Long-term reduction of seclusion and forced medication on a hospital-wide level: Implementation of an open-door policy over 6 years.

BACKGROUND: Psychiatric inpatient treatment is increasingly performed in settings with locked doors. However, locked wards have well-known disadvantages and are ethically problematic. In addition, recent data challenges the hypothesis that locked wards provide improved safety over open-door settings regarding suicide, absconding and aggression. Furthermore, there is evidence that the introduction of an open-door policy may lead to short-term reductions in involuntary measures. The aim of this study was to assess if the introduction of an open-door policy is associated with a long-term reduction of the frequency of seclusion and forced medication. METHOD: In this 6-year, hospital-wide, longitudinal, observational study, we examined the frequency of seclusion and forced medication in 17,359 inpatient cases admitted to the Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken (UPK) Basel, University of Basel, Switzerland. In an approach to enable a less restrictive policy, six previously closed psychiatric wards were permanently opened beginning from August 2011. During this process, a systematic change towards a more patient-centered and recovery-oriented care was applied. Statistical analysis consisted of generalized estimating equations (GEE) models. RESULTS: In multivariate analyses controlling for potential confounders, the implementation of an open-door policy was associated with a continuous reduction of seclusion (from 8.2 to 3.5%; ηp2=0.82; odds ratio: 0.88) and forced medication (from 2.4 to 1.2%; ηp2=0.70; odds ratio: 0.90). CONCLUSION: This underlines the potential of the introduction of an open-door policy to attain a long-term reduction in involuntary measures.

[Time for Change: What We can Learn from the USA about Primary Care of the Depressed Elderly]. / Zeit für Veränderung ­ Was wir für die hausärztliche Versorgung älterer depressiver Menschen von den USA lernen können.

Depression is a common psychiatric disorder in older people. It is often accompanied by comorbid somatic conditions, and affected patients become frequent users of the health care system. Due to its relevance not only for the individual but also for society, reflection on the current health care service and optimization possibilities for the depressed elderly seems important and necessary. Mostly, the general practitioner is not only the first point of contact, but is also responsible for the entire treatment of depression. Due to the limited possibilities of primary care, for several years, there have been collaborative care programs in the USA that provide an optimized networking and collaboration between different health care providers and use specially trained care managers to support the usual primary health care service with short behavioral interventions. In Germany, there are also new approaches and models to improve the health care service for the depressed elderly, but these require further evaluation.

[Cognitive Behavioral Therapy for Anxiety and Depression in Patients with Parkinson's Disease]. / Kognitive Verhaltenstherapie von Angst und Depression bei Patienten mit Morbus Parkinson.

Non-motor symptoms in patients with Parkinson's disease (PD) are gaining more and more interest. Diagnosis of mental disorders in particular, such as anxiety and depression, are often not a part of the professional's diagnostic procedure in spite of the high prevalence rate. To provide these patients with comprehensive treatment, proper diagnosis and appropriate therapy are required. Cognitive Behavioral Therapy (CBT) has been one of the most efficient therapies for anxiety and depression, also in a group setting. This review compares studies that examined patients with PD diagnosed with anxiety disorders and/or depression. In eight studies, CBT in an individual setting was assessed. Three of these had a single case study design, three did not have a control group and two were randomized controlled trials. Two interventions were telephone-based and two were in a group therapy setting. Several results indicate that there is a decline in depressive symptoms as well as anxiety after CBT. There are very few randomized controlled studies on this issue. The efficacy of group treatment needs to be investigated better in order to offer patients effective treatment, keeping in kind their special circumstances.

[German Translation and Validation of the Scale for Evaluation of Neuropsychiatric Disorders in Parkinson's disease (SEND-PD)]. / Deutsche Übersetzung und Validierung der Checkliste zur Erfassung neuropsychiatrischer Störungen bei Parkinsonerkrankung (CENS-PE).

