[Admission status of alcohol and drug-dependent patients in "high threshold" access to withdrawal treatment]

OBJECTIVE AND METHODS

106 patients (64.2% male and 35.8% female) who applied for a withdrawal treatment by phone call, were interviewed concerning the admission context with the aim to find out whether the admission regulations prevent patients from undergoing treatment.

RESULTS

72.6% of all patients were admitted as inpatients. The average waiting period was 8 days. 15.1% were known to have previously suffered from conclusions and 4.7% from delirium tremens; for these patients, the waiting period was significantly shorter.

CONCLUSIONS

High-threshold admission is not an insurmountable difficulty. Waiting periods and soberness at admission are accepted. Setting up admission conditions is, on the one hand, justified, whereas on the other hand chronic patients are often not reached. Telephone contacts with patients willing to undergo treatment should be replaced by contacts in an outpatient setting.

Increased automatic spreading activation in healthy subjects with elevated scores in a scale assessing schizophrenic language disturbances

BACKGROUND

Previous studies on semantic priming have suggested that schizophrenic patients with language disturbances demonstrate enhanced semantic and indirect semantic priming effects relative to controls. However, the interpretation of semantic priming studies in schizophrenic patients is obscured by methological problems and several artefacts (such as length of illness). We, therefore, used a psychometric high-risk approach to test whether healthy subjects reporting language disturbances resembling those of schizophrenics (as measured by the Frankfurt Complaint Questionnaire subscale 'language') display increased priming effects. In addition, the Schizotypal Personality Questionnaire was used to cover symptoms of schizotypal personality. Enhanced priming was expected to occur under conditions favouring automatic processes.

METHODS

One hundred and sixty healthy subjects performed a lexical decision semantic priming task containing two different stimulus onset asynchronicities (200 ms and 700 ms) with two experimental conditions (semantic priming and indirect semantic priming) each.

RESULTS

Analyses of variance revealed that the Frankfurt Complaint Questionnaire-' language' high scorers significantly differed from low scorers in three of the four priming conditions indicating increased automatic spreading activation. No significant results were obtained for the Schizotypal Personality Questionnaire total and subscales scores.

CONCLUSIONS

In line with Maher and Spitzer it is suggested that increased automatic spreading activation underlies schizophrenia-typical language disturbances which in our study cannot be attributed to confounding variables such as different reaction time baselines, medication or length of illness. Finally, results confirm that the psychometric high-risk approach is an important tool for investigating issues relevant to schizophrenia.

Comorbidity of opiate dependence and mental disorders

In a 5-year-follow-up study of 350 opiate addicts in contact with a drug help system in Hamburg, 272 clients (78%) were interviewed a second time after 1 year. The objective of the study was to examine the correlation between mental disorders and drug consumption and its relationship to clients' general life situation. In the majority of the opiate addicts, a pattern of polydrug consumption was observed, but the amount of drugs consumed was clearly lower after 1 year. In the initial survey, a mental disorder according to ICD-10 could be diagnosed for 55% of the sample. Among groups formed by the severity and course of mental disorders or their symptoms, a significant correlation was observed, particularly at the time of follow-up, between the extent of drug consumption and the course of the mental disorder. Other areas, like physical health or social problems/conflicts, were also related to comorbidity (i.e., heavy drug consumption and/or mental disorder). These interrelationships should be taken into account in treatment, care and guidance to increase the prospects for successful treatment.

[The impact of the central serotonin system on alcoholism and therapeutic consequences]

Several studies support the assumption that the development and/or maintenance of alcoholism is due to a deficit of the central serotonergic system. But it still remains open whether the imbalance in the serotonergic functioning is due to genetic factors or whether it is a result of alcoholism. It has been hypothesised that both mechanisms interact with each other creating a vicious circle. The efficacy of serotonin reuptake inhibitors (SSRIs) in treating alcoholism supports the pathophysiological assumptions. Citalopram (40 mg) and Fluoxetine (60-80 mg) significantly reduce ethanol intake. However, treatment effects disappear after a treatment period of more than 4 weeks in most of the studies. Chronic and heavy alcoholics benefit less from treatment. Better treatment results were obtain in alcoholics with primary depression, especially with a prolonged treatment period. The promising treatment outcome in primary depressed alcoholics suggests an efficacy of SSRIs in alcoholism with primary anxiety disorders, although no data are available. The results of the studies in this field support the following therapeutic consequences: 1. Alcoholics with primary depression should be treated with SSRIs. 2. A short-term treatment with SSRIs in primary alcoholism without comorbid psychiatric diseases can be considered, e.g. to prevent treatment drop-outs or for relapse prevention. 3. So far, treatment in alcoholics with primary anxiety disorders is not supported simply due to a complete lack of data. Studies on this problem are imperative.

