an die psychiatrische Klinik.

OBJECTIVE: Psychiatrists' and general practitioners' expectations regarding psychiatric hospitals were evaluated using qualitative methodology. DESIGN: A content analysis was carried out of interviews with 27 psychiatrists and 24 general practitioners. The statements were analysed quantitatively to assess their relative importance. RESULTS: Immediate delivery of discharge summaries and continuous patient-related communication were mentioned most frequently. In addition, psychiatrists assigned much importance to therapy referral after completion of inpatient care and to the prescription of less expensive drugs. Nearly half of all statements related to the communication process between local and clinic physicians, a quarter to aspects of referral, and a quarter to quality of inpatient care. Differences between psychiatrists and general practitioners mainly concerned aspects of medical education. CONCLUSION: Taking into account these findings, more attention should be paid to psychiatrists' and general practitioners' expectations to reduce problems of interaction between clinicians and their colleagues in private practice; this might be helpful to improve the continuity of psychiatric care.

Association of dopamine D3-receptor gene variants with neuroleptic induced akathisia in schizophrenic patients: a generalization of Steen's study on DRD3 and tardive dyskinesia.

Neuroleptic induced akathisia is a common and distressful extrapyramidal side effect of antipsychotic treatment. A significant proportion of the variability of its development has been left unexplained and has to be attributed to individual susceptibility. Since hereditary factors have been discussed in the etiology of acute akathisia (AA), part of the individual susceptibility might be of genetic origin. Moreover, AA is regarded as a forerunner of tardive dyskinesia, a drug-induced chronic movement disorder, which may be associated with homozygosity for the Ser9Gly variant of the DRD3 gene. Considering expression studies, which demonstrated functional variants of DRD3 polymorphisms, we investigated whether homozygosity for the Ser9Gly variant of the DRD3 gene is associated with AA. Homozygosity for the Ser9Gly variant of the DRD3 gene was connected to an 88% incidence of AA as compared with a considerably lower 46.9% incidence of AA in schizophrenic patients nonhomozygous for the 2-2 allele (exact P = 0.0223). Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:187-191, 2000.

[What do general practitioners expect from a psychiatric clinic? Wish for closer cooperation]. / Was erwarten Hausärzte von einer psychiatrischen Klinik? Wunsch nach engerer Zusammenarbeit.

OBJECTIVE: In the present study the views of family doctors on what constitutes "ideal" cooperation with a psychiatric hospital were investigated. METHOD: The views expressed by 24 family doctors and recorded in interviews were analyzed qualitatively with the aim of assessing their importance. RESULTS: Regular exchange of information between family doctor and psychiatrist, prompt receipt of the discharge report, a named contact person on admission and during hospitalization, competent psychiatric inpatient care, and the possibility of being able to directly refer patients were felt to be the most important points. Almost a half of all the views expressed related to intercommunication. CONCLUSION: Psychiatric hospitals should give more consideration to the views and wishes of family doctors as a means to resolving possible problems of interaction and to improving the care afforded mentally sick patients.

Neuroleptic therapy influences basal ganglia activation: a functional magnetic resonance imaging study comparing controls to haloperidol- and olanzapine-treated inpatients.

Functional magnetic resonance imaging (fMRI) is a non-invasive technique for mapping the working brain. Using a fingertapping task, imaging of subcortical regions has proven to be difficult. We studied an inpatient under treatment with olanzapine and haloperidol, focusing on subcortical brain activation. We compared this patient with normal controls and with patients using haloperidol or olanzapine. Brain activation was induced by a unilateral self-paced fingertapping task. Brainvoyager software package (version 3.7) was used for data analyzing. Significant increases in blood oxygen level-dependent response were found in the contralateral motor area and the ipsilateral cerebellum in all patients. Differences with regard to the subcortical regions could be revealed in both the examinations of the same patient and the different treatment groups. Functional magnetic resonance imaging is an important method to study the interaction between basal ganglia, thalamus and the motor cortex. It is especially helpful to investigate intra-individual differences under different treatment conditions.