OBJECTIVE: The aim of the present study was to validate and provide a German version of the Scale for Evaluation of Neuropsychiatric Disorders in Parkinson's disease (SEND-PD) of Martínez-Martín et al. (2012). METHOD: The German version of the SEND-PD was evaluated in a sample consisting of 96 patients with Parkinson's disease (PD) (mean age: 65.3 years ±â€Š9.6, 29 female). This scale includes 12 items, representing the domains psychotic symptoms, mood/apathy and impulse control disorders. Reliability and validity analyses were conducted. RESULTS: The examined patients presented a few neuropsychiatric symptoms. Explorative factor analyses identified the proposed three dimensions solution. The items of the mood/apathy domain were homogenous and selective, and the domain showed acceptable internal consistency. For the other two domains, the values were only partially acceptable. Convergent, discriminate and construct validity were shown. CONCLUSION: The German version of the SEND-PD is sufficiently reliable and valid to be adopted in German speaking countries. However, since patients showed only a few symptoms in the dimensions of psychotic symptoms and impulse control disorders, these two domains can be evaluated only to a limited extent.

[German translation and validation of the Stress Appraisal Measure (SAM)]. / Deutsche Übersetzung und Validierung des Stress Appraisal Measure (SAM).

OBJECTIVE: In the present study, the German-language version of the Stress Appraisal Measure (SAM) by Peacock and Wong was validated in a student population. SAM is a relatively short questionnaire (28 items) that evaluates a current, stress-triggering event. The theoretical background is provided by the stress model of Lazarus and Folkman. METHOD: 85 students (age: 23; 59 female, 26 male) were exposed to two stress scenarios in order to test whether they were suited to provoke stress. A factor analysis was performed and the internal consistency of the seven SAM scales was determined. In addition, the convergent validity of SAM with State and Trait Anxiety Inventory (STAI), Coping Inventory for Stressful Situations (CISS) and specific emotion scales was investigated via Pearson's product-moment correlation. RESULTS: The two stress scenarios were suited to evoke stress. The factor structure and the internal consistency of the individual scales, as well as the convergent validity of SAM were replicated with minor limitations in the present German version. Some items (especially from the fifth factor) were only replicated partially. CONCLUSION: SAM can also be employed in the German language version.

[Domestic violence against women of a crisis intervention population - forms of violence and risk factors]. / Häusliche Gewalt bei Frauen einer Kriseninterventionspopulation - Formen der Gewalt und Risikofaktoren.

UNLABELLED: BACKGROUND AND HYPOTHESES: Domestic violence is common and can lead to severe physical and psychological problems. Thus, we have investigated the frequency of occurrence, forms and risk factors of domestic violence against female patients on a crisis intervention ward. METHODS: 115 women were screened with the "screening spouse violence" (SPG) and the "index of spouse abuse" (ISA). RESULTS: The life time prevalence concerning spouse violence was 70 %. Out of 74 women who were currently living in a relationship 28 (38 % )were victims of violence in the last 12 months prior to their admission. Women who experienced violence had a significantly lower level of education. CONCLUSION: Screening for domestic violence in female patients in the field of crisis intervention and psychiatry should become a standard of "good clinical practice".

Insular volume abnormalities associated with different transition probabilities to psychosis.

BACKGROUND: Although individuals vulnerable to psychosis show brain volumetric abnormalities, structural alterations underlying different probabilities for later transition are unknown. The present study addresses this issue by means of voxel-based morphometry (VBM). METHOD: We investigated grey matter volume (GMV) abnormalities by comparing four neuroleptic-free groups: individuals with first episode of psychosis (FEP) and with at-risk mental state (ARMS), with either long-term (ARMS-LT) or short-term ARMS (ARMS-ST), compared to the healthy control (HC) group. Using three-dimensional (3D) magnetic resonance imaging (MRI), we examined 16 FEP, 31 ARMS, clinically followed up for on average 3 months (ARMS-ST, n=18) and 4.5 years (ARMS-LT, n=13), and 19 HC. RESULTS: The ARMS-ST group showed less GMV in the right and left insula compared to the ARMS-LT (Cohen's d 1.67) and FEP groups (Cohen's d 1.81) respectively. These GMV differences were correlated positively with global functioning in the whole ARMS group. Insular alterations were associated with negative symptomatology in the whole ARMS group, and also with hallucinations in the ARMS-ST and ARMS-LT subgroups. We found a significant effect of previous antipsychotic medication use on GMV abnormalities in the FEP group. CONCLUSIONS: GMV abnormalities in subjects at high clinical risk for psychosis are associated with negative and positive psychotic symptoms, and global functioning. Alterations in the right insula are associated with a higher risk for transition to psychosis, and thus may be related to different transition probabilities.