Impact of ethnicity on the prevalence of psychiatric disorders among migrants in Germany

OBJECTIVES

Studies on psychiatric disorders among migrants have described higher rates, especially of schizophrenia. Some evidence points to the possibility of misdiagnosis for this higher rate; other studies point to the underrepresentation of migrants in psychiatric services, leading to artefactual epidemiological data.

METHODS

All admission records of migrants to a psychiatric clinic from 1993 to 1995 were assessed for diagnosis, symptomatology and treatment.

RESULTS

Admissions of 408 migrants, 8.1% of total admission, were assessed. Of these, 38.7% received a diagnosis of a schizophrenic disorder, significantly more than the other clinic patients. The mean age at admission was 34.0 years, at onset of illness 28.6 years and at time of migration 20.4 years. Only 8.3% were mentally ill at the time of migration. Language problems correlated with the diagnosis of a schizophrenic disorder.

CONCLUSION

An underrepresentation of migrants shows differences in the use of psychiatric services. Some evidence from the mental status and reported language problems may explain the higher rate of schizophrenia due to misdiagnosis.

Maintenance treatment of opiate addicts in Germany with medications containing codeine--results of a follow-up study

AIMS

Outpatient maintenance treatment of opiate addicts with codeine/dihydrocodeine is a common approach in the treatment of drug addicts in Germany. This study was carried out to assess possible benefits of codeine maintenance in terms of patients' health stabilization, social rehabilitation and drug consumption.

DESIGN

Three-year follow-up study.

SETTING

Three practices of substituting physicians in large-city areas in Germany.

PARTICIPANTS

Of a random sample of 297 people attending for opiate outpatient treatment in 1993, 199 were successfully followed up 3 years later.

MEASUREMENTS

Measures of health, living conditions, employment, criminal activities and drug use were collected at baseline and follow-up. The data were based on standardized interviews and medical examinations by the attending doctors as well as on questionnaires from the patients.

FINDINGS

Based on a 67%-follow-up rate, after 3 years of codeine maintenance there was improvement in general health and mental problems. The living and working situation remained more or less unchanged and stabilized at a satisfactory level. The same applies to the consumption of drugs.

CONCLUSION

The patients' progress shown in this study was comparable to that achieved by methadone maintenance in similar geographical regions. Codeine has a weaker pharmacological effects and our results suggest that codeine maintenance treatment deserves more attention and controlled trials to assess the benefits compared with methadone (or other opioids).

[Prevalence of psychiatric disorders in opiate dependent patients in contact with the drug treatment system]

In the course of a 5-year follow-up study concerning comorbidity in opiate addicts, 350 patients were investigated initially in various addiction centres in Hamburg. More than two thirds of the participants of the study are male, with an average age of 29 years at the time of the investigation. Most of them are receiving methadone maintenance treatment (42%), about one fourth is in residential rehabilitation and another 17% in inpatient detoxification treatment. The patients have been consuming heroin for an average of 9 years. For 55% of the opiate addicts (at least) one more psychic disorder in accordance with ICD-10 has been diagnosed (lifetime prevalence). F6 personality disorders have not been taken into consideration. The 6-month prevalence is 37%, 2-week prevalence 23%. For 43% of the opiate addicts, the predominant disorders belong to the group of neurotic, endurance, and somatoform disorders (F4), and for 32% of the patients to the group of affective disorders (F3). Schizophrenic, schizotypic and delusional disorders (F2) are less frequent (5%). Another 5% of the opiate addicts suffer from eating disorders (F5). These are partly multiple diagnoses cases; there is an average of 1.3 diagnoses per patient. Women are clearly more often affected by comorbidity than men. Most disorders first occur between the age of 18 and 21 years. Therefore, (lifetime) prevalence rates are twice to three times as high as that of the average German population, according to the present state of knowledge. This underlines the great importance of specific diagnostic and explorative methods for the treatment of addiction. Psychic disorders or disturbances that might adversely affect the course of treatment should be given more consideration.

[Opiate dependent patients in inpatient detoxification. Prevalence of somatic diseases in hospital admissions]

AIM

To investigate whether the impression that prevalence rates of diseases in drug addicts undergoing detoxification could be verified empirically. In addition, to make an attempt to identify possible relationships responsible for this development.

