[Handling of potentially critical items in acute psychiatry (a study of the Federal Directors Conference)]. / Umgang mit potenziell kritischen Gegenständen in der Akutpsychiatrie (eine Studie der Bundesdirektorenkonferenz).

BACKGROUND: In Germany, an average of 25 people per day died by suicide in 2018. This rate has been declining steadily since the 1980s and has so far halved; however, there is no absolute prevention of suicide; even under optimal protected conditions through therapy and care, approximately 5% of successful suicides occur in psychiatric institutions. Despite the high level of awareness of the risk of potentially dangerous objects, there is a lack of uniform written instructions for action. OBJECTIVE: The aim of the study was to evaluate the handling of potentially critical objects in acute care units during the treatment of suicidal patients, with special emphasis on the handling of disposable razors. METHODS: A 10-item questionnaire on the handling of potentially critical items in closed/facultatively open intensive care/acute care units was developed and sent to 100 psychiatric hospitals throughout Germany. RESULTS AND DISCUSSION: The nationwide survey provided feedback from 39 psychiatric hospitals throughout Germany. The results confirmed a broad critical awareness of potentially dangerous objects; however, the handling of these objects proved to be heterogeneous. Psychiatric clinics and departments have been practicing the control and securing of these objects for decades but there is a lack of written recommendations for handling them. In everyday life, the handling of these objects is taught within the ward, through the ward rules and/or orally. This illustrates a lack of uniform nationwide regulations or guidelines in Germany and thus the lack of corresponding written instructions for handling.

Pharmacological treatment for schizoaffective disorder : A comparison with schizophrenia and bipolar disorder.

BACKGROUND: Bipolar disorder and schizophrenia are severe mental illnesses, each with a prevalence of approximately 1-2% in the general population. There is considerable controversy about differentiating schizophrenia from schizoaffective or bipolar disorder owing to many similarities in psychopathology, progression, and biological factors. The aim of this study was to identify similarities and differences in the pharmacological treatment of these disorders by comparing the prescription patterns. METHOD: In this retrospective, explorative study we analyzed the prescribed medication of 300 patients with bipolar, schizophrenic, or schizoaffective disorders from data obtained from ten German adult psychiatric clinics of the LWL ("Landschaftsverband Westfalen-Lippe") psychiatric network. RESULTS: Only 21.8% of patients analyzed were consistently compliant in taking their medication before hospitalization. Polypharmacy was applied in 75.6% of cases, whereby 2.27 psychopharmacological agents were prescribed at discharge. Briefly, we observed greater similarity between prescription patterns associated with bipolar and schizoaffective disorders than with schizophrenia prescription patterns. CONCLUSION: Polypharmacy tends to be more the rule than the exception, especially when patients present with affective psychotic features. Bipolar and schizoaffective disorders cannot be differentiated according to their prescription patterns.

Influence of levothyroxine in augmentation therapy for bipolar depression on central serotonergic function.

INTRODUCTION: Adjunctive treatment with supraphysiological doses of levothyroxine (L-T4) in bipolar depression shows promise, but the neurobiological mechanisms underlying clinical improvement are unknown. It has been postulated from animal studies that exogenous thyroid hormones may exert their modulatory effects in patients with affective disorders via an increase in serotonergic neurotransmission. Therefore, we investigated the loudness dependence of auditory evoked potentials (LDAEP) as a measure of central serotonergic activity and response to L-T4. METHODS: This 6-week, double-blind, randomized, placebo-controlled study assessed the efficacy of L-T4 adjunctive to continuing treatment with mood stabilizer and/or antidepressant medication in 20 patients with bipolar depression. LDAEP was assessed before and after treatment with L-T4. RESULTS: Scores of the Hamilton Depression Rating Scale and Montgomery Asberg Depression Rating Scale decreased significantly during the study. There was no difference in pre- and post-treatment LDAEP between the groups, and no correlation between LDAEP and psychometric measures in the course of the study. DISCUSSION: The hypothesis of a relationship between response of augmentation therapy with levothyroxine in bipolar depression and serotonergic activity could not be confirmed.

Metabolic syndrome: a follow-up study of acute depressive inpatients.

