[Alcohol intoxication in emergency medicine]. / Alkoholintoxikierte in der Notfallmedizin.

Every year more than 100,000 people with an alcohol intoxication are admitted to German hospitals. Many of them refuse inpatient observation or treatment. Therefore the physician in charge at the emergency room has to decide, how to proceed. The capacity to consent has to be judged, especially if the patient insists on being discharged. In this context the risks of injuries, complicated alcohol withdrawal, aggressive and suicidal behavior must be evaluated. In this article the juridical aspects and the necessary mental and physical assessments especially in case of discharge of the patient against medical advice are presented. Essential aspects are summarized in checklists.

Ethyl glucuronide (EtG): better than breathalyser or self-reports to detect covert short-term relapses into drinking.

AIMS: The assessment of relapses is widely used as an outcome measure of alcohol dependence treatment. However, the methods of assessing relapses range from questionnaires to biological markers of alcohol for different time spans. The aim of this study was to compare the relapse rates of weekend home stays during long-term alcohol dependence treatment, assessed by ethyl glucuronide (EtG), breath alcohol tests and self-reports. METHODS: Two hundred and ninety-seven alcohol-dependent patients receiving a long-term inpatient treatment programme participated. After a weekend at home (Friday to Sunday) they were evaluated for relapse by personal interviews and with breath alcohol tests. A concomitantly collected urine sample was later assessed for EtG with liquid chromatography-tandem mass spectrometry (LC-MS/MS analysis). RESULTS: Of the total, 37.7% of the patients were positive for EtG at least once. Breath alcohol tests had been positive in only 4.4% and in personal interviews only 5.7% of the patients had admitted relapse. 15.6% of EtG tests were positive, but breath alcohol tests were negative (Cohen's kappa = 0.056). Ninety-three per cent of the relapses were only detected by EtG. CONCLUSION: In addition to breath alcohol tests and interviews, urinary EtG can clearly improve the verification of relapse in inpatient treatment programmes allowing for weekend stays at home. Without EtG testing, a high amount of relapses will stay undetected.

[Functional diagnostics of mobility control, mobility stabilization and hypermobility. Reliability of clinical tests - results of a multicenter study]. / Funktionelle Diagnostik der Bewegungssteuerung, Bewegungsstabilisation und Hypermobilität. Reliabilität klinischer Tests - Ergebnisse einer Multicenterstudie.

BACKGROUND: Complex forms of musculoskeletal dysfunction are thought to be risk factors for the development of chronic pain syndromes of the locomotor system. Unfortunately there are insufficient data on the reliability and validity of clinical tests for musculoskeletal dysfunctions. METHOD: The intrarater and interrater reliability of clinical tests for hypermobility and for the stabilisation system were examined in a multicentre trial. A total of 68 patients in 6 centres were functionally examined by 2 examiners once (intrarater reliability) and by 1 examiner twice (interrater reliability). RESULTS: The tests for hypermobility showed good to very good reliability. The results for the stabilisation system were more variable whereby 23 tests showed a kappa-coefficient greater than 0.5 and 15 tests good to very good reliability. DISCUSSION: All tests for hypermobility and 23 tests for the stabilisation system are suitable for further evaluation. The broad range in test reliability might be explained by the differences in examiner skills demanded by each test. Therefore, dependent on their validity, some tests will be useful in specialized centres while others might be used in primary care.

[Reasons for referral to a gerontopsychiatric department]. / Gründe für die Einweisung in eine gerontopsychiatrische Klinik.