METHOD

Between 1989 and 1993, within the framework of a detoxification program, 1041 opiate addicts were investigated for the presence of somatic diseases. For this purpose, the overall sample was divided up into 3 groups corresponding to the following time periods: 1989/1990, 1991/1992, 1993. The baseline data comprised the standardised history at the time of admission, the results of the initial clinical examination, and the serological and clinico-chemical findings during the further course.

RESULTS AND INTERPRETATION

A deterioration in the general state of health associated with more risky drug consumption patterns and social isolation was established. Apparently, low-threshold treatment programs and prophylactic strategies made available to almost two-thirds of the addicts in Hamburg have proved unable to prevent the deterioration of the situation of a subpopulation of addicts.

[Consumption patterns and motivation for use of addictive drugs in schizophrenic patients]

In particular studies conducted in the U.S. display a tendency for schizophrenics to combine hallucinogens and amphetamines, whereas other studies report on a combination of psychotropic substances with a similar range of action. Influencing negative symptoms is reported to be the motivation for consumption. A total of 222 patients with a schizophrenic disorder (F2) and addiction (F1) were examined. The main substance was alcohol (F10.1 or F10.2; 52.2%), followed by cannabis (F12; 25%), opiates (F11; 4.1%), sedatives or hypnotics (F13; 2.7%) and cocaine (F16; 0.5%). A multiple drug use (F19) is reported by 14% of them. The most frequent combination was alcohol and cannabis, whereas hallucinogens and amphetamines were only rarely combined. Actual multiple consumption was reported by 55% of the patients, while lifetime multiple consumption applied to 72%. The motivation seems to be an unspecified sedation of unpleasant affective symptoms of schizophrenia. The most frequently seen combinations do not correlate with the reports published in the literature. The great variations in motivation seem to mainly reflect the importance of the availability of the substance.

Surgery in Israel

The evolution and development of surgery in Israel reflects the influence of its dramatic historical events. The immigration of surgeons, particularly since the fourth decade of the 20th century, highly contributed to the framework of modern surgery. Medical education occurs at 4 medical schools, in Jerusalem, Tel Aviv, Haifa, and Beer Sheva, and postgraduate surgical training takes place in all public hospitals, most of which are university hospitals or have university-affiliated departments, and is controlled by the Scientific Council of the Israel Medical Association (Tel Aviv). Health care is provided by 4 health insurance funds and has been recently influenced by the National Health Insurance Bill and the Bill of Patient's Rights. Surgical standards are high and similar to the very best of Western countries. The geographical location of Israel in the Middle East, surrounded by hostile Arab countries, has dramatically influenced the development of Israeli surgery. The practice of surgery ranges from full-time service in state and insurance-funded mostly academic hospitals, to private part-time clinics for wealthy and insured patients. Surgical training occurs only in departments accredited by the Scientific Council, which are mostly affiliated with the 4 medical schools. A surgical residency in Israel usually requires 6 years, and its guidelines and regulations are elaborated and recommended by the Israel Surgical Society and controlled by the Scientific Council. Most Israeli surgeons were trained in Israeli hospitals, but a substantial number of surgeons immigrated to the country, especially from eastern Europe.

[Dimensional structure of the German version of the Brief Psychiatric Rating Scale (BPRS)]

Since the early 1960s the Brief Psychiatric Rating Scale (BPRS) has been one of the most frequently used standardized methods in international psychiatric research. The BPRS is used mainly for the rating of psychopathological symptoms of schizophrenic subjects. According to the results of factorial analyses, the original version of the BPRS is divided into five subscales, which have been preserved in the German translation. The validity of this original scale structure for the German BPRS version has not been investigated, however. A principal-components analysis of the 18 BPRS items carried out on the data of 301 schizophrenics yielded four factors that are comparable with four of the original subscales: Thought disturbance, Hostility/suspiciousness, Anxiety/depression, and Anergia. These results are compared with earlier findings and similarities and differences are discussed.

Psychopathology in patients with schizophrenia and substance abuse: a comparative clinical study

In a 3-month epidemiologic survey at the Psychiatric Clinic of the University Hospital Hamburg-Eppendorf, a total of 372 patients between 18 and 60 years of age were screened with a variety of clinical psychiatric tests. Of the entire group, a subgroup of 180 patients was placed into one of four index groups: schizophrenics with first-rank symptoms and with (n=47) or without (n=52) concomitant past or acute use of psychotropic substances; alcoholics (n=63), and patients with alcoholic psychosis (n=18). In almost all areas examined, the group of schizophrenics with substance abuse was revealed to be a severely disturbed subgroup of schizophrenics with a long history of disease. Particularly with respect to psychopathology, there was an increase in depressive and suicidal tendencies.

