[At the boundaries of self-determination: ethical and juridical dimensions of involuntary abortion and sterilization]. / De grenzen van zelfbeschikking: ethische en juridische dimensies van onvrijwillige abortus en sterilisatie.

A young woman, diagnosed with schizophrenia, was admitted to a psychiatric clinic with an acute relapse of her illness. Two months later, while still at the clinic, she was found to be pregnant. Due to her illness she was not considered competent to decide whether to have an abortion. Treatment was complicated by the chronic nature of her illness, a total lack of family and social support and mild mental retardation. Eventually she gave birth to a healthy baby and then was sterilized with the consent of her guardian. Ethical and juridical aspects are discussed here.

Life expectancy following psychogeriatric reactivation. Identification of prognostic characteristics of survival assessed on admission.

OBJECTIVES: To estimate life expectancy of psychogeriatric patients having participated in a reactivation program. To identify prognostic characteristics - on admission - for survival after discharge. DESIGN: A prospective, clinical-empirical observational study. SETTING: A Dutch psychiatric-skilled nursing home. PARTICIPANTS: Psychogeriatric patients (n = 75) suffering from very mild to moderate cognitive function disorders in conjunction with psychiatric function disorders. INTERVENTION: Interdisciplinary reactivation program. MEASUREMENTS: General, functional and diagnostic patient characteristics assessed on admission for the psychogeriatric reactivation program, and survival rate after discharge over a period of 7 years. RESULTS: The probability of survival for patients who were discharged from the psychogeriatric reactivation program to their own homes or to a residential home with restricted support ('independent' group, n = 53) was higher (1/HR = 3.2) than for patients who were discharged to a nursing home ('dependent' group, n = 22). The median survival period of the reference group (community-dwelling elderly people) was 95 months (95% confidence interval, CI: 74-116), that of the 'independent' group 35 months (95% CI: 25-45) and that of the 'dependent' group 13 months (95% CI: 3-22). For the reactivated patients (n = 75), gender was the only general characteristic of prognostic value for survival after discharge (the survival rate for women was higher; hazard ratio (HR) = 3.07; 95% CI: 1.61-5.85). Age was statistically insignificant. One functional characteristic, the Global Deterioration Scale, was of prognostic significance (HR = 1.58; 95% CI: 1.11-2.23). The diagnostic characteristics of prognostic significance were: psychiatric function disorders (paranoia; HR = 2.19; 95% CI: 1.11-4.28), somatic comorbidity (urogenital pathology; HR = 1.83; 95% CI: 1.13-2.94; cardiopulmonary pathology; HR = 1.56; 95% CI: 1.16-2.07) and adequacy of the caregiver system (HR = 0.59; 95% CI: 0.33-1.03). The specific diagnostic classifications of cognitive function disorders (DSM-IV) were not of prognostic significance. It was possible to account for 32% of the variance in survival after discharge. CONCLUSION: The survival rate of the 'independent' group of patients was obviously higher (1/HR = 3.2) than that of the 'dependent' group. There was no overlap in the 95% CI of the median survival period after discharge. The results suggest that with respect to survival the two groups of psychogeriatric patients who participated in the intensive reactivation program differed definitely. Additionally, patients belonging to the 'independent' group had a greater chance to benefit from a reactivation program. The program should pay special attention to the patient characteristics on admission, which demonstrated a significant negative correlation to survival. These patient characteristics belonged to five domains (i.e. gender, cognitive function disorders, psychiatric function disorders, somatic comorbidity and adequacy of the caregiver system) The five dimensions are of clinical interest for optimizing the selection of patients who may derive most benefit from a reactivation program. The development of a valid prognostic instrument is a prerequisite for optimal medical decision-making for such intensive intervention programs, as is the analysis of cost-effectiveness. In order to draw firm conclusions, it is recommended that a large-scale study with a randomized, parallel-group design will be performed. Our group has started such a research program in July 2001.

Psychogeriatric reactivation in a psychiatric-skilled nursing home: a clinical-empirical exploration.

