Levosimendan

Levosimendan is a recently developed drug which is not yet approved for clinical routine use in Germany. The clinical use is limited to a few selected cases and it has been used as a salvage therapy in patients with severe heart insufficiency. As a potent inodilator it has been given to patients with severe heart failure, when all other therapeutic options have failed. However, in some European countries levosimendan is used in clinical routine situations and the European Society of Cardiologists has included the drug in their guidelines for treatment of acute heart failure. The following article describes the main pharmacological characteristics of levosimendan and summarises the indications for this new drug for physicians working in the field of anaesthesia or intensive care.

Quality of life: a dimension in multiaxial classification

The study provides an overview of the historical aspects of multiaxial classification. Particular reference is paid to the multiaxial formats of ICD-10, DSM-IV and the WPA International Guidelines for Diagnostic Assessment (IGDA). The IGDA proposes a tetraaxial format with quality of life as one axis as well as an axis on symptomatology, an axis on adaptive functioning and an axis on environmental/psychosocial conditions. The axis on quality of life is added in recognition of the increasing importance placed upon the patient's perception of his/her capacity of self fulfillment and the attention paid to quality of life as a major descriptor of health status as well as an outcome measure of clinical care.

Abuse of psychiatry

The Geneva Declaration of 1948 states that doctors shall not permit considerations of religion, nationality, race, party politics or social standing to intervene between their duty as a doctor and their patients. They shall not use their medical knowledge contrary to the laws of humanity. The UN Principles of Medical Ethics also reminds doctors that their professional relation to persons deprived of their liberty is solely to evaluate, protect or improve their health. Similarly, the Hawaii Declaration from 1983 and the Madrid Declaration from 1996 outline the ethical duties of the psychiatric profession. Thus, there is no doubt as to the professional role as it is delineated in the medical ethics codes. The presence of such codes is, however, only one of the necessary steps to prevent the abuse of psychiatry; others include educational interventions or the establishment of international networks.

The Nordic Comparative Study on Sectorized Psychiatry: continuity of care related to characteristics of the psychiatric services and the patients

The problem addressed in this paper is how continuity of care is related to characteristics of psychiatric services, previous events in a patient's pattern of care and patient characteristics. The present paper is a part of a Nordic Comparative Study on Sectorized Psychiatry in seven catchment areas in four Nordic countries. One-year-treated-incidence cohorts were used. Each patient was followed for 1 year after the first contact with the psychiatric service. Continuity of care was measured by the time from discharge from hospital to the first subsequent day-patient or outpatient contact. Notable findings were large differences in the continuity of care in the seven services, high proportions of discharges without any aftercare contacts and long time lags between discharges and aftercare contacts in most of the catchment areas. A Cox regression analysis revealed that aftercare following hospitalisation seems to be more probable if the outpatient services are located geographically close to the patients, if the hospitalisation lasted between 2 and 4 weeks, if there was a community care contact shortly before the hospital admission and if the patient is not retired and not divorced. Staff resources were not related to continuity of care.

The Nordic Comparative Study on Sectorized Psychiatry: patients who use only psychiatric in-patient care in comprehensive community-based services--a 1-year follow-up study

In the present paper a sample of patients using psychiatric in-patient care only is characterized and analysed with regard to characteristics of the psychiatric services. This paper forms part of the Nordic Comparative Study on Sectorized Psychiatry, designed to investigate contact rates and use of psychiatric care by new patients in 7 catchment areas in 4 Nordic countries during a 1-year follow-up. One-year treated incidence cohorts were used. The logistic regression analysis revealed that the variable 'psychiatric service' was one of the statistically significant determinants of using only in-patient care during the follow-up. The diagnostic groups with the highest probability of using only in-patient care were dependencies and functional psychoses. The following factors were associated with a high risk of using only in-patient care: older age, being referred by another psychiatrist, having received previous psychiatric in-patient care, male sex, being retired, and not living with one's parents or a partner. Patients who used only in-patient care had fewer admissions and days in in-patient care than others during the 1-year follow-up period. Lack of 24-hour emergency services in out-patient care correlated positively with the use of only in-patient care.