Opioid addiction and suicidality

The prevalence of suicide attempts among opioid addicts is reported to lie between 8% and 17%, with some studies reporting an even higher rate among special groups of addicts. Yet there is insufficient knowledge about which addicts have a higher risk of suicide and which other factors seem to be involved in the constellation leading to the suicide attempt; the study of different subgroups of addicts is thus necessary. This paper reports a study on suicide attempts among a sample population in a detoxification unit and another group undergoing codeine maintenance treatment. There was a high rate of suicide attempts among both groups (23% of those in the detoxification unit and 28% of those maintained on codeine), but treating physicians tended to underestimate suicidality. The results lead to the conclusion that among a subgroup of addicts suicidality plays a larger role; a greater emphasis should thus be placed on the underlying psychopathology and the treatment needed.

[Drug substitution treatment of heroin dependent patients with codeine preparations--treatment effects from the viewpoint of the physicians and patients]

The controversy caused by the debate on treatment and substitution strategies in drug addiction is unchanged. This is particularly true concerning the use of codein-based drugs in the substitution of heroin abusers. However, only a few studies on the effects of this old and widely used method of substitution have been carried out. This article presents one retrospective and prospective study on the effects of the codein-based substitution in heroin abusers (n = 416). With respect to the issues addressed by this study such as somatic and psychic health, social integration, delinquincy and consumption patterns, patients as well as clinicians report an improvement in general health and fewer of the problems usually associated with heroin abuse, similar to the results from substitution treatment elsewhere.

[Basic symptoms in schizophrenia and alcoholism. A methodological comparative study]

The results of a study on the subjective basic symptoms associated with schizophrenia and drug abuse (especially alcoholism) are presented. A total of 242 psychiatric inpatients (74 with a dual diagnosis of schizophrenia and drug consumption, 81 schizophrenics, and 87 alcoholics) were included. The three groups did not differ with regard to the general score of subjective basic symptoms measured by the Frankfurt Complaint Questionnaire (Frankfurter Beschwerde-Fragebogen, FBF). Further analyses showed that the FBF statements are only partly typical for schizophrenia; another part is connected with alcoholism. Two new scales ("FBF-S" and "FBF-A") were created from the schizophrenia-typical items and the alcoholism-typical items, respectively. In "FBF-S" schizophrenics (with and without alcoholism) had higher scores than patients suffering from alcoholism alone; in "FBF-A" alcoholics (with and without schizophrenia) reached higher scores than schizophrenic patients. Consistent correlations with independent parameters of psychosis and alcoholism confirm the validity of "FBF-S" and "FBF-A". It is concluded that the FBF's capacity to discriminate different diagnoses can be improved and that the model of basic disturbances must be re-evaluated.

Suicide among schizophrenic adolescents in the long-term course of illness

The significance of the suicide problem for patients showing first symptoms of schizophrenic disorders between 14 and 18 years of age is presented in a long-term follow-up study including two follow-up periods after a minimum of 5 and 11 years. The suicide rate of 13.1% is significantly higher than in other studies with patients who developed a schizophrenic psychosis in a later period of life. In addition, there is a significant sex difference in the rate of suicide--21.5% of the men and 6% of the women--although the latter made more attempts at suicide.

Oral administration of insulin in solid form to nondiabetic and diabetic dogs

It was previously demonstrated that a biologically active insulin could cross the mucosal membrane in the gut by using surface active substances. In this report we describe studies in which insulin administered orally, in a solid formulation, was effectively absorbed in the canine model. The insulin was mixed with cholate and soybean trypsin inhibitor. It was delivered orally, as enterocoated microtablets, to nondiabetic and diabetic (pancreatectomized) dogs in a fasting state. The time interval between the administration of the drug and the beginning of a decrease in the plasma glucose levels was 60-140 min. This decrease reached a minimum level of 20-40 % of the initial values and lasted for more than 90 min following administration of the drug. In this model a pronounced increment in plasma insulin levels was shown prior to the drop of plasma glucose concentrations. It is concluded that with this novel oral insulin formulation a beneficial biological effect can be achieved in the treatment of diabetes.