OBJECTIVE: To identify prognostic characteristics for the probability of discharge of psychogeriatric patients with functional-psychiatric pathology, in order to optimize patient selection for the reactivation programme. METHODS AND MATERIALS: A retrospective, clinical, empirical study in a Dutch psychiatric nursing home. A group of 102 patients, consecutively enrolled in a psychogeriatric reactivation programme and who met the inclusion and exclusion criteria, was retrospectively examined. The general, functional and diagnostic characteristics were assessed at baseline. RESULTS: The general characteristics of the reactivation-programme patients were not of prognostic value. However, functional characteristics (GDS, HI and ADL score) were prognostically important. In addition, diagnostic characteristics were identified within the following four domains: cognitive function disorder, functional-psychiatric pathology, an inadequate caregiver system at home, and somatic comorbidity. The prognostic value of the specific diagnostic classification of cognitive function disorders (with the exception of delirium) was irrelevant. CONCLUSION: Reactivation seems a promising programme for frail, elderly psychogeriatric patients with functional-psychiatric pathology, but without substantial deterioration of cognitive function disorders and self-care deficits. It proved possible to make advance estimates of the probability of discharge for such patients, which is of clinical interest. Before a reliable and valid prognostic instrument can be constructed, the patients' functional and diagnostic characteristics should be prospectively assessed. Ideally, a study with a randomized, controlled, parallel group design would be used for this purpose.

[Epidemiology of attempted suicide in The Hague]. / Epidemiologie van parasuïcide in Den Haag.

OBJECTIVE: To estimate the incidence of parasuicide in a metropolitan area and to identify subgroups of individuals with the purpose of developing secondary preventive strategies. DESIGN: Longitudinal prospective case register study (1987-1993). METHOD: In the city of the Hague, the Netherlands, all individual contacts concerning parasuicidal behaviour were registered by the participating facilities i.e., hospitals, community mental health organizations and emergency services. Demographic and case-related information was recorded. Record linkage of the anonymized data including those of the municipal coroner concerning suicide was done by the project administration for longitudinal monitoring. RESULTS: Over the registration period of 7 years (1987-1993) 4458 parasuicidal acts were recorded involving 3333 individuals. The age and sex distribution was in accordance with formerly published national and local data, but the real numbers of parasuicide rates were 50-100% higher than those usually presented in the literature. Repetition of parasuicide during an average follow-up period of 3.8 years occurred in 18.2% of all cases and the repetition rate increased over time. The suicide risk within a year after the last registered parasuicide came to 1.5% for men as well as women, and that within four years to 1.9% for women and 2.9% for men. Men and women with a history of three or more acts of parasuicide had a suicide risk of over 5% in a follow-up period of 4 years. The incidence of parasuicide was highest in the younger age groups of non-European women (including Turkish women), in particular those with an ethnocultural background in Surinam.

[Comments on a case of physician-assisted suicide of a patient with an organic psychiatric disorder]. / Kanttekeningen bij een casus over hulp bij zelfdoding bij een patiënt met een organisch-psychiatrische stoornis.

Well-documented case histories concerning the role of physicians in assisted suicide are rarely published in medical journals even in the Netherlands; this applies in particular if the patient's suffering is mainly due to a psychiatric disorder. In this issue physician-assisted suicide is described in a patient suffering from a psycho-organic disorder. The case illustrates the problems the attending physician encountered in his decision-making process against the background of the actual professional views and the legal regulations in the Netherlands. When the doctor's considerations as well as his actions are discussed with reference to the official criteria and regulations, the conclusion is that notwithstanding some minor procedural inconsistencies, he acted in accordance with the accepted medical, ethical, and legal standards in this country.

Risk of left ventricular dysfunction in patients with probable Alzheimer's disease with APOE*4 allele.

OBJECTIVE: To examine the association between the APOE genotype and cardiovascular disease in Alzheimer's disease (AD) patients. DESIGN: Case register study of 100 consecutive referrals to a Memory Clinic where type of dementia and cardiovascular comorbidity were diagnosed and APOE genotype was determined. SETTING: The Memory Clinic, University Hospital Rotterdam Dijkzigt. PARTICIPANTS: One hundred Memory Clinic patients, 59 to 91 years of age, who attended the Memory Clinic in the period between January 1994 and March 1996. MEASUREMENTS: Relative risk of cardiovascular morbidity in probable AD, based on clinical and ECG findings. RESULTS: The diagnosis of probable AD was more frequent in APOE*4 allele-carrying AD patients. When comparing homozygotes for APOE*4 with homozygotes for APOE*3, a nine-fold increase in prevalence of cardiac ischemia on ECG was found in the former. When grouping parameters of left ventricular dysfunction, the prevalence was 7.2 (95% confidence interval 1.2-42.6) times greater in probable Alzheimer patients with APOE4/4. CONCLUSIONS: In patients with probable AD, APOE*4 is associated with cardiac disease indicative of left ventricular dysfunction.