Previous studies pointed out the high prevalence of the metabolic syndrome among patients with bipolar disorder and major depression. A link between depression and a metabolic syndrome remains in dispute despite these studies. This study was conducted to evaluate the occurrence of the metabolic syndrome in depressive inpatients, to analyze the association between the severity of depression and the metabolic syndrome and to screen specific laboratory values in the course of depressive illness. 60 acute depressive patients were recruited for the study and underwent psychometric testing [21-item Hamilton Depression Rating Scale (HAMD), Beck Depression Inventory (BDI), Clinical Global Impression Scale (CGI) and Global Assessment of Functioning Scale (GAF)] and a metabolic syndrome screening using the modified criteria of the American National Cholesterol Education Program (NCEP) Treatment Panel III (ATP III). Moreover, CRP, cholesterol, HDL-cholesterol, fasting glucose, triglyceride and leptin levels were measured. 42 patients were reexamined in state of (partial) remission. Depression was reassessed using the 21-item HAMD, and laboratory values were analyzed a second time. 25% of the depressive patients fulfilled the criteria of metabolic syndrome (MS+). Only in the MS+ group, a positive correlation between triglyceride blood levels and severity of depression became evident as well in the state of acute depression as in the state of remission. In the group of patients without metabolic syndrome, laboratory values were not associated with severity of depression. An association between metabolic parameters and the course of depression could only be detected in the group of patients with metabolic syndrome. These findings suggest that, in these patients, a beneficial outcome of depressive illness may improve the metabolic situation.

Self concept, action control and ADHD symptoms under methylphenidate treatment in adults with ADHD.

INTRODUCTION: Self-efficacy of adults with ADHD might be changed unfavourably under methylphenidate treatment. Therefore, we sought to investigate the initial situation and changes under this medication, regarding features related to self-efficacy (self concept, locus of control and action control). METHODS: 3 self-rating scales (FSKN, IPC, and HAKEMP-90/ACS-90) were applied to 24 adults with ADHD combined type, before and after 5 months of methylphenidate treatment. RESULTS: No negative changes with respect to ADHD symptoms or any questionnaire were found under medication. In fact, both ADHD symptom domains, 5 out of 10 self concept subscale scores, and all 3 action control subscale scores changed favourably. Regression analysis revealed that only facets of self concept, but not of locus of control or of action control, predicted the patients' response to stimulant medication (i.e., a reduction of ADHD symptoms). DISCUSSION: Positive changes of self-concept and action control features under methylphenidate treatment in this study may encourage therapists to treat adults with ADHD with stimulants, thus not being at risk to decrease their patients' self-efficacy. In combined pharmacological/psychotherapeutic approaches, self-concept scales could be used to predict treatment outcome, and in order to monitor interactions between ADHD symptom reduction and self concept.

Drug prescription patterns in schizophrenia outpatients: analysis of data from a German health insurance fund.

INTRODUCTION: The aim of this study was to investigate routine administrative data from a major German health insurance fund, Techniker Krankenkasse, which covers 5.4 million insured individuals. Using a retrospective cohort design, this study analysed data collected from patients with a hospital diagnosis of schizophrenia in 2003 (index hospitalisation) in order to evaluate prescription patterns of antipsychotic drugs. METHODS: Patients with an ICD-10 diagnosis of schizophrenia, at least one year prior membership with the insurance fund and a follow-up period of one year were identified. Results were standardised by age and stratified by the severity of their illness, defined by the number of hospital bed days during the three years preceding the index hospitalisation. RESULTS: A total of 3,121 patients with schizophrenia (male 56.4%, female 43.6%) received 56 692 single prescriptions of antipsychotics. Of these, 35.4% of the prescriptions were for typical and 64.6% for atypical antipsychotics; 55% were for high-potency, 45% for low-potency typical antipsychotics. The most frequently prescribed drugs were olanzapine (26.6%), clozapine (21.3%) and risperidone (19%). There were no relevant gender differences concerning prescription patterns. During a 12-month follow-up period after the first hospitalisation, 1 372 patients (43.9%) were treated exclusively with an atypical antipsychotic, another 499 patients (16%) had a combination of an atypical plus a low-potency typical antipsychotic. Thus, basal therapy with an atypical was observed in 59.9% of our study population. Only 327 patients (10.5%) were treated exclusively with a typical antipsychotic. A total of 645 patients (20.7%) were treated with a combination of atypical plus typical antipsychotic. Changes of medication within one substance group occurred more often with typical antipsychotics (50%) as compared to atypical antipsychotics (25%). DISCUSSION: At 60%, the proportion of patients in this study treated with atypical antipsychotics was surprisingly high. Of significant interest is the frequent prescription of clozapine (14%). The results are discussed in comparison to comparable studies from other countries.