BACKGROUND: The need of specific gerontopsychiatric wards has not been estimated thus far, although psychiatric disorders are very common among the elderly. AIM: The purpose of this study was to describe reasons for referral of old patients to a psychiatric department providing full services for 252,000 inhabitants. METHODS: All 975 admissions within 2 years were evaluated in this prospective study. RESULTS: During the study period 645 patients aged over 64 years were admitted 830 times to the gerontopsychiatric wards. About half of them were referred by physicians in private practice, about 30% came via the emergency room, and 18% were transferred from other departments or hospitals. The most frequent reasons for referral were disorientation, confusion, or delirious states (31.9%), hallucinations or delusion (21.6%), aggression or excitation (17.7%), depression (17.6%), refusal of feeding or drinking (14.4%), agitation or restlessness (13.9%), suicidality or suicide attempt (13.3%), and disruptive behaviour (13.0%). In 81.8% of the cases, behaviour endangering themselves or others was an important cause of referral. The amount of specific gerontopsychiatric beds needed in hospital was estimated as ten beds per 10,000 inhabitants aged 65 or more. CONCLUSIONS: The greatest proportion of the patients referred to gerontopsychiatric wards showed behaviour endangering themselves or others-typical indications for psychiatric inpatient treatment.

[Prescription of drugs without registered indication]. / Verabreichung von Medikamenten ausserhalb der zugelassenen Indikationsgebiete ("off-label-use") -- Für welche Medikamente und psychiatrischen Indikationen liegen hinreichend wissenschaftlich fundierte Studien vor?

In the medical treatment of psychiatric patients drugs not registered for this specific indication are often prescribed. This so-called "off-label-use" is an increasing matter of discussion in the last years. In the article several aspects concerning "off-label-use" of psychotropic drugs debated in Germany are reviewed. According to a sentence of the German Supreme Court for Social Law an "off-label-use" is only allowed under strong conditions. Furthermore, controlled randomized studies are judged to be the basis of an evaluation of the permission to prescribe an "off-label" medication. Since in clinical practice a comprehensive research of suitable controlled studies is time consuming, in this article controlled randomized studies concerning the main problematic fields of psychopharmacotherapy: treatment of single psychopathological symptoms, therapy resistance, contraindications or severe side-effects, absence of well-established medical treatment strategies and "add-on"-therapy are reviewed. The problems and legal aspects of an "off-label-use" in psychiatry are discussed.

[Legal decisions of german supreme courts about prescription of drugs for not registered indications ("off-label-use")]. / Rechtsprechung zur Verabreichung von Medikamenten ausserhalb der zugelassenen Indikationsgebiete ("off-label-use").

In the medical treatment of patients drugs not registered for this specific indication are often prescribed. This so-called "off-label-use" is an increasing point of discussion and in the past years had to be settled in court more than once. The debate covers some questions, i. e. whether the health insurance funds have to pay for the prescribed "off-label-use" drugs, and who is responsible in case of side-effects. In this article the most relevant court decisions of German Supreme Courts are reviewed. The decisions show some changes. According to a recent sentence of the German Supreme Court for Social Law an "off-label" medication to be paid by health insurance funds is only allowed under strong conditions: presence of a life-threatening disease or a disease causing a long term severe impairment of the quality of life, no other medication available, and sufficient data from scientific literature supporting an clinical efficacy of the drug. However, in case of an "off-label" medication the physician is fully responsible for all legal consequences.

Wishes and expectations of alcoholic patients concerning their therapy.

AIM: To assess the wishes and expectations of alcoholic patients concerning their therapy. METHODS: 227 alcohol-dependent patients from three sites in two cities in Germany completed a questionnaire about their aspirations for the outcome (20 items) and their expectations about the elements (23 items) of treatment. RESULTS: Some components of treatment were equally important to men and women (a life without alcohol, individual sessions during therapy). Women attached more importance than men to 'strengthening of self-esteem' and 'an environment of tranquillity and security'. Most patients in this study were aware of their alcohol dependence, which limits the generalizability of these results to patients at earlier stages of recovery. CONCLUSION: Patients request individual, patient-oriented treatment. Some differences in expectations between men and women suggest that a gendered approach in treatment could mean an increase in patients' satisfaction, and thus a decrease in drop-outs.

[Hyperlipidemia - side-effect of "Atypical" neuroleptics?]. / Hyperlipidämie - Nebenwirkung von "atypischen" Neuroleptika?