Abnormal amino acid metabolism in patients with early stage Alzheimer dementia.

Plasma levels of several amino acids were studied in 14 patients with early stage probable Alzheimer's disease (AD) and 17 age-matched controls. In the AD patients a possible relationship between amino acid levels and behavioural symptomatology was also investigated. We found significantly reduced levels of tryptophan and methionine in plasma samples from the AD patients compared to the control subjects. Moreover, plasma tyrosine/large neutral amino acids (LNAA) ratio and the ratio of plasma taurine and the product of the plasma levels of methionine and serine (TSM-ratio) were significantly increased in the AD patients in comparison with the controls. However, no difference was found in plasma tryptophan/LNAA ratio and in homocysteine levels between both groups. Concerning the behavioural symptomatology no significant correlation was found between the Reisberg Behave AD scale and plasma amino acid levels or ratios. The reported findings suggest that abnormal amino acid metabolism is present in the early stages of AD. We hypothesize that this abnormality could play a role in the pathogenesis of behavioural changes occurring in later stages of AD.

A study of familial aggregation of depression, dementia and Parkinson's disease.

Depression is often accompanied by other disorders including Alzheimer's disease and Parkinson's disease. We studied the familial aggregation of these disorders in order to examine the possibility of a shared genetic origin. In a population-based study of 6596 subjects, we studied the association of self-reported depression, which required treatment by a psychiatrist, to family history of psychiatric disease, dementia, and Parkinson's disease. A family history of psychiatric disease was significantly associated with overall depression as well as with unipolar (n = 303 patients) and bipolar (n = 27 patients) depression. The risk of unipolar depression was associated with the presence of two or more demented individuals among their first degree relatives (e.g. parents, siblings and children). Since there was no evidence for familial aggregation in subjects with only one demented relative, our study suggests that unipolar depression may be associated specifically to a strongly familial, form of dementia. The risk of bipolar depression was increased for those with one or more relatives with dementia and, perhaps, for those with relatives with Parkinson's disease. The familial aggregation of depression with dementia and perhaps Parkinson's disease suggests that there may be shared susceptibility gene(s) underlying these diseases. Our study indicates further that there may be differences in the genetic etiology between unipolar and bipolar depression.

Physician-assisted death in psychiatric practice in the Netherlands.

BACKGROUND: In 1994 the Dutch Supreme Court ruled that in exceptional instances, physician-assisted suicide might be justifiable for patients with unbearable mental suffering but no physical illness. We studied physician-assisted suicide and euthanasia in psychiatric practice in the Netherlands. METHODS: In 1996, we sent questionnaires to 673 Dutch psychiatrists - about half of all such specialists in the country - and received 552 responses from the 667 who met the study criteria (response rate, 83 percent). We estimated the annual frequencies of requests for physician-assisted suicide by psychiatrists and actual instances of assistance. RESULTS: Of the respondents, 205 (37 percent) had at least once received an explicit, persistent request for physician-assisted suicide and 12 had complied. We estimate there are 320 requests a year in psychiatric practice and 2 to 5 assisted suicides. Excluding those who had ever assisted, 345 of the respondents (64 percent) thought physician-assisted suicide because of a mental disorder could be acceptable, including 241 who said they could conceive of instances in which they themselves would be willing to assist. The most frequent reasons for refusing were the belief that the patient had a treatable mental disorder, opposition to assisted suicide in principle, and doubt that the suffering was unbearable or hopeless. Most, but not all, patients who had been assisted by their psychiatrists in suicide had both a mental disorder and a serious physical illness, often in a terminal phase. Thirty percent of the respondents had been consulted at least once by a physician in another specialty about a patient's request for assisted death. The annual number of such consultations was estimated at 310, about 3 percent of the estimated 9700 requests for euthanasia or physician-assisted suicide in medical practice. CONCLUSIONS: Explicit requests for physician-assisted suicide are not uncommon in psychiatric practice in the Netherlands, but these requests are rarely granted. Psychiatric consultation for medical patients who request physician-assisted death is relatively rare.

