The relation between suicidal feelings and mental disorders in the elderly: results from the Berlin Aging Study (BASE)

BACKGROUND

The purpose of this study was to demonstrate the influence of several risk factors (particularly physical and mental disorders, loneliness and housing conditions) on the wish to die in the elderly.

METHOD

Using data from a population-based sample of 516 senior citizens (70 to 103 years of age) in Berlin (Germany), we compared 54 persons with death wishes with 462 persons without death wishes on several psychosocial risk factors, physical health and psychiatric diagnoses. A logistic regression analysis was also conducted.

RESULTS

. The data indicate that the wish to die is strongly associated with the presence of a mental disorder, especially major depression, while higher age, female gender, subjective assessment of physical health and negative living conditions were all only moderately related to death wishes.

CONCLUSIONS

Our results emphasize the need for very careful diagnosis of death wishes in the very old and question the view that it is a normal and understandable phenomenon in older age.

Dosage finding and outcome of venlafaxine treatment in psychiatric outpatients and inpatients: results of a drug utilization observation study

BACKGROUND

Venlafaxine is an antidepressive drug with the special characteristic of inhibiting both synaptic serotonin and norepinephrine reuptake. This double action is dosage dependent, with the relatively weaker inhibition of norepinephrine becoming clinically relevant only at higher dosages. This allows treatment to be tailored towards the needs of individual patients through differential dosing. It is unknown, however, how physicians use this unique feature in prescribing venlafaxine in routine treatment.

METHOD

Data from a drug utilization observation (DUO) study, including 6706 patients, are used to investigate which patient and setting variables predict dosage of venlafaxine as prescribed by psychiatrists in inpatient and outpatient settings. Treatment outcome and adverse drug reactions (ADR) were analyzed for different dosage groups.

RESULTS

Treatment setting is the most important factor in predicting high (> 75 mg/day) or low (up to 75 mg/day) dosage of venlafaxine, with inpatients receiving higher dosages. Severity of illness and a history of previous treatment with major antidepressives are also related to higher dosages. Although the total rate of ADR did not increase with increased dosage, the profile of drug reactions changed. Response to therapy was better in cases of non-chronic, major depression with no treatment history of antidepressives. Additionally, increased dosage increased the likelihood of response in outpatients. In both settings, very high dosages predicted better response to venlafaxine among severely ill patients.

CONCLUSION

Venlafaxine at a dosage of 75 mg/day is sufficient for the majority of cases. In extremely ill patients, higher dosages are associated with additional benefits. Therefore, a stepