[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.

[Prevalence of sleep-related breathing disorders of inpatients with psychiatric disorders]. / Prävalenz schlafbezogener Atmungsstörungen bei stationären Patienten mit psychischen Erkrankungen.

BACKGROUND: Sleep-related breathing disorders seriously impair well-being and increase the risk for relevant somatic and psychiatric disorders. Moreover, risk factors for sleep-related breathing disorders are highly prevalent in psychiatric patients. The aim of this study was for the first time in Germany to study the prevalence of obstructive sleep apnea syndrome (OSAS) as the most common form of sleep-related breathing disorder in patients with psychiatric disorders. METHODS: In 10 psychiatric hospitals in Germany and 1 hospital in Switzerland, a total of 249 inpatients underwent an 8­channel sleep polygraphy to investigate the prevalence of sleep apnea in this group of patients. RESULTS: With a conspicuous screening result of 23.7% of the subjects, a high prevalence of sleep-related breathing disorders was found to occur among this group of patients. Male gender, higher age and high body mass index (BMI) were identified as positive risk factors for the detection of OSAS. DISCUSSION: The high prevalence indicates that sleep apnea is a common sleep disorder among psychiatric patients. Although OSAS can lead to substantial disorders of the mental state and when untreated is accompanied by serious somatic health problems, screening procedures are not part of the routine work-up in psychiatric hospitals; therefore, sleep apnea is presumably underdiagnosed in psychiatric patients. In view of the results of this and previous studies, this topic complex should be the subject of further research studies.

[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.

Neurology and psychiatry: waking up to opportunities of sleep. : State of the art and clinical/research priorities for the next decade.

In recent years, evidence has emerged for a bidirectional relationship between sleep and neurological and psychiatric disorders. First, sleep-wake disorders (SWDs) are very common and may be the first/main manifestation of underlying neurological and psychiatric disorders. Secondly, SWDs may represent an independent risk factor for neuropsychiatric morbidities. Thirdly, sleep-wake function (SWF) may influence the course and outcome of neurological and psychiatric disorders. This review summarizes the most important research and clinical findings in the fields of neuropsychiatric sleep and circadian research and medicine, and discusses the promise they bear for the next decade. The findings herein summarize discussions conducted in a workshop with 26 European experts in these fields, and formulate specific future priorities for clinical practice and translational research. More generally, the conclusion emerging from this workshop is the recognition of a tremendous opportunity offered by our knowledge of SWF and SWDs that has unfortunately not yet entered as an important key factor in clinical practice, particularly in Europe. Strengthening pre-graduate and postgraduate teaching, creating academic multidisciplinary sleep-wake centres and simplifying diagnostic approaches of SWDs coupled with targeted treatment strategies yield enormous clinical benefits for these diseases.

[Single or double moral standards? Professional ethics of psychiatrists regarding self-determination, rights of third parties and involuntary treatment]. / Moral oder Doppelmoral? Das Berufsethos des Psychiaters im Spannungsfeld zwischen Selbstbestimmung, Rechten Dritter und Zwangsbehandlung.

The current intensive discussion on the legal and moral aspects of involuntary treatment of psychiatric patients raises a number of ethical issues. Physicians are unambiguously obligated to protect patient welfare and autonomy; however, in psychiatric patients disease-related restrictions in the capacity of self-determination and behaviors endangering the rights of third parties can seriously challenge this unambiguity. Therefore, psychiatry is assumed to have a double function and is also obligated to third parties and to society in general. Acceptance of such a kind of double obligation carries the risk of double moral standards, placing the psychiatrist ethically outside the community of physicians and questioning the unrestricted obligation towards the patient. The present article formulates a moral position, which places the psychiatrist, like all other physicians, exclusively on the side of the patient in terms of professional ethics and discusses the practical problems arising from this moral position.

[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.

[Sleep medicine differential diagnostics in psychiatry and psychotherapy]. / Schlafmedizinische Differenzialdiagnostik in Psychiatrie und Psychotherapie.

Complaints about disturbed sleep or increased daytime sleepiness are among the most frequent symptoms reported to psychiatrists by patients. Such complaints can be symptoms of an underlying psychiatric disorder or indicative of a separate or comorbid sleep disorder. Hence, basic knowledge in the differential diagnosis of sleep medicine pathologies is pivotal for psychiatrists and psychotherapists. In the present overview following a description of the diagnostic methods, the diagnostic work-up according to the major symptomatic clusters, namely disturbances in initiating and maintaining sleep, abnormal nocturnal movements and excessive daytime sleepiness will be presented.

