Rehabilitation of cognitive and motor functions in younger and older patients with vascular brain damage, rheumatologic illness and in post-surgery patients.

This study presents results of inpatient rehabilitation (as monitored by Functional Independence Measure (FIM)) of patients with vascular brain damage (n = 78), post surgery patients (n = 62) and of patients with rheumatologic illness (n = 45). These patients were divided into two age groups (cut off point 65 years). There were significant differences in the FIM scores in all three diagnosis groups between the younger and the older patients at discharge, the younger patients reaching a higher FIM score. However, there were no substantial differences between the two age groups in FIM gains the length of stay in any of the diagnosis groups. This study indicates that although younger patients reach higher FIM score at admission and at discharge the patients older than 65 improved in a comparable way during the same length of stay thus requiring comparable financial resources.

Joint actions of parents and adolescents in health conversations.

Based on an action theory approach, 32 videotaped parent-adolescent conversations about health in two Canadian ethno-cultural groups were analyzed to identify and describe the joint action of parents and adolescents in the health domain. The data include manifest behavior (the conversation), internal processes (recalled thoughts and feelings on viewing the videotape of the conversation), and social meaning. These data were analyzed using the goals, functions, and elements of the conversations. Five categories of joint actions emerged from these data: sharing and exploring information, values, and beliefs about health; negotiating and struggling about aspects of the adolescent's independence; providing and receiving guidance; adjusting to family and home issues; and fostering joint understanding by giving voice to the adolescent.

An exercise in improving suicide reporting in print media.

This study was conducted to support the publication of guidelines for media reporting on suicide. First, quantitative and qualitative aspects of suicide reporting in Swiss print media were surveyed over a time span of 8 months. The results were presented at a national press conference, and written guidelines for suicide reporting were sent out to all newspaper editors. The results of the survey and the guidelines were discussed in a personal meeting with the Editor-in-Chief of the main tabloid. After the publication of the guidelines a second, identical survey was conducted. The main variables regarding frequency, form, and content of the newspaper reports before and after the press conference were compared. The number of articles, on the one hand, increased over the 3 years between the first and second survey, but the quality of reporting clearly improved on the other. The personal contact with the editor of the tabloid was probably the most effective means of intervention.

The joint actions of adolescents in peer conversations about career.

Ten career conversations between adolescent peers were video-taped to examine the joint actions of adolescents that emerge in actual conversations about career. Based on an action-theoretical approach, joint action refers to the intentional behavior of a group of people attempting to realize a common goal or engage in a common process. The actual conversations and the adolescents' recall of their thoughts and feelings during the conversations were used to identify the joint actions that occurred in the conversations and the meaning that the conversations had for the adolescents. Goals of the actions included educational planning, career selection, and personal future. The functions the adolescents undertook in the conversations to reach these goals were identified as exploring, formulating, validating, and challenging. Based on these results, it was proposed that self-refinement was the project that energized and guided the joint actions and lent meaning to the conversations.

Patient-disease characteristics and coping strategies predict hospitalization in emergency psychiatry.

OBJECTIVE: The goal of this study was to analyze how far patient-disease characteristics (sociodemographic variables, previous psychiatric treatment, way of referral, the patient's current diagnosis), and the patient's coping strategies are connected with the consecutive disposition for inpatient or outpatient treatment. METHODS: Data from a one-year intake of the psychiatric emergency service at a University Hospital (N = 1439) were monitored and analyzed with regard to the decision on treatment. Four hundred eighty-one patients were hospitalized and 530 were assigned to outpatient treatment. Two subsamples of twenty-eight patients from each group filled out the Bernese Coping Modes questionnaire before the decision with regard to the treatment disposition was taken. RESULTS: The patient's psychiatric history, the way of referral as well as the current axis I diagnosis made a significant contribution to the treatment decision. Overall, patient-disease characteristics allowed for correct classification of 69.3 percent of cases. However, coping was a comparable predictor of hospitalization. CONCLUSIONS: It is argued that the search for patient-disease characteristics in the psychiatric emergency room should be complemented by a more extensive monitoring of the patients' way of coping with their current crisis.

Attempted suicide. Do we understand the patients' reasons?

This explorative study compared the patients', doctors', and nurses' views regarding their attribution of reasons for attempting suicide and the patients' emotional state immediately preceding their suicide attempts. A sample of 30 out of 94 consecutive patients seen in the emergency room of University Hospital were examined shortly after they had attempted suicide. Immediately after the routine clinical interview, conducted by a psychiatric resident and a nurse, patients filled in a questionnaire giving 14 possible reasons for attempting suicide as well as 8 feelings characterizing the emotional state preceding the suicide attempt. In the meantime, and without prior discussion of the case, the resident and the nurse independently completed the same questionnaire. In addition, sociodemographic and clinical data were obtained. Intrapersonal reasons such as to get relief from a terrible state of mind or from an unbearable situation were most frequently chosen by patients, nurses, and doctors alike. The most striking difference was found for "loss of control": this item was chosen significantly more often by patients than by nurses and doctors. Accordingly, patients reported significantly more often feelings of anxiety/panic and emptiness (mental vacuum), whereas feelings of despair and powerlessness/hopelessness were mentioned most frequently by nurses and doctors. Mental health professionals should bear in mind that many suicide attempters experience feelings of anxiety/panic prior to their suicidal act, and that a majority report having lost control over themselves, thus indicating a state of emotional crisis.

Coping and psychosocial adaptation: longitudinal effects over time and stages in breast cancer.

OBJECTIVES: This study examined the relationship between coping and psychosocial adaptation in cancer patients over time and across distinct clinical events. METHODS: In a prospective longitudinal study 74 patients with breast cancer were observed for 3 to 5 years at 3- to 6-month intervals. A total of 684 interviews were conducted at different observation points. Three rating scales were used to assess coping and adjustment: first, the Bernese Coping Modes, an observer rating scale devised to elicit 26 coping modes aggregated in this paper as the five Basic Coping Strategies of support, self-control, denial, diverting, and negative-emotional; second, an observer rating scale to ascertain psychosocial adaptation; and third, a self-rating scale as a measure of either emotional distress or well-being. RESULTS: a) When aggregated in illness stages, coping and distress data on the observed clinical time points showed greater variability than time measures alone (analysis of variance (ANOVA) for repeated measures p < .001). b) A significant relationship between the Basic Coping Strategies and psychosocial adaptation was demonstrated using discriminant and correlational analysis. Furthermore, in stage-dependent Pearson r correlations (p < .05 to .001), a clear-cut relationship was found for hospitalization, chemotherapy, and rehabilitation, but not for convalescence and metastasis. c) A positive relationship was demonstrated between psychosocial adaptation and strategies that can be generally categorized as good forms of coping such as support and self-control, and, to a lesser degree, diverting and denial. Conversely, poor coping exerted a negative effect on almost all illness stages and on most criteria of adjustment. CONCLUSIONS: In long-term studies on psychosocial adaptation and coping, stage-related measures should be preferred to time measures alone. The implications of different strategies for the psychological treatment of cancer patients are discussed.

[The treatment of torture and war victims]. / Die Behandlung von Folter- und Kriegsopfern in der Schweiz.

Torture is a means of repression in non democratic societies. Although banned, it is widely practised. About 30% of the refugees recognized 1987 in Switzerland were tortured. Torture and war lead to severe bio-psycho-social sequels which are described as "post traumatic stress disorder" (PTSD). This can be treated. Several centres for treatment of torture victims were recently established in many countries since health workers and health care providers felt helpless facing the consequences of torture and asked for professional support. The foundation of the Swiss Red Cross Therapy Centre for victims of torture was the response to their demand in Switzerland. The centre offers a wide range of therapies for victims of torture and training for health personnel. It further aims to facilitate the establishment of more institutions of this kind.

Suicide attempters in a psychiatric emergency room population.

OBJECTIVE: The aim of this study was to describe the characteristics of psychiatric emergencies when the precipitating event for the emergency room visit was a suicide attempt, compared with other reasons for admission. METHOD: For 1 year, all consultations (N = 1438) of a psychiatric emergency service were documented in a detailed questionnaire covering sociodemographic and diagnostic data as well as information about the consultation and the disposition decision. In 163 consultations, deliberate self-harm with possible fatal outcome was the precipitating event. In order to control for diagnosis, all emergency consultations with an adjustment disorder were analyzed in a second step (N = 366). In this subgroup, deliberate self-harm was the precipitating event in 78 cases. RESULTS: Compared with the other emergencies, the suicide attempters were better integrated in the occupational as well as in private life. They were more often referred by others, and significant others such as relatives and friends were more frequently involved in the consultation. Nevertheless, the suicide attempters were significantly more often hospitalized. By and large, the same results were found when analyzing the consultations with adjustment disorders only. However, within a ligh-risk subgroup of suicide attempters, no differences with regard to disposition decision were found. CONCLUSION: Clinicians should not automatically refer suicide attempters for inpatient treatment, particularly in low-risk patients and when the suicidal intent and the lethality of the suicidal act are not too threatening. Residents should be instructed more thoroughly in suicidology before being assigned to the emergency room.

Contacts of suicide attempters with GPs prior to the event: a comparison between Stockholm and Bern.

The aim of this study was to investigate patterns of contact made with GPs by subjects in two cities prior to attempting suicide, in order to determine whether differences in the health care systems could be a possible factor influencing the help-seeking behaviour of people experiencing suicidal crises. Structured interviews were conducted with suicide attempters from geographically defined catchment areas in two countries with private and national health care systems, respectively. The subjects were suicide attempters, admitted consecutively, aged > or = 15 years and living either in Stockholm (n=202) or in Bern (n=66). Patients living in Bern had seen their GPs more regularly and more frequently throughout the year. There was an increase in the number of visits to the GP prior to the suicide attempt in both cities, but it was greater in Stockholm than in Bern. However, in Stockholm fewer patients who saw their GP in the week before the attempt talked about their suicidal thoughts. The differences in help-seeking behaviour between the two patient samples may be related to the higher number of practising GPs and a more personal and consistent patient-doctor relationship in Bern. It is possible that the private medical care system in Switzerland lowers the threshold enabling patients to talk to their GP about their suicidal plans. The results suggest that in both cities there is scope for improving communication of the suicidal patient with his or her doctor.

[The Bern Coping Forms BEFO--an instrument for self- and observer rating of coping with illness]. / Berner Bewältigungsformen BEFO-ein Instrument zur Selbst- und Fremdbewertung der Krankheitsverarbeitung.

Coping is an integral part of any illness behaviour, and has major implications inter alia for the doctor-patient relationship, hence, indirectly also for rehabilitation outcome. The Berne Coping Forms BEFO permit coping representation, for one, from the perspective of the observer (observer rating) and, for the other, from that of the patient (self-rating). The instrument is applicable for any diagnostic area or context, whether preventive programme, acute or chronic conditions, rehabilitation, or assessment of stressors in carers or relatives, and many more. The instrument is comprised of 30 categories of coping modes, oriented by three dimensions (action-,cognitive and emotion-related). Numerous studies have demonstrated adequacy of the instrument's psychometric properties. Associations between observer and self-rating are good, as is repeat reliability of the self-rating form, while the required reliability levels are reached in observer repeat ratings. Interrater agreement is good even with minimal previous training. The instrument has stood the test for differentiated assessment of coping modes in varying forms of illness-generated stress. It moreover permits characterization of coping style changes over time, i.e. in the different disease phases. Also, sociocultural differences and coping effectiveness can be substantiated. BEFO interpretation is determined by the research focus at hand, and presupposes differentiated evaluation of illness behaviour. Training and instruction are thoroughly dealt with in a manual, and comparative videos can be made available.

Trauma-related disorders in psychiatrists' and general practitioners' private practice in Switzerland.

A questionnaire addressing traumatic stress related issues was mailed to every third psychiatrist in private practice and to every fifth general practitioner in Switzerland (N = 1406, number of returns 517 (37%). Trauma-related disorders seem to be underdiagnosed. Patients suffering from rape, accidents and war related trauma were most often mentioned. Psychiatrists knew more about specific treatment possibilities than general practitioners. Only 14% of the responding clinicians were satisfied with the existing therapeutic services for trauma victims; more psychiatrists voiced a need for their improvement. A majority suggested interdisciplinarity and the cooperation of institutions and therapists in private practice for the treatment of trauma-related disorders. It is proposed that further education should be tailored according to the target professional group.

[Psychotraumatology in medical practice--a survey]. / Psychotraumatologie in der ärztlichen Praxis--eine Umfrage.

In a representative national survey, general practitioners and psychiatrists were asked about their experience and knowledge with regard to psychological sequelae of traumatic life events. A questionnaire addressing 10 traumatic stress related issues was mailed to every fifth general practitioner and psychiatrist in private practice in Switzerland (N = 1284). The return rate was 37%. Every second doctor reported having experiences in treating posttraumatic disorders. Sexual abuse and accidents were the mostly mentioned traumas. General practitioners are frequently confronted with acute stress disorders, while psychiatrists more often have to deal with PTSD. Psychiatrists knew more about specific treatment possibilities than general practitioners. Only a minority was satisfied with the existing therapeutic services for trauma victims. Few doctors (more psychiatrists than GPs) had plans for further education. A majority suggested interdisciplinary treatment approaches. When planning further education, preference should be given to interdisciplinary approaches, taking into consideration at the same time the specific needs of different professional groups.

Family Health- promotion Proj ects: An Action-theoretical Perspective.

The concept of the family health-promotion project is introduced as a means of describing and analysing health-promoting processes in a family. We suggest that an action-theoretical conceptualization provides a language for dealing with socially embedded human behaviour. The levels of project organization are described and the issues discussed are: hierarchical organization, communication, goal structure, steering, control, regulation, energizing, perspectives and construction, group or joint action, three-dimensional structure of group action, dual enfolding of group actions, properties of group action and of family projects. The research design and methods of a current study on a family health-promotion project are presented and explained.

Coping and the decision to hospitalize in emergency psychiatry.

This study was done to clarify whether and in what way a patient's coping repertoire can be linked to the disposition decision in a psychiatric emergency service. For 1 year, all consultations (N = 1439) of a psychiatric emergency service were documented in a detailed questionnaire covering sociodemographic and diagnostic data as well as information about the disposition decision. Depending on disposition, three groups were identified: outpatients (N = 530), inpatients (N = 481), and a nonintervention group (N = 428). In addition, over a 5-month period, patients were requested to fill in the "Bernese Coping Modes" questionnaire. Thus, a sample of 28 patients undergoing outpatient crisis intervention and 28 patients referred to inpatient treatment was obtained. Statistical analysis included Chi square-test, t-test, Mann-Whitney U-test, and logistic regression analysis. Assessment of coping repertoire contributed more than the diagnosis to the decision to hospitalize. Outpatients have a larger coping repertoire (t = 3.48, p = 0.001) than inpatients and show higher values in "acceptance-stoicism," "dissimulation," "tackling," "giving meaning," "altruism," "optimism," and "relativizing." Logistic regression revealed relativizing, altruism, and optimism as being most important. Self-referral to emergency psychiatry was also correlated with outpatient treatment. Other criteria such as being without work, living alone, history of previous hospitalization, and the diagnosis of a psychotic or mood disorder were significantly correlated with referral to inpatient treatment. More attention should be paid to patients' coping repertoires in emergency services when deciding about the need for inpatient treatment.

A comparison of the drugs taken in fatal and nonfatal self-poisoning.

The objective of this study was a) to compare patterns of drug use in fatal and nonfatal overdoses and b) to find out if toxic drugs are overrepresented in overdoses with fatal outcome. A total of 179 cases of fatal overdoses in Switzerland (population 6.6 million) were compared with 269 medically treated self-poisoners from the agglomeration of Berne (population 301,630). Because of frequent multiple drug use, all the different compounds taken singly or in combination with other drugs were recorded and grouped according to drug types. The patterns of the frequencies of drugs used were remarkably similar in both groups. The majority of the drugs were psychotropics (81% in fatal and 68% in nonfatal overdose). Twenty-nine completed suicides were the result of drug combinations specifically recommended by EXIT. In the remaining cases benzodiazepines were used most frequently in both attempted and completed suicide, often in combination with other drugs or alcohol. Barbiturates were the only drugs recorded significantly more often in fatal overdoses (9% vs 3%). No significant difference was found for tricyclic antidepressants (13% vs 10%), or other types of drugs. The results are consistent with our assumption that drugs with higher toxicity would be overrepresented in overdoses with fatal outcome. Barbiturates, which are well known to be dangerous in overdose, were clearly associated with fatal overdoses, but not tricyclic antidepressants. This, in our view, suggests that the risk of prescribing tricyclic antidepressants should not be overestimated. The frequent use of benzodiazepines in completed suicide, however, indicates that there are no truly safe drugs in overdose.

Understanding deliberate self-harm: the patients' views.

Patients were asked to explain why they had attempted suicide, by spontaneous description and by the use of lists of problems and motives presented to them. They were also asked what help they would have accepted before the event, and what the consequences of the suicide attempt were. The main motive for attempting suicide mentioned was an acute and unbearable state of mind. Interpersonal (manipulative) motives were of much less importance to the patients. In contrast, the problems which patients thought had an influence on what they had done were mainly interpersonal problems and, to a lesser degree, health problems. Especially younger individuals saw interpersonal difficulties as the main problems. Many patients reported that in the suicidal crisis they would not have been prepared to accept help. Most felt the suicide attempt had positive consequences for them.

[Characteristics of young suicide attempters and their importance for helpers]. / Charakteristika junger Suizidversucher und ihre Bedeutung für den Helfer.

66 suicide attempters were interviewed with the European Parasuicide Study Interview Schedule (EPSIS) and characteristics of persons under the age of 26 were compared with those over 26.82% of the young suicide attempters gave interpersonal conflicts as reasons for their suicide attempts while most older persons gave psychiatric disorders as reasons. The younger group also had significantly lower scores on the Beck Depression Inventory and the Hopelessness Scale. While younger suicide attempters rarely had sought help from their GP within the month preceding the attempt one third of the older group had done so. It is concluded that in order to understand the reasons why people attempt suicide a differential approach combining the concept of crisis as well as the concept of illness is needed. Helpers should know that young suicide attempters rarely show signs of clear psychiatric disorder but usually attempt suicide because they are unable to cope with interpersonal conflicts.

Coping with breast cancer over time and situation.

This study examines the variability and stability of coping in cancer subjects over time and situation. In a prospective longitudinal design 74 breastcancer patients have been followed for 3-5 yr at 3-6 monthly intervals. A variety of measures related to coping and adjustment were taken. This report limits itself to the findings of an instrument developed for this study, the Bernese Coping Modes in which 26 coping modes were rated by observers. Results confirm arguments in favour of both variability and stability in coping activity over time and situation. Two measures support stability: rank values and a multivariate measure (MDS) with three constant dimensions: (1) support and acceptance; (2) denial; (3) diversion by thought and action. Evidence for variability is: the potential range of coping modes and a large variety of additional modes at most observation times. Subsequently time measures of coping were attributed to eight predefined illness stages as distinct clinical situations. Thus variability or richness of coping further increased. The implications of these findings for measurement in coping research are discussed.

Suicide prevention: spreading the gospel to general practitioners.

General practitioners were trained in the recognition and treatment of suicide risk either by written text alone or combined with a seminar meeting. They filled in questionnaires before and after training. In the seminar group, knowledge and attitudes changed significantly, while those doctors receiving written material only had similar results to those without training.