La introducción clínica de la iproniazida y la imipramina: medio siglo de terapéutica antidepresiva / The clinical introduction of iproniazid and imipramine: half a century of antidepresant therapy

Los primeros fármacos antidepresivos, imipraminae iproniazida, fueron introducidos en clínica en 1957.El origen de la iproniazida, un isopropil derivado dela isoniazida, se encuentra en los agentes antituberculososque se venían utilizando desde principios de ladécada de 1950.Los primeros datos sobre los efectos de la iproniazidaen pacientes depresivos no tuberculosos fueroncomunicados por Kline y cols. en 1957, quienes valoraronsu eficacia en pacientes con depresión psicóticacrónica, abriendo las puertas al primer grupo de fármacosespecíficamente antidepresivos (los inhibidoresde la monoamino-oxidasa, IMAO). Simultaneamente,tuvo lugar otro gran avance histórico en elmanejo de la depresión: el descubrimiento de los antidepresivostricíclicos, cuyo primer exponente y prototipofue la imipramina. La historia de estos antidepresivoscomenzó en los primeros años de la década de1950, gracias al desarrollo de sustancias iminodibenzólicasestudiadas en ese momento como posiblesagentes antihistamínicos, y a la perspicacia del psiquiatrasuizo Kuhn, quien ensayó un hipotético agenteantipsicótico de la compañía farmacéutica suiza J.R.Geigy (G-22355), en 300 pacientes esquizofrénicos.Aunque su eficacia antipsicótica fue inferior a la dela clorpromazina, su actividad antidepresiva fue superiora la de cualquier sustancia conocida hasta lafecha. El nuevo fármaco, denominado imipramina,se comercializó en la primavera de 1958, y sigue siendoun agente de referencia, sobre todo en investigaciónclínica. Sin embargo, la vida comercial de laiproniazida fue corta, pues se retiró del mercadoamericano en 1961 por problemas de seguridad (ictericiay nefrotoxicidad).En cualquier caso, la importancia en la historia dela psiquiatría de estos dos agentes ha sido capital,pues abrió las puertas a un evidente fenómeno de desestigmatización de la asistencia psiquiátrica y a laincorporación de la Atención Primaria al tratamientode los problemas de salud mental

In 1957, the first antidepressant drugs introducedinto clinic were imipramine and iproniazid. Iproniazid’sorigin, an isopropyl derivative of isoniazid, was includedin anti-tuberculosis agents that were used frombeginning of the 1950 decade. The first data about iproniazideffects in depressive patients without tuberculosiswere presented by Kline’s team in 1957, whichassessed the efficacy in patients with chronic psychoticdepression,opening the door to the first group of specificallyantidepressant drug (monoamine oxidaseinhibitors, MAOI). At the same time, there was anotherhistoric advance in the management of depression: thediscovery of tricyclic antidepressants, whichimipramine was its first agent and prototype.Imipramine’s history began in the first years of thedecade of 1950, thanks to development of iminodibenzolicsubstances, studied like possible anti-hystaminergicagents in that moment, and the perceptiveness of theSwiss psychiatrist Kuhn, who tested a hypotheticantipsychotic agent of Swiss Pharmaceutical CompanyJ.R. Geigy (G-22355) in 300 schizophrenic patients.Despite its antipsychotic efficacy was lower than chlorpromazine,its antidepressant’s activity was higher thanany other substance known at this moment. New drug,called imipramine, was launched in the spring of 1958,and it continues being an agent of reference, especiallyin clinical research. Nevertheless, the commercial lifeof iproniazide was short, because it was withdrawnfrom the American market in 1961 due to safety problems(jaundice and nephrotoxicity). In any case, thesetwo agents have a great significance in psychiatric history,like that opening the door at the phenomenon ofdestigmatization of psychiatric assistance and the incorporationto primary care to treatment of mental healthproblems

Amisulpride augmentation in patients with schizophrenia partially responsive or unresponsive to clozapine. A randomized, double-blind, placebo-controlled trial.

INTRODUCTION: Only limited data are available on the effectiveness of augmented antipsychotics to clozapine therapy in chronic schizophrenia. We conducted a randomized, double-blind, placebo-controlled pilot study to evaluate the efficacy and safety of augmentation with the atypical neuroleptic amisulpride to clozapine in a small sample group of patients. METHODS: 16 patients with the DSM-IV diagnosis of chronic schizophrenia and partially responsive to clozapine participated in this pilot study. Patients on a steady dose of clozapine randomly received either clozapine and amisulpride 400 mg/day (n=7) or clozapine and amisulpride 600 mg/day (n=6) or clozapine and placebo for 6 weeks (n=3). Efficacy measures were BPRS, CGI, GAF and MADRS score. Side effects and prolactin levels were obtained. Primary outcome measure were BPRS score changes. RESULTS: The beneficial effect of augmented amisulpride at a daily dose of 600 mg was observed in the mean scores of secondary outcome measures, as assessed by GAF, CGI and MADRS. Measures of primary objectives failed to improve significantly. No reduction in BPRS total score was achieved due to lack of power of the study, whereas the BPRS subscore "activity" had a tendency to improve. Amisulpride was more beneficial in a higher than a lower dose. No severe side-effects occurred, but tremor, bradykinesia, akathisia and elevated prolactin levels were recorded. DISCUSSION: Augmented amisulpride improved the global outcome of patients suffering from chronic schizophrenia in this pilot study and tended to be a helpful treatment option in cases of partial or non-responsiveness to clozapine. Limitations emerge from the small sample size and lack of power. Further investigation requires a larger number of patients to be included.

Patients' use of alternative methods parallel to psychiatric therapy: does the migrational background matter?

OBJECTIVE: Unconventional medicine is widespread in nearly every culture and often used parallel to professional help. This survey evaluates the use of unconventional methods of psychiatric in-patients with vs. without a background of migration. METHOD: A total of 167 psychiatric in-patients underwent a structured interview. One hundred patients were migrants (group 1) and were compared with 67 German in-patients (group 2). RESULTS: Nearly 50% of all patients reported of at least one unconventional therapy. Both migrants and natives used healing methods parallel to professional help. The migrant group rathered to use folk medical concepts and the native group rathered alternative medicine. Around half of the patients with experience of complementary therapy believed it to be efficacious. CONCLUSION: The results suggest that nearly half of the psychiatric patients use alternative medicine and a quarter believe in its efficacy. People with a more traditional background tend to use folk medical practices.

Off-label prescribing in a German psychiatric hospital.

INTRODUCTION: This study examines the prevalence of off-label prescriptions in a large German psychiatric hospital. The influence of a 2002 decision by the Federal Social Court regarding reimbursement issues is investigated. METHODS: Two random samples ( N(1)=125; N(2)=126) of all patients treated in the years 2001-2002 and 2003-2004, respectively, were examined. All prescriptions of psychotropic drugs were evaluated and categorized as CLEARLY OFF-LABEL, PROBABLY OFF-LABEL, or ON-LABEL. Label status for each product was judged according to the information stated in the officially authorized Summary of Product Characteristics. RESULTS: In 2001-2002 20% of all prescriptions of psychotropic drugs were clearly off-label, and 19% were probably off-label. In 2003-2004 the numbers were 21% and 26%, respectively. There was a significant increase in probable and combined probable and clear off-label use. There was no significant influence of sex and patients' age on off-label prescribing, but treatment duration showed a significant positive correlation with off-label use. Drugs prescribed on discharge were significantly more often prescribed off-label than drugs prescribed during the whole duration of treatment. DISCUSSION: Prevalence of psychiatric off-label use in Germany is high. These results are in accordance with international surveys. The restrictive interpretation of the legal reimbursement provisions applied by the German Federal Social Court has not caused a decrease in off-label use. Although measures have been taken to solve the legal problems arising from off-label-use, further solutions are needed to ensure both patient and prescriber safety.

[Paranoia erotica (de Clerambault syndrome) in affective disorder]. / Paranoia erotica (de-Clerambault-Syndrom) bei affektiver Störung.

Erotomania is a rare delusional disorder usually associated with other psychic disorders, especially paranoid schizophrenia. The primary form without comorbidity is very rare. A case report is presented with characteristic features of the pure form of erotomania in a female patient that was nevertheless an affective disorder. A historical review is presented and the division of Clérambault's syndrome into primary and secondary categories critically discussed.

[Folk medical practices in psychiatric patients of Turkish origin in Germany]. / Volksmedizinische Praktiken bei psychiatrischen Patienten türkischer Herkunft in Deutschland.

The treatment of Turkish patients is peculiar due to differences of socio-cultural background and speech. Magic conceptions of pathogenesis and nosogeny have a broad acceptance in a part of population. Magic faith healers, Hocas, are authorities to be consulted for treatment. In ritual acts they intend to stave off noxious influences and to strengthen the healing power with sacred formulas and through powerful objects. To investigate the importance, utilisation and attitude towards the Hocas of Turkish psychiatric patients living in Germany we conducted an interview with 55 psychiatric inpatients. Our findings were a reduced importance of Hocas due to influences of the Western culture and modern medicine. "Folk" medicine is still important for patients with psychic disorders and is used parallel to modern medical facilities.