[Lump sum payment system in psychiatry and psychosomatics: concomitant research - quo vadis?]. / Pauschalierendes Entgeltsystem in der Psychiatrie und Psychosomatik : Begleitforschung - quo vadis?

The new lump sum payment scheme for psychiatric and psychosomatic services is coming into force in 2013. This constitutes another step on the way to performance-based financial compensation of inpatient and day hospital treatment in psychiatric and psychosomatic hospitals in Germany. This fundamental change needs to be accompanied by scientific evaluation with regards to its effects. This article reflects on the legal foundations of such evaluations and the current progress of preparation. Furthermore, own approaches for analysing the effects of the new finance scheme are presented.

Chronic insomnia: clinical and research challenges--an agenda.

Chronic insomnia afflicts up to 10% of the population in Western industrialized countries. It is characterized by delayed sleep onset, problems in maintaining sleep, early morning awakening or the feeling of non-restorative sleep coupled with significant daytime impairments on an emotional, social or professional level. It can occur as a co-morbid condition in any other medical or mental disorder, but also as a primary condition. Within the last decade new diagnostic and differential diagnostic approaches have been suggested that enhance diagnostic precision. Epidemiological data and data relating to the health care and cost situation of chronic insomnia suggest a huge burden for society. Chronic insomnia leads to a clear-cut increased risk for psychopathology (i. e., affective disorders) and probably also for cardiovascular and metabolic dysfunction. The pathophysiology of the condition is still poorly understood and will profit from integrating modern neuroscientific approaches (animal studies, molecular biology, neuroimaging, neurophysiology, etc.). Current treatment strategies are mainly based on cognitive behavioural interventions (CBT-I) and hypnotic treatment with benzodiazepine receptor agonists and sedating antidepressants. Although the effectiveness of these treatments has been clearly demonstrated, a substantial proportion of patients proves to be treatment-resistant or profits only poorly. The question of long-term pharmaceutical treatment of chronic insomnia, at least in Europe, is unresolved and urgently needs answers. Novel rational treatment avenues require clues on causes and mechanisms from integrated neuroscientific approaches. The important issues concerning insomnia treatment in the future especially in Europe will be reviewed and discussed critically.

Glucose tolerance in depressed inpatients, under treatment with mirtazapine and in healthy controls.

Impaired glucose tolerance and diabetes have been associated with depression, and antidepressant treatment is assumed to improve impaired glucose tolerance. However, antidepressant treatment is also considered as a risk factor for the development of diabetes. Reports about glucose tolerance under antidepressant treatment frequently lack appropriate control groups. We conducted the oral glucose tolerance test (OGTT) in 10 healthy controls selected from an epidemiological sample with a negative lifetime history of mental Axis I disorder. Controls were carefully matched to a sample of inpatients with major depression that participated in an OGTT before and after antidepressant treatment with mirtazapine. All participants underwent a standard OGTT protocol. In patients, a second (after 2 weeks) and a third (after 4-6 weeks) OGTT was performed under treatment with mirtazapine. Compared to healthy controls, we observed significantly impaired glucose tolerance in acutely depressed patients. Effect size calculation indicated a moderate to large effects on glucose and insulin concentrations in response to an OGTT. Although glucose tolerance improved under mirtazapine treatment, insulin sensitivity was still impaired and remained significantly lower in patients compared to controls.

[The relevance of the TNF-alpha system in psychiatric disorders]. / Die Bedeutung des TNF-alpha-Systems für Erkrankungen des Gehirns.