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S): a tool for the assessment of difficulties in selected areas of functioning of patients with mental disorders

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S) is an instrument for clinicians' assessment and rating of difficulties in maintaining personal care, in performing occupational tasks and in functioning in relation to the family and the broader social context due to mental disorders. The WHO DAS-S was developed and underwent preliminarily testing in the context of two international field trials of the multiaxial presentation of ICD-10 for use in adult psychiatry. The instrument was found to be useful, user-friendly and reasonably reliable for use by clinicians belonging to different schools of psychiatry and psychiatric traditions. Further work on the WHO DAS-S should include development of national adaptations of the instrument, studies of concurrent validity of the instrument and modification of the instrument to accommodate changes in the next edition of the International Classification of Impairments, Disabilities and Handicaps (ICIDH).

The Nordic comparative study on sectorized psychiatry. Utilization of psychiatric hospital care related to amount and allocation of resources to psychiatric services

As a part of a Nordic comparative study on sectorized psychiatry, utilization of inpatient care was related to resources and dynamic qualities of psychiatric services in seven catchment areas in four Nordic countries. One-year treated incidence cohorts were used. Each patient was followed for 1 year after first contact with the psychiatric service. Data were collected concerning number of beds and staff, number of long-term patients and turnover rate of patients in inpatient care. Findings gave some support to the earlier reports that the utilization of inpatient care is determined by the supply of available beds. Highly staffed community services did not themselves reduce the use of inpatient services, but availability of day care services seemed to reduce utilization of inpatient care among psychotic patients.

Contextual aspects of mental disorders: a proposal for axis III of the ICD-10 multiaxial system

After several years of development and testing, the World Health Organization (WHO) has recently completed work on the multiaxial presentation of ICD-10 for use in adult psychiatry. Axis III of the ICD-10 multiaxial system is intended for clinicians' reporting of contextual factors which may influence the diagnosis, treatment or prognosis of mental disorders that are recorded on Axis I. It was tested in two WHO-co-ordinated international field trials and found to be user-friendly, reasonably reliable and useful in routine clinical work, in the training of mental health professionals and in research on mental disorders.

The Nordic comparative study on sectorized psychiatry. I. Treated point prevalence and characteristics of the psychiatric services

Comparative studies relating characteristics of psychiatric services to rates of treated prevalence are scarce. As part of a Nordic comparative study on sectorized psychiatry, a point-prevalence study was performed in 5 sectorized psychiatric services with comprehensive service facilities for a defined population under responsibility. The rates of treated prevalence on a census day were related to a number of characteristics of the respective services and to accessibility of care. The results showed a great variation in one-day point prevalence in the 5 services, with almost fourfold differences. There were also marked differences in the diagnostic distribution of the cohorts. A positive correlation was found between number of beds and point prevalence, measured both as total point prevalence and impatient prevalence. The rates of beds and psychiatrists were most strongly related to the prevalence of patients with organic disorders and functional psychoses. A closed referral system was associated with a lower level of treated prevalence.

General health assessment in refugees claiming to have been tortured

General health assessment of refugees claiming to have been previously exposed to torture takes place in a psychological atmosphere affected by the difficult situation of the refugee. Thirty-one refugees, mainly from the Middle East and Africa, were assessed as regards their physical and mental health. Assessment took place with the help of professional interpreters and was, during each interview, performed by two medical doctors using double-blind techniques. Based on a number of highly significant (P < 0.001) correlation coefficients and Kappa values, observers agreed frequently on gradients of symptom intensity and less frequently on absolute symptom levels. However, agreement was almost complete when assessing the presence of intense symptoms and the absolute absence of a symptom. Symptom patterns were demonstrated to be consistent, clinically interpretable and, furthermore, closely associated (P < 0.0001) with self-reported global (general) health. Reliability was moderate with respect to clinical observation during interview.