[Patients in intensive care after a suicide attempt with legal drugs - risk profile and course]. / Patienten mit Intensivpflichtigen Medikamentösen Suizidversuchen - Risikoprofil und Verlauf.

Little is known about the risk profile and the further history of patients who attempted suicide by severe medicinal intoxication.All patients residing in Basel (n = 190) admitted to the intensive care unit between 01/01/1998 and 12/31/2001 because of a suicide attempt with legal drugs were investigated regarding psychopathology and sociodemographic features. Also, until the end of 2005, further suicide attempts as well as potential cases of death were followed up.All 190 patients had psychiatric disorders. Compared to the general population, female sex, single status, low educational level, unemployment and invalidity were found significantly more often. Until the end of 2005 almost half of 118 patients followed up in our outpatient department committed further suicide attempts. 28 patients died, 6 of these by suicide.These patients should preferably not be prescribed medication with a low therapeutic range and they should receive intensive follow-up care.

Assessing the opinions and experiences of German-speaking psychiatrists regarding necessary changes for the 11th revision of the mental disorders chapter of the International Classification of Disorders (ICD-11).

We performed an Internet-based questionnaire survey of the opinions of German-speaking psychiatrists regarding the experiences with the 10th revision of the international classification of mental disorders (chapter F of ICD-10). We received 304 completed questionnaires including more than 500 free-text comments. The responding group was characterized by professionally experienced middle-aged psychiatrists. German-speaking psychiatrists were comparatively content with ICD-10. Most diagnostic categories received a "satisfied" or "very satisfied" rating by the majority of respondents. Negative "goodness of fit" ratings--a possible indicator of the need for revision--were not higher than 50% for any category. Based on free-text entries, neurasthenia was the single diagnostic category most often suggested for deletion in ICD-11. Changes were considered necessary mainly for dementias and personality disorders. Adult attention deficit disorder and narcissistic personality disorder were the two diagnostic categories most frequently suggested to be added as new categories. This study provides valuable information related to perceived clinical utility of the classification, though with a narrow sample. Information about clinicians' experiences should be combined with scientific evidence for the revision process of ICD-11.

Neuroimaging predictors of transition to psychosis--a systematic review and meta-analysis.

OBJECTIVES: In early stage psychosis research the identification of neurobiological correlates of vulnerability to schizophrenia is an important hurdle. METHODS: We systematically reviewed the neuroimaging publications on high-risk subjects with subsequent transition to psychosis (HR-T) and conducted a meta-analysis calculating the effect size Cohen's d. RESULTS: Out of 30 identified studies 25 met the inclusion criteria. Structural (s)MRI studies showed small to medium effect sizes of decreased prefrontal, cingulate, insular and cerebellar gray matter volume in HR-T compared to high-risk subjects without transition (HR-NT). Meta-analysis revealed relatively larger whole brain volumes in HR-T compared to HR-NT subjects (mean Cohen's d 0.36, 95% CI 0.27-0. 46). Compared to HR-NT, HR-T subjects showed in functional imaging studies reduced brain activation in prefrontal cortex, reduced neuronal density, and increased membrane turnover in frontal and cingulate cortex with medium to large effect sizes. CONCLUSIONS: Despite methodological differences between studies, structural and neurochemical abnormalities in prefrontal, anterior cingulate, medial temporal and cerebellar cortex might be predictive for development of psychosis within HR subjects.

Psychopathological rating scales as efficacy parameters in adult ADHD treatment investigations - benchmarking instruments for international multicentre trials.

INTRODUCTION: The selection of appropriate instruments in clinical studies is an essential point to detect the effects of pharmacological and/or psychotherapeutic treatments. METHODS: We performed a Medline search to identify the controlled pharmacological treatment studies and controlled and open psychotherapeutic investigations since 1999 in adult ADHD. The efficacy parameters were collected in order to compare their psychometric properties and psychopathological content. RESULTS: We identified 21 pharmacological and 6 psychotherapeutic treatment studies. The ADHD-Rating Scale-IV (ADHD-RS-IV), the Conners Adult ADHD Rating Scale-Observer Version (CAARS-O), and the Wender Reimherr Adult Attention Disorder Rating Scale (WRAADDS) are the clinical expert rating scales, which were used most frequently. The Conners Adult ADHD Rating Scale-Self -Report: Short Version (CAARS-S:S) and the Adult ADHD Self-Report Scale (ASRS) are self-report rating instruments which have found general acceptance. DISCUSSION: The instruments offer appropriate psychometric properties. The psychopathological item content of the ADHD-RS-IV and the CAARS-O is focused on inattention, impulsivity and hyperactivity. The WRAADDS comprises additionally emotional symptoms and disorganization.

The effects of antipsychotics on the brain: what have we learnt from structural imaging of schizophrenia?--a systematic review.

Despite a large number of neuroimaging studies in schizophrenia reporting subtle brain abnormalities, we do not know to what extent such abnormalities reflect the effects of antipsychotic treatment on brain structure. We therefore systematically reviewed cross-sectional and follow-up structural brain imaging studies of patients with schizophrenia treated with antipsychotics. 30 magnetic resonance imaging (MRI) studies were identified, 24 of them being longitudinal and six cross-sectional structural imaging studies. In patients with schizophrenia treated with antipsychotics, reduced gray matter volume was described, particularly in the frontal and temporal lobes. Structural neuroimaging studies indicate that treatment with typical as well as atypical antipsychotics may affect regional gray matter (GM) volume. In particular, typical antipsychotics led to increased gray matter volume of the basal ganglia, while atypical antipsychotics reversed this effect after switching. Atypical antipsychotics, however, seem to have no effect on basal ganglia structure.

["Self-screen prodrome"--self-rating for the early detection of mental disorders and psychoses]. / "Selbstscreen-Prodrom"--Ein Selbstbeurteilungsinstrument zur Früherkennung von psychischen Erkrankungen und Psychosen.

OBJECTIVE: In the past years, the significance of early detection of psychoses has been increasingly recognized. Screening for the onset of disorders should focus on individuals seeking treatment in an outpatient setting and should preferably operate stepwise. Within a prospective study for the early detection of psychoses (FePsy = Früh Erkennung von PSYchosen) the self-rating instrument "Self-screen Prodrome" was developed to differentiate between healthy individuals, individuals with psychosis or an at-risk mental state for psychosis and patients with other ICD-10 diagnoses. METHOD: The "Self-screen Prodrome" was developed by taking established risk factors and early signs of disease into account. In particular, prodromes and pre-psychotic symptoms were captured. A total score and a subscale were analyzed with regard to validity and reliability. RESULTS: The total score "Self-screen Prodrome" distinguished between outpatients with a mental disorder and healthy individuals (Cut-off > or = 6; sensitivity: 85 % specificity: 91 %). Additionally the subscale distinguished between psychosis-(risk)-individuals and outpatients with other ICD-10 psychiatric diagnoses (Cut-off > or = 2; sensitivity: 85 % specificity: 39 %). CONCLUSION: The "Self-screen Prodrome" is a useful instrument that a) separates mentally ill patients from healthy individuals and b) filters individuals with a risk of developing psychoses from patients with other ICD-10 diagnoses for further screening. The next step in the early detection of psychoses for identified individuals should be a detailed psychiatric exploration by experts.

[Diagnostics of depressive disorders]. / Diagnostik depressiver Störungen.

Many reliable and valid instruments for screening, assessment of severity of depressive disorders and classification according to ICD-10 or DSM-IV criteria are available. Most instruments are available as self-, as well as observer-based rating questionnaires and interviews. The aim of this overview is to give a comprehensive review of well-established instruments in German speaking countries.

[The Basel Screening Instrument for Psychosis (BSIP): development, structure, reliability and validity]. / Das Basel Screening Instrument für Psychosen (BSIP): Entwicklung, Aufbau, Reliabilität und Validität.

BACKGROUND: Early detection of psychosis is of growing clinical importance. So far there is, however, no screening instrument for detecting individuals with beginning psychosis in the atypical early stages of the disease with sufficient validity. We have therefore developed the Basel Screening Instrument for Psychosis (BSIP) and tested its feasibility, interrater-reliability and validity. AIM: Aim of this paper is to describe the development and structure of the instrument, as well as to report the results of the studies on reliability and validity. METHOD: The instrument was developed based on a comprehensive search of literature on the most important risk factors and early signs of schizophrenic psychoses. The interraterreliability study was conducted on 24 psychiatric cases. Validity was tested based on 206 individuals referred to our early detection clinic from 3/1/2000 until 2/28/2003. RESULTS: We identified seven categories of relevance for early detection of psychosis and used them to construct a semistructured interview. Interrater-reliability for high risk individuals was high (Kappa .87). Predictive validity was comparable to other, more comprehensive instruments: 16 (32 %) of 50 individuals classified as being at risk for psychosis by the BSIP have in fact developed frank psychosis within an follow-up period of two to five years. CONCLUSIONS: The BSIP is the first screening instrument for the early detection of psychosis which has been validated based on transition to psychosis. The BSIP is easy to use by experienced psychiatrists and has a very good interrater-reliability and predictive validity.

[Attention deficit hyperactivity disorder in adults. Benchmarking diagnosis using the Wender-Reimherr adult rating scale]. / ADHS-Diagnose bei Erwachsenen. Nach DSM-IV, ICD-10 und den UTAH-Kriterien.

We report on a study comparing different systems for the diagnosis of attention deficit hyperactivity disorder (ADHD) in adulthood. Recruited for evaluation were 168 patients referred to our ADHD outpatient unit. We used the Diagnostic and Statistical Manual of Mental Disorders 4th edn. (DSM-IV), International Classification of Diseases 10th edn. (ICD-10), and Utah criteria for diagnostic assessment and the Wender Utah rating scale, ADHD Self Report (ADHD-SR), and Wender Reimherr Adult Attention Deficit Disorder Rating Scale as psychopathological assessment tools. We present basic psychometric data of the Wender-Reimherr Interview (WRI). Internal consistency was determined as 0.82 (alpha). The inter-rater reliability was 1.0 (kappa coefficient) regarding ADHD diagnoses, and the ICC was 0.98 referring to the WRI total scores. The convergent validity with the ADHD-SR was 0.65 (Spearman coefficient). In 126 of 168 patients an ADHD diagnosis was made according to at least one of the three systems. The DSM-IV diagnostic set led to 119 ADHD diagnoses. As compared with the two other systems, this is about the minimum level for an ADHD diagnosis. All of the 87 ADHD diagnoses according to ICD-10 were covered by DSM-IV. The ICD-10 had no independent psychopathological items and therefore offered no additional points for the diagnostic procedure than the DSM-IV. The situation regarding Utah criteria is different. These criteria contain seven psychopathological domains: inattention, hyperactivity, disorganisation, impulsivity, affective lability, overreactivity, and hot temper. They can be assessed by use of the WRI. Ninety-three of 168 patients were diagnosed as having ADHD according to the Utah concept, which is much lower than with the DSM-IV. The particular definition of the disorder by the Utah criteria resulted in seven patients having only a Utah diagnosis but no DSM-IV diagnosis. Thus we are in a position to say that the Utah criteria have a relatively high level for making an ADHD diagnosis but in certain cases move beyond the DSM-IV. Of the patients 56% had ADHD diagnoses according to all three classification instruments. Examining the factor structure of the ADHD psychopathology represented by seven WRI and three ADHD-SR subscales, we found a two-factor solution explaining for 63% of the variance. Factor 1 was designated by impulsivity, affective lability, hyperactivity, and hot temper; factor 2 consisted of inattention, disorganisation, and overreactivity.

[Screening domestic violence. A German-language screening instrument for domestic violence against women]. / Screening Partnergewalt. Ein deutschsprachiges Screeninginstrument für häusliche Gewalt gegen Frauen.

Domestic violence is frequent. But up to now there is no screening instrument available in German which would allow a simple assessment. In this article a short screening interview is published that allows the identification of women who became victims of domestic violence. Such a screening interview has not been published in German speaking countries until now. A screening interview originally developed in English speaking countries called "Partner Violence Screen" (PVS) was translated, modified and validated in a population of female patients of a crisis intervention ward. The original version of the PVS consisted of 3 items which have been extended by two items, so that the modified version of the PVS is composed of 5 items now. In a validation study this instrument was compared to a much more detailed, 30 item self rating scale "Index of Spouse Abuse" (ISA). In addition to the validation of the PVS a life-time version of the PVS was developed which refers to the entire life period since the 18th birthday. The original version of the PVS showed a sensitivity of 0.79 and a specificity of 0.70. In the modified version "Screening Partner Violence" the sensitivity was 0.80 and the specificity 0.78. This screening instrument, which was translated and further developed by the authors, proved to be helpful for identifying domestic violence. With this instrument a screening interview is available for the first time in German speaking countries that can be accomplished with women in different institutions without losing much time.