After the introduction of the so-called 'atypical antipsychotics' some reports concerning hyperlipidemia observed in patients treated with these drugs have been published. The studies and case reports available up to now were reviewed. The available data show that hyperlipidemia particularly occurred in patients receiving clozapine, olanzapine and also quetiapine. Predominately elevated serum levels of triglycerides have been reported. The underlying pathomechanism still remains widely unclear. Since hyperlipidemia is an important symptom of the so called 'metabolic syndrome' which is often associated with severe complications like cardial and vascular diseases, more attention should be paid to hyperlipidemia as a potential side effect of antipsychotics.

[Diabetes mellitus type II--induced by "atypical" neuroleptics?]. / Diabetes mellitus Typ II--induziert durch "atypische" Neuroleptika?

After the introduction of the so-called "atypical antipsychotics" in the clinical practice hyperglycemia as well as increased triglyceride and cholesterol serum levels were reported in patients treated with some of these agents. The studies and case reports available up to now were reviewed. Some epidemiologic studies show that diabetes mellitus occurs more often in patients treated with atypical antipsychotics if compared to conventional antipsychotics. The available data show that hyperglycemia and diabetes mellitus type II were particularly observed in patients receiving clozapine and olanzapine. Also diabetic ketoacidosis was most frequently reported in patients treated with these drugs. The underlying pathomechanism still remains widely unclear. There is some evidence for an important role of insulin and also leptin. Their secretion seems to be influenced by some atypical antipsychotics. Since overweight is a known risk-factor for diabetes mellitus type II, the weight inducing effect of atypical antipsychotics may also play an important role. Since diabetes mellitus type II often lead to severe diseases, the serum glucose levels should be paid more attention in the treatment with atypical neuroleptics.

Motivational intervention: an individual counselling vs a group treatment approach for alcohol-dependent in-patients.

AIMS: The present study aimed to evaluate whether individual counselling for alcohol-dependent patients in three sessions is as effective as a 2-week group treatment programme as part of an in-patient stay in a psychiatric hospital which was to foster motivation to seek further help and to strengthen the motivation to stay sober. Of particular importance was the external validity of the results, i.e. a 'normal' intake load of in-patients in detoxification and a wide variety of motivation to stop drinking were to be investigated. METHODS: Subjects eligible for the study were all patients with alcohol problems admitted to a psychiatric hospital, but without psychosis, as the main diagnosis, and with a maximum of 10 detoxification treatments in the past. A randomized-controlled trial was conducted with 161 alcohol-dependent in-patients who received three individual counselling sessions on their ward in addition to detoxification treatment and 161 in-patients who received 2 weeks of in-patient treatment and four out-patient group sessions in addition to detoxification. Both interventions followed the principles and strategies of motivational interviewing. RESULTS: Six months after intervention, group-treatment patients showed a higher rate of participation in self-help groups; however, this difference had disappeared 12 months after treatment. The abstinence rate among the former patients did not differ between the two intervention groups. CONCLUSION: Group treatment may lead to a higher rate of participation in self-help groups, but does not increase the abstinence rate 6 months after treatment.

Impaired serum cortisol stress response is a predictor of early relapse.

AIMS: to investigate a possible association of cortisol stress response during early abstention with relapse. METHODS: Thirty-six alcohol-dependent males, half of them with a comorbid anxiety disorder, and 15 healthy controls were exposed to a standardized psychosocial stress test. Thirty-one of the patients were assessed for relapse 6 weeks after discharge. RESULTS: The relapsers showed almost no cortisol responses in the stress test. Comorbid anxiety disorder influenced neither stress response nor relapse. CONCLUSIONS: During early abstention from alcohol, reduced stress-responsivity of the hypothalamo-pituitary-adrenocortical axis seems to be connected to early relapse.

[Alcohol and stroke. Is moderate alcohol consumption protective?]. / Alkohol und Schlaganfall. Wirkt geringmässiger Konsum protektiv?

It is now increasingly recognized that mild to moderate consumption of alcohol is associated with reduced mortality and coronary heart disease. Alcohol consumption and mortality follows a J-shaped association, with increasing mortality in heavy drinkers. There is some evidence from epidemiological studies that mild to moderate alcohol consumption may also reduce the risk of ischemic stroke and overall stroke in persons over 40 years of age. However, these studies have been criticized for not adequately considering possible confounding factors. Moreover, alcohol consumption is associated with an increased risk of intracerebral and sub-arachnoid hemorrhage, and binge drinking is a strong risk factor for both ischemic and hemorrhagic stroke. Alcohol consumption probably has no beneficial effects in young subjects. On the basis of the current evidence, it is not justified to advise an otherwise healthy, mild to moderate consumer of alcoholic beverages to quit drinking. However, it seems premature to advise alcohol consumption generally for prevention of stroke.

[Addiction in the elderly - an underestimated diagnosis in clinical practice?]. / Sucht im Alter Ein unterschätztes Problem in der klinischen Versorgung älterer Menschen?

According to several studies in the USA, alcohol abuse is common among elder people, particularly among those admitted to hospital. Corresponding data for Germany are lacking as yet. In this study, the frequency of addiction problems in the elderly admitted to hospital was investigated using the data from 1990 to 1998 of the psychiatric department at the General University Hospital of Lübeck, Germany. Furthermore, the documentations of all consultations in that period were reevaluated. The psychiatric consultation service covers two general hospitals providing inpatient treatment for about 200,000 inhabitants. Diagnoses were made according to the ICD-10 criteria. In 17.7% of the males older than 64 years and in 4.2% of the elderly females admitted to the psychiatric department, alcohol dependency was diagnosed, while 5.8% of the elderly patients showed substance abuse, most often of benzodiazepine. Among the patients visited in the psychiatric consultation service, 10.8% of the elderly males and 3.2% of the elderly females were alcohol addicts and 3.9% substance abusers. The frequency of alcohol-induced neuropsychiatric complications, particularly withdrawal delirium and amnestic syndrome, increased with age. Also, benzodiazepine withdrawal delirium most frequently occurred in older patients. These results underscore that, although the prevalence rate seems to be lower than among the younger population, in the elderly population substance abuse still is a relevant medical problem, since the rate of neuropsychiatric complications increased with age.

[Attitudes of alcoholics to addiction-related topics]. / Befragung von Alkoholkranken zum Thema Sucht.

PURPOSE: In Germany the attitudes towards alcohol consumption and smoking are rather heterogeneous. Although it is well accepted that both behaviours are harmful and often lead to addiction, thus far the attitudes of alcoholics to addiction-related topics have not been evaluated. METHODS: In this investigation 228 alcoholics were asked to complete a questionnaire of addiction-related topics. RESULTS: The attitudes were rather realistic, concerning the harmful effects of alcohol. The beliefs were only slightly influenced by personal involvement (e.g. divorce). Different opinions were given as to the riskiness of illegal drugs. The attitude towards the reasons of alcoholism are most important for therapeutical decisions. Only a third of the patients believed that they themselves were responsible for their addictive behaviour while nearly half accused socioeconomical factors. The curability of their alcoholism as well as their own competence to overcome alcoholism was estimated rather realistically by the patients. The results could not be generalized since the sample mainly consisted of alcoholics who themselves sought an alcohol-specific treatment service. Furthermore the data analysis shows that about 90 % of them regarded themselves as alcoholics. CONCLUSION: Future studies have to show whether these attitudes differ from those of the general population and from alcoholics not seeking-help.

[Medical treatment of psychiatric disorders in alcoholics]. / Medikamentöse Behandlung von psychiatrischen Störungen bei Alkoholabhängigen.