Changes regarding the immune system and specifically the cytokine system, of which tumor necrosis factor-alpha (TNF-alpha) is a part, have been shown to be involved in the development of neurological and psychiatric disorders such as multiple sclerosis, Parkinson's and Alzheimer's disease, depression, schizophrenia or narcolepsy. Besides, there is evidence that the risk of stroke correlates with the serum concentrations of different cytokines. Additionally, body weight, age and neuroendocrinological mechanism have a strong influence upon plasma levels of TNF-alpha and its soluble receptors (sTNF-Rs). TNF-alpha might contribute to the pathogenesis of these diseases by an activation of the hypothalamo-pituitary-adrenocortical (HPA) axis, an activation of neuronal serotonin transporters, the stimulation of the indoleamine 2,3-dioxygenase which leads to tryptophan depletion, by immunologically mediated destruction of neurons, or neurotoxic release of glutamate. Psychotropic drugs influence the TNF-alpha system, too. During psychopharmacological treatment of schizophrenia, some antipsychotics might act on neurotransmitter metabolism via inducing the proinflammatory cytokine system. Hopefully, these hypotheses may lead to new therapeutical strategies for psychiatric patients in the near future.

Depression, comorbidities and the TNF-alpha system.

Depression has frequently been reported to be associated with other physical diseases and changes in the cytokine system. We aimed to investigate associations between a medical history of depression, its comorbidities and cytokine plasma levels in the Bavarian Nutrition Survey II (BVS II) study sample and in patients suffering from an acute depressive episode. The BVS II is a representative study of the Bavarian population aged 13-80years. The disease history of its 1050 participants was assessed through face-to-face interviews. A sub-sample of 568 subjects and 62 additional acutely depressed inpatients of the Max Planck Institute of Psychiatry participated in anthropometric measurements and blood sampling. Tumor necrosis factor-alpha (TNF-alpha) and soluble TNF receptor (sTNF-R) p55 and sTNF-R p75 plasma levels were measured using enzyme-linked immunosorbent assays. A history of depression was associated with a higher incidence of high blood pressure, peptic ulcer, dyslipoproteinemia, osteoporosis, allergic skin rash, atopic eczema and thyroid disease. Within the BVS II sample, participants with a history of depression differed from subjects who had never had depression with regard to sTNF-R p55 and sTNF-R p75 levels even when controlling for age, BMI and smoking status. Acutely depressed inpatients showed even higher levels of sTNF-R p55 and sTNF-R p75 than subjects in the normal population. TNF-alpha levels were also significantly elevated in acutely depressed patients. These results confirm earlier studies regarding the comorbidities of depression and support the hypothesis that activation of the TNF-alpha system may contribute to the development of a depressive disorder.

The effects of sleep and sleep deprivation on metabolic, endocrine and immune parameters.

Sleep curtailment is becoming widespread in modern society. In parallel with this, more and more studies are dealing with the health consequences of sleep deprivation. This short review focuses on the main results of studies examining the effects of sleep and sleep deprivation on metabolism with extra emphasis on appetite regulation, and on the endocrine and immune system.

Improvement of cognitive functions in chronic schizophrenic patients by recombinant human erythropoietin.

Schizophrenia is increasingly recognized as a neurodevelopmental disease with an additional degenerative component, comprising cognitive decline and loss of cortical gray matter. We hypothesized that a neuroprotective/neurotrophic add-on strategy, recombinant human erythropoietin (rhEPO) in addition to stable antipsychotic medication, may be able to improve cognitive function even in chronic schizophrenic patients. Therefore, we designed a double-blind, placebo-controlled, randomized, multicenter, proof-of-principle (phase II) study. This study had a total duration of 2 years and an individual duration of 12 weeks with an additional safety visit at 16 weeks. Chronic schizophrenic men (N=39) with defined cognitive deficit (>or=1 s.d. below normal in the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)), stable medication and disease state, were treated for 3 months with a weekly short (15 min) intravenous infusion of 40,000 IU rhEPO (N=20) or placebo (N=19). Main outcome measure was schizophrenia-relevant cognitive function at week 12. The neuropsychological test set (RBANS subtests delayed memory, language-semantic fluency, attention and Wisconsin Card Sorting Test (WCST-64) - perseverative errors) was applied over 2 days at baseline, 2 weeks, 4 weeks and 12 weeks of study participation. Both placebo and rhEPO patients improved in all evaluated categories. Patients receiving rhEPO showed a significant improvement over placebo patients in schizophrenia-related cognitive performance (RBANS subtests, WCST-64), but no effects on psychopathology or social functioning. Also, a significant decline in serum levels of S100B, a glial damage marker, occurred upon rhEPO. The fact that rhEPO is the first compound to exert a selective and lasting beneficial effect on cognition should encourage new treatment strategies for schizophrenia.