Neuroleptic malignant syndrome under treatment with antidepressants? A critical review.

Neuroleptic malignant syndrome (NMS) is a rare complication of treatment with neuroleptics. The pathophysiology is not fully known. A dopaminergic transmission block in the basal ganglia and hypothalamus is thought to be the pathophysiological mechanism of NMS. Several cases of NMS have been reported, precipitated by medication without a direct effect on the dopaminergic system. This Medline analysis concerns 23 cases of antidepressant-induced NMS reported in the literature with the differing pathophysiological hypotheses on the precipitation of NMS. The results indicate no hard evidence of an antidepressant-evoked NMS. However, various hypotheses assuming an disturbed balance of the dopaminergic and non-dopaminergic system may be relevant in animal studies, but are without clinically relevant proof presently. An antidepressant-induced NMS is a very rare complication on the basis of pretreatment with neuroleptics causing chronic dopamine blockade and elevated plasma level of neuroleptics due to comedicated antidepressants.

[Coincidence of epilepsy and Asperger syndrome. Case report and review]. / Koinzidenz von Epilepsie und Asperger-Syndrom. Kasuistik und Ubersicht.

Asperger syndrome is an autistic disorder and was first described by Hans Asperger in 1944 without further acceptance in the literature over almost four decades. Following several publications in the 1980s, for the disorder became more widely known and was first introduced into ICD-10 and DSM-IV as a new diagnosis in 1988 and 1994, respectively. The etiology is unknown. We present a female patient with typical features of Asperger syndrome, suffering also from epilepsy and internal medical disorders. The associated diseases, diagnostic criteria and possible therapeutic options are discussed.

[Paroxetine-induced neuroleptic malignant syndrome]. / Paroxetin-induziertes malignes neuroleptisches Syndrom.

We report on a 22-year-old schizophrenic patient who attempted suicide and suffered an epidural hemorrhage. 16 days after the neurosurgical operation. After several weeks of treatment with promethazine, 1 day after intake of paroxetin he partially lost consciousness and developed extrapyramidal symptoms and vegetative disorders. Hyper-Ck-aemia up to 680 U/l was observed. Malignant neuroleptic syndrome (MNS) was diagnosed, which led to withdrawal of paroxetin and promethazine. He was put on dantamacrine and amantadine until the symptoms resolved. To date there have been few reports on MNS under tricyclic antidepressants and selective serotonin inhibitors. The influence of the central serotonergic system on the pathophysiology of MNS is discussed.

[Neuroleptic malignant syndrome from treatment with antidepressives]. / Malignes neuroleptisches Syndrom unter der Behandlung mit Antidepressiva.

The neuroleptic malignant syndrome (NMS) is a rare complication in the treatment of neuroleptics. The pathophysiology is not fully known. A dopaminergic transmission block in the basal ganglia and the hypothalamus is thought to be the pathophysiological mechanism of NMS. There are some findings against the single role of dopamine receptor blockade: NMS is rare under neuroleptic treatment, although a strong dopamine receptor blockade is found even with a low dosis of neuroleptics. NMS can develop even after longterm treatment with neuroleptics and is not improved by dopamine agonists within the expected period. NMS may even develop when neuroleptics are reduced. Several cases have been reported of NMS precipitated by medication without a direct effect on dopaminergic system. Only rare case reports describe NMS under antidepressants. We report on all cases of NMS associated with antidepressants and present the different pathophysiological hypotheses on the precipitation of NMS.

[Asperger syndrome--an overview of diagnostic criteria]. / Asperger-Syndrom--eine Ubersicht der diagnostischen Kriterien.

Asperger syndrome is an autistic disorder which was first described in 1944 without further acceptance in the literature over almost four decades. Following several publications in the "80's, the disorder became more widely known. Asperger syndrome was introduced into ICD-10 and DSM-IV as a new diagnosis in 1988 and 1994, respectively. Several authors developed own criteria. Until now, some of the diagnostic criteria of Asperger syndrome remain controversial. We present a survey and a comparison of the criteria in the classification of DSM-IV, ICD-10 and of other authors. Six criteria are widely accepted, but there are divergent opinions about the criteria "intelligence" and "speech development".