The Danish psychiatric register as a tool in epidemiology

The electronic part of the nationwide Danish Psychiatric Central Register is now almost 25 years old. In this period it has proved its high value in administration, planning, treatment of patients, and not least in psychiatric research. Due to its national coverage, the register makes it easy to conduct epidemiological studies, such as analysis of trends, register linkage research, identification of representative cohorts for further analysis and follow-up studies of clinically identified cohorts. After many years of political turmoil, the register now seems to have assumed a more reasonable form, making allowance for both research interest and data protection. A proposed directive on the protection of medical data from the European Community may be a serious threat to the register and will probably eliminate all epidemiological and clinical research based on registers.

Quantifying depressive symptomatology: inter-rater reliability and inter-item correlations

In this study an evaluation of the inter-rater reliability of the Hamilton Depression Rating Scale, the Melancholia Scale and the Montgomery-Asberg Depression Rating Scale has been carried out. Furthermore, the inter-item correlations of these scales have been investigated in relation to diagnostic ratings. It was found that the quantitative scales had satisfactory inter-rater relationship. Only low agreement was found between the quantitative and diagnostic scales, as expected, while there was high agreement between the quantitative scales. The relevance of introducing new scales and the definition of major depression are discussed.

The use of case vignettes in studies of interrater reliability of psychiatric target syndromes and diagnoses. A comparison of ICD-8, ICD-10 and DSM-III

This study is part of the ICD-10 field trials in which the use of case vignettes for interrater agreement has been examined. From our electronic database of 880 consecutively admitted inpatients we selected 24 cases that were transcribed to vignettes covering the first 5 ICD-10 target syndrome of dementia, substance use disorders, schizophrenia, mood and anxiety disorders. ICD-10 was compared with ICD-8 and DSM-III. The results showed that all 3 standard classification systems obtained an acceptable interrater agreement. Among the diagnoses, depressive disorders gave rise to most disagreement between the raters. Discrepancies between the methods of measuring interrater agreement were found when intraclass reliability was compared with consensus calculations for the individual patient.

Psychiatry and the death penalty

Mentally ill people are not to be judged by the same rules as the mentally fit. Prisoners evaluated medically unfit for execution must undergo psychiatric treatment until their mental health is restored. Psychiatrists are placed in an ethical dilemma when asked to judge the mental health of prisoners on death row. A high prevalence of psychiatric and neurological disorders are reported on death row. Health professionals have an important role in implementing codes of ethics prohibiting any involvement in the execution process. Resolutions have already been passed by several associations including the World Medical Association, the American Psychiatric Association and Nordic medical associations.

The use of a psychiatric register in predicting the outcome "revolving door patient". A nation-wide cohort of first time admitted psychiatric patients

A nation-wide cohort of all first admitted patients to all Danish psychiatric institutions over a 1 year period and aged 15 years or more was followed for 10 years in the Danish psychiatric register. Revolving door patients were defined as patients with a minimum of four admissions and 1) no admission or discharge period lasting for more than 1/4 of the observation period or 2) at least four admissions over the first 1/4 of the observation period. The revolving door population comprised 1,397 patients with an incidence rate of 0.42 males and 0.32 females per 1,000. Forty-three point five percent belonged to the same diagnostic group at first and last diagnostic assessment ranging from 28.3% in "organic psychosis" to 57.6% in "neurosis". A multiple contingency analysis showed a number of variables at first admission significantly associated with the outcome "revolving door". Many were conditioned by others and the independent variables were "age group", "main diagnosis" and "sex". Patients aged 15-24 years constituted a high risk group among schizophrenics. The 15-24 age group was further at high risk among females with personality disorder or abuse and males with manic depressive and psychogenic psychosis. Living close to a psychiatric institution was in males associated with the outcome independently of age and diagnosis, in females it was restricted to personality disorder. Revolving door patients were significantly younger than others and more likely to suffer from schizophrenia or alcohol/substance abuse.