[Treatment with psychotropic drugs in various facilities for mentally handicapped patients]

798 mentally retarded adults (> 19 years) in different types of residential care were studied with regard to psychotropic drug treatment and associated behaviour problems. The frequency of psychotropic medication amounts to 11.2% for residents of community-based group homes, 31.4% for residents of large institutions and 74.6% for long-term care patients of a Psychiatric Clinic. Neuroleptics were the most often prescribed drugs. After controlling for the degree of mental retardation, it could be shown that for persons with behaviour problems the probability of psychotropic drug treatment was 3 times as high in the group homes, and 5.7 times as high in the large institutions, as for the corresponding groups without behaviour problems.

Schizophrenia with onset in adolescence: an 11-year followup

This study examined the course of illness and factors affecting it in schizophrenias with onset between the ages of 14 and 18. Noteworthy in comparison to findings from other followup studies is the higher proportion of chronic courses of illness, about 50 percent. In addition, the type of course of illness corresponds in general with the treatment status. A possible explanation for this observation is the early age of onset, at which point the patient has not yet developed a sufficient degree of social and emotional independence and maturity before developing a schizophrenic psychosis. The age of onset is also shown to be an important predictor for the overall course of illness, as in other studies.

Sex-role orientation and work adaptation of male nurses

Three competing hypotheses regarding the influence of sex-role orientation on work-stress (pressure and strain at work) and work-attraction (work centrality and satisfaction) adaptation of 154 male nurses were contrasted. The findings reveal that even in a female-dominated profession, masculine-type male nurses were, on the whole, the best adapted type while the feminine-type male nurses were the least. The androgynous-type nurses, though ranking high in pressure and strain stemming from their work, nevertheless ranked highest in work satisfaction. In contrast, the undifferentiated were not stressed nor pressured at work, but they did not enjoy their work. These analyses were repeated for 54 female nurses. Among the female nurses no significant differences were found between the four sex role orientations, indicating that the differences found among the male nurses stemmed from the special situation in which a male nurse finds himself. It is suggested that change in the nature of the nursing profession into more "masculine" tasks also may partially explain the results.

[Diathermy-induced gas explosion in the intestinal tract]

Surgical diathermy is widely used in modern operating rooms, although explosion in the gastrointestinal tract is a known serious complication. We report a case of colonic explosion following use of diathermy. Based on our experience and the available data, it is recommended that in cases of gastrointestinal tract obstruction, poor bowel preparation or following use of oral mannitol for bowel preparation, diathermy should be avoided in opening the gastrointestinal lumen.

Production of 6-keto-PG F1 alpha in hyperstimulated cycles: in vivo and in vitro studies

Prostacyclin (PG12), a potent vasodilator, is believed to be involved in increasing permeability within the wall of the preovulatory follicle. In ovarian hyperstimulation syndrome (OHSS), increased vascular permeability has been shown to lead to massive fluid accumulation in ovarian cysts and the peritoneal cavity. The objective of the in vitro and in vivo studies reported herein was to examine the production of 6-keto PGF1 alpha (a breakdown metabolite of PG12) during the luteal phase of women who develop OHSS, as well as the capacity of human granulosa luteal cells (GLC) obtained from stimulated in vitro fertilization (IVF) cycles to synthesize PGF1 alpha in vitro in long-term cultures. The in vivo results showed that during the luteal phase of women with OHSS, there is no increase in 6-keto PGF1 alpha production compared with the levels obtained from the luteal phase of normal ovulatory women. The GLC (representing early corpus luteum function) secreted significant amounts of 6-keto PGF1 alpha, but only in the first 48 hours of culture. Human chorionic gonadotropin (hCG) had no additional augmentative effect upon the production of 6-keto PGF1 alpha throughout the culture period. It is concluded that 6-keto PGF1 alpha is not produced in significant amounts during the luteal phase, and therefore PG12 probably does not play a major role in the etiology of OHSS.

[Therapeutic treatment with neuroleptics. II: Subjective mechanisms of effect, compliance and consequences for treatment strategy]

The problems of subjective acceptance and reaction by the patients to the effects produced by neuroleptics, have been receiving far more less attention so far than the "objective" aspects, and have not yet been empirically tested to the same extent. However, papers have been published recently in connection with this complex within the framework of researches into concept of disease and into compliance. These papers supply proof of the tremendous significance of the patient's attitude to, and assessment of, pharmacotherapeutic measures. The following aspects are pointed out to be particularly important: The attitude and relation of the patient to his psychosis; the style of coping in the sense of integration or disintegration of the psychosis into the process of life; the dysphoric reactions to neuroleptics; and the disease pattern or disease model. Practical model examples are given to illustrate three possibilities of a more intensive connection between neuroleptic therapy and other therapeutic measures.