PURPOSE: Epidemiological studies show that alcoholics have a high life-time prevalence of psychiatric illnesses, particularly of anxiety, depressive and schizophrenic disorders. But the complex relationships between elevated alcohol consumption and psychiatric symptomatology frequently Iead to problems in finding diagnosis and thereafter in planning therapeutic strategies. METHODS: In this article the results of the studies concerning the medical treatment of psychiatric comorbidity of alcoholics are critically reviewed. RESULTS: According to the available results a therapy with antidepressive drugs indicated in alcoholics with depression lasting over 14 days. Anxiety disorders seem to have little influence on the course of alcoholism. Thus, an anxiolytic medication has to be considered carefully in view of the addiction potency of tranquilizers. There is a paucity of data concerning drug treatment of schizophrenics with alcohol abuse. Thus far only a few studies have shown an effect of a drug treatment of the psychiatric comorbidity on the drinking behavior. CONCLUSION: There is a lack of studies on specific treatment strategies of psychiatric comorbid alcoholics, particularly of schizophrenics with alcohol abuse.

Acceptance of pharmacotherapy for relapse prevention by chronic alcoholics.

The willingness to take medication is a major prerequisite for compliance with biological treatment approaches in psychiatric disorders. The aim of this study was to investigate the willingness of alcoholics to improve relapse prevention using drug therapy, since there has been little information about the acceptance of such a medication as yet. 261 chronic alcoholics consecutively referred for detoxification completed a newly developed questionnaire containing items on drinking history, recent treatments, and beliefs about drug therapy for relapse prevention. In order to draw comparisons, 67 self-help group attendees and 29 alcoholics consulting an outpatient advice service were also recruited. 67.8% of the recently detoxified alcoholics were prepared to take medication for relapse prevention, if prescribed, while 60% the self-help group attendees refused drug therapy. There was no correlation between the acceptance of drug treatment and duration of dependence. Subjects willing to take a medication more often believed their alcoholism to be curable, and they reported a higher craving frequency. 55% of those willing to take a medication were willing to pay for the drugs, but in most cases, at a level lower than the equivalent of 5 beers. As drug therapy acceptance is a crucial part of compliance with, and success of medical relapse prevention, our results underscore the necessity of a thorough exploration into the health beliefs of the patient and joint development of a treatment rationale prior to prescription.

The course of anxiety, depression and drinking behaviours after completed detoxification in alcoholics with and without comorbid anxiety and depressive disorders.

We studied the associations between comorbid anxiety and depressive disorders in treated alcoholics, the course of current anxiety and depression during the early and late post-detoxification periods, and drinking behaviours after discharge. Lifetime psychiatric comorbidity was assessed in 100 alcoholics using the Composite International Diagnostic Interview (CIDI). Three subgroups defined as group DA (comorbid depressive and anxiety disorders, n = 15), group A (anxiety disorder only, n = 23), and group NO (no comorbid disorder, n = 62) were studied. Beginning 21 +/- 13 days after cessation of drinking, state anxiety (STAI-X1), trait anxiety (STAI-X2) and depression (BDI) were assessed once per week (t1 to t4) and once more 6 months after discharge (t5, n = 68). The severity of psychopathology decreased during the first 4 weeks after detoxification in all subgroups. However, trait anxiety remained at higher levels in both the comorbid subgroups from t1 to t4. In the follow-up sample, 60.5% of the non-comorbid subjects remained abstinent, but only 26.7% of all comorbid patients and only 12.5% of those with comorbid depressive disorder plus severe current trait anxiety or depression at t1. Independent of their comorbidity status, relapsers at t5 had already reported more trait anxiety than abstainers at t1. We conclude that severe trait anxiety persisting after 3 weeks of abstinence, comorbid depressive and/or anxiety disorders, and combinations of these with moderate or severe current anxiety and depressive states represent the greatest risks of relapse and therefore may indicate a treatment need.

Bodyweight gain with atypical antipsychotics. A comparative review.

