[A female patient with late-onset schizophrenia and fear of Katwijk disease]. / Een patiënte met laat ontstane schizofrenie en angst voor de Katwijkse ziekte.

A 66-year-old patient had suffered from late-onset schizophrenia from the age of 44. Her family history included reports of brain haemorrhages, possibly resulting from hereditary amyloidal angiopathy of the Dutch type (Katwijk disease). She was very afraid for having this disease. The progression of the psychiatric symptoms and the age at which they began, led us to suspect an organic process. Differential diagnoses that were discussed included cerebral amyloidal angiopathy, frontal lobe dementia and Huntington's disease.

[Psychiatric research of the ability to drive after driving under influence of alcohol: description of 101 offenders and recommendations for prevention]. / Onderzoek naar rijgeschiktheid door de psychiater na rijden onder invloed; beschrijving van 101 overtreders en aanbevelingen voor preventie.

BACKGROUND: Driving under influence of alcohol is very likely to lead to traffic accidents. Nowadays, fewer people are driving under influence of alcohol, probably because of law enforcement and information campaigns: however, the number of serious offenders (alcohol blood level > 1,3 per thousand upon arrest) and recidivists is on the increase. These serious offenders and recidivists are obliged to submit to an examination by a psychiatrist. AIM: To determine the characteristics of the serious offenders and recidivists who have to be examined by a psychiatrist and to improve current preventive measures. METHOD: By studying the files of 101 offenders, we had access to personal characteristics, circumstances of the arrest, alcohol anamnesis, laboratory research results, and to physical and psychiatric research and results. By means of descriptive statistics we were able to identify characteristics of the group and, where possible, to compare these with the characteristics of the general population. RESULTS: The group consisted mainly of men aged about 40 from the lower social classes who had been arrested for their deviant driving behaviour or for causing traffic accidents. Of these persons 92% were alcohol abusers or were alcohol dependent and, fairly often, had comorbid psychiatric problems as well. CONCLUSION: Preventive measures can be further improved by an increase in social control, more rapid detection of deviant driving behaviour, appropriate and prompt treatment of alcohol problems and comorbidity associated with such problems.

Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses?

OBJECTIVE: The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses. THEORY: On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality. METHODS: Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire. RESULTS: The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation ('age') and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales. CONCLUSIONS: The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national 'schizophrenia standard' (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.

A tentative model of aggression on inpatient psychiatric wards.

Violence in psychiatric hospitals threatens the safety and well-being of patients and staff members. The determinants and correlates of inpatient aggression are not well understood. The authors present an explanatory model of aggressive behavior that attempts to integrate patient, staff, and ward variables. In the proposed model, the patient's psychopathology and distorted cognitions are exacerbated by environmental and communication stressors found on psychiatric wards. The model emphasizes that repeated inpatient aggression may be the result of a vicious circle, whereby a patient's violent behavior is often followed by an increase in stress on the patient caused by environmental or communication factors, heightening the risk of another outburst of violence.

A randomized, double-blind study of fluoxetine and maprotiline in the treatment of major depression.

In a six-week double-blind randomized trial, preceded by a one-week single-blind placebo treatment, the efficacy and the side-effects of fluoxetine (40-80 mg/d) (n = 30) and maprotiline (50-150 mg/d) (n = 35) were compared in hospitalized patients with DSM-III Major Depression without psychotic features. Efficacy was measured by means of the Hamilton Depression Rating Scale, the Raskin Depression Scale, the Covi Anxiety Scale, and a Clinical Global Impression. Side-effects were evaluated by an Adverse Events Scale. A statistically significant improvement was achieved in both treatment groups but success rates were modest. No differences in efficacy were found between the two groups. In addition, no statistically significant differences were found between the two groups either in frequency or in severity of adverse events. In fact, the only statistically significant difference found was in weight change: weight loss in the fluoxetine group and weight gain in the maprotiline group.

Double blind comparative study of remoxipride and haloperidol in acute schizophrenic patients.

In the present 6-week double-blind, randomised, multicentre study, the atypical neuroleptic remoxipride was compared to haloperidol in acute schizophrenic patients (DSM-III). Seventy-one patients entered the study, 36 in the remoxipride group and 35 in the haloperidol group. There were ten early withdrawals, four in the remoxipride group and six patients in the haloperidol group. The Present State Examination (PSE) profile revealed a similar reduction in the symptom clusters of psychosis in both treatment groups. Forty-seven per cent of the patients in the remoxipride group and 34% of the patients in the haloperidol group showed clinically relevant improvement (reduction of BPRS total score greater than or equal to 50%). All extrapyramidal symptoms except "glabella tap" occurred significantly less frequently in the remoxipride group as compared to the haloperidol group. Substantially lower incidences of EPS were found by active questioning in the remoxipride group compared to the haloperidol group. In addition, considerably lower incidences were observed in the remoxipride group with respect to drowsiness/somnolence, tiredness/fatigue and concentrating difficulty. At the end of treatment 66% of the patients in the haloperidol group and 22% in the remoxipride group were using anticholinergics. No consistent changes were found in the mean plasma HVA level in either treatment group. In responders (reduction of BPRS total score greater than or equal to 50%) lower baseline HVA levels were observed in both treatment groups. This study indicates that the newly developed neuroleptic remoxipride is an effective antipsychotic compound, which is clinically safe and well tolerated. In particular, few EPS were induced by remoxipride, as compared to haloperidol.

A double-blind comparative study of remoxipride and haloperidol in acute schizophrenia.

Seventy-one patients were entered into a multicentre, double-blind randomized study to compare the efficacy and safety of remoxipride with those of haloperidol in the acute treatment of schizophrenia or schizophreniform disorder. The patients, who were well-matched regarding demographic characteristics, were aged 18-64 years. Four patients in the remoxipride group and 6 in the haloperidol group discontinued treatment prematurely. The mean daily doses during the last week of treatment were 363 mg remoxipride and 9 mg haloperidol. At this time 22% of patients on remoxipride and 66% of those on haloperidol were taking anticholinergics (p less than 0.001). The clinical efficacy was similar in both groups as judged by Present State Examination (PSE) profile and Brief Psychiatric Rating Scale (BPRS) ratings. Several adverse symptoms occurred significantly more frequently during treatment with haloperidol than with remoxipride, particularly where extrapyramidal symptoms were concerned. No clinically relevant changes occurred in the laboratory tests in either group.