A randomized trial of geriatric liaison intervention in elderly medical inpatients.

OBJECTIVE: The aim of this study was to examine the effect of psychogeriatric intervention in a group of elderly medical inpatients over 75 years of age. In addition to usual care, intervention consisted of multidisciplinary joint treatment by a psychogeriatric team. The main purpose of intervention was to obtain the optimal level of physical functioning. METHOD: In a prospective randomized trial the effect of the intervention (N = 140) compared with usual care (N = 97) was estimated for physical functioning, length of stay, and nursing home placement within 12 months of discharge. RESULTS: Substantially more patients assigned to the intervention group improved in their physical functioning, and fewer became worse. The mean length of stay was 5 days shorter for the intervention group. There were more readmissions to hospital in the usual care group (29.9%) compared with the intervention group (17.4%). Of the patients assigned to the intervention treatment, 18% were admitted to a nursing home. In the usual care group this was 27%. The effects of intervention remained statistically significant for all the outcome variables after controlling for possible confounding baseline characteristics. CONCLUSIONS: The intervention we studied had clinically relevant effects on important outcome variables. Psychiatric co-morbidity was an important risk factor for the outcome of the patients in our study. By combining elements from a psychiatric and geriatric consultation service with elements from a unit-driven service, we were able to improve health care for the elderly in our hospital in a feasible and cost-effective way.

Alcohol abuse among general hospital inpatients according to the Munich Alcoholism Test (MALT).

The aim of this study was to assess the prevalence of alcohol abuse in a general hospital inpatient population. The study population consisted of 1138 consecutive admissions to three surgical and two medical wards of the University Hospital Rotterdam during a 6-month period. According to the Munich Alcoholism Test (MALT), 7.7% of the patients were identified as having an alcohol problem, but only 0.6% had alcohol abuse recorded as a discharge diagnosis by the Central Medical Registration Unit. In comparison to nonalcoholic patients, alcoholics more often were male and less than 65 years old. They more frequently reported that they lived alone, had prematurely left school, and were unemployed. With regard to medical characteristics, alcoholic patients more often suffered from neurological diseases and intoxication. Compared with nonalcoholics they more frequently had a psychiatric history, and drug abuse and smoking were more prevalent in this group. The alcoholic and nonalcoholic patients did not differ with regard to use of psychotropic medication, although the former more often used vitamins. Based on the above-mentioned discriminating features, the percentages of correctly classified alcoholic patients and nonalcoholic patients were 74% and 73%, respectively, with an overall percentage of 73%.

Trait-anxiety and achievement motivation are positively correlated with memory performance in patients who visit a geriatric outpatient clinic with amnestic symptoms.

Memory performance was studied in relation to anxiety and achievement motivation in a sample of 35 patients who were referred to a geriatric outpatient clinic for their complaints of memory dysfunction. State-anxiety appeared not to be associated with memory performance or the severity of dementia. Trait-anxiety and achievement motivation were associated positively with memory performance and negatively with the severity of dementia. The evaluation of anxiety symptoms in the assessment of dementia is recommended.

Value of the Mini-Mental State Examination and informants' data for the detection of dementia in geriatric outpatients.

The Dutch version of the Mini-Mental State Examination was administered to 138 elderly patients who were referred to a geriatric outpatient clinic for a variety of reasons. An optimal cut-off point of 24/25 was found for the detection of dementia. At this cut-off point, the Mini-Mental State Examination was 87.6% sensitive and 81.6% specific in detecting dementia. The discriminative validity was influenced by education and by the presence of psychiatric disorders other than dementia. Informants' data showed better sensitivity and specificity than the Mini-Mental State Examination for the detection of dementia. The findings suggest that informants' data are a primary source of information for the detection of dementia in geriatric outpatients.

Mental illness, neuroticism and life events in a Dutch village sample: a follow-up.

In a 5-year follow-up of 32 patients identified during a survey of a Dutch village in 1969, approximately two-thirds were found to have recovered. This result was reflected in the scores on a self-reporting questionnaire. A control group showed little change over those years. The persistence of psychiatric problems was related to life experience, as measured by a life-event interview.