The atypical antipsychotics have been shown to have superior efficacy compared with typical antipsychotics such as haloperidol, particularly in the treatment of negative symptoms of schizophrenia. Furthermore, they induce less extrapyramidal effects. However, following clinical use, marked bodyweight gain has been frequently observed with some of the atypical antipsychotic drugs. In order to examine and compare the frequency, amount and conditions of bodyweight gain during treatment with atypical antipsychotics, studies concerning bodyweight gain with these agents were identified through a MEDLINE search from 1966 to March 2000. Although comparison is limited by the different designs and recruitment procedures of the reviewed studies, the available data support the notion that the frequency as well as the amount of bodyweight gain is high in patients treated with olanzapine (average bodyweight gain 2.3 kg/month), clozapine (1.7 kg/month), quetiapine (1.8 kg/month), and possibly also zotepine (2.3 kg/month). Moderate changes in bodyweight have been observed in the treatment with risperidone (average bodyweight gain 1.0 kg/month). Ziprasidone seems to induce only slight bodyweight changes (0.8 kg/month). Bodyweight gain most frequently occurs in the first 12 weeks of treatment. Patients who were underweight at the beginning of treatment are at highest risk of gaining bodyweight. The underlying pathomechanism still remains largely unclear. The relative receptor affinities of the atypical antipsychotics for histamine H1 receptors as well as the ratio of their affinity for serotonin 5-HT2 and dopamine D2 receptors appear to be the most robust correlate of bodyweight gain. Furthermore, the induction of leptin secretion may have an important impact on bodyweight gain in patients treated with atypical antipsychotics. Although many questions concerning the pathogenesis of bodyweight gain remain unresolved, this adverse effect has to be taken into consideration when prescribing the atypical antipsychotics, particularly in view its affect on compliance during long term treatment and the long term effects of obesity on mortality and morbidity.

The severity of alcohol withdrawal is not age dependent.

Age has been considered to contribute to the severity of the alcohol withdrawal syndrome (AWS). To evaluate the relationship between age and the severity of the AWS, we examined 723 alcoholics [518 males, 205 females, mean age (+/- SD): 42.8 +/- 10.5 years, mean duration of alcohol dependence: 11.0 +/- 8.0 years] consecutively referred to a unit for detoxification of alcoholics in a general hospital. The severity of the AWS was assessed by the AWS scale of Wetterling et al. (1997; Alcohol and Alcoholism 32, 753-760). The history of alcohol abuse as well as drinking behaviour in the last 6 months was assessed by a semi-structured interview. There were 41 alcoholics aged > or =60 years; they were compared with younger patients. The average severity of AWS did not differ between age groups. Daily alcohol intake and frequency of drinking were higher in younger alcoholics, but even when adjustment was made for this, severity of AWS was equal in both age groups. A relationship between severity of AWS and age was not detected.

[Psychiatric consultation services for the elderly. Changes in utilization due to the new German legislation concerning guardianship and restructuring of health care providers]. / Psychiatrischer Konsiliardienst bei älteren Patienten. Anderungen der Anforderungen durch Inkrafttreten des Betreuungs- und Gesundheitsstrukturgesetzes?

In the discussion of increasing costs of health care in Germany, the frequent and long hospital stays of elderly patients are often pointed out. Since these patients very frequently suffer from psychiatric disorders, psychiatric consultation is often required. This study was aimed at investigating whether new German laws concerning guardianship and the structure of health care providers change conditions for psychiatric consultation services. For this purpose, the documentation of all consultations in the years 1991 to 1995 was retrospectively evaluated. In about 3% of all patients aged over 65 referred to the General University Hospital of Lübeck, psychiatric consultation was ordered. The most frequent diagnosis was senile dementia. Comparison of the requests and psychiatric recommendations show a significant increase in wishes and recommendations for guardianship. Moreover, there is evidence of the increasing need of consultation in elderly patients. Possibly due to the new law concerning the structure of health care providers and the number of requests and recommendations to transfer patients to psychiatric wards, these results show that the new laws do affect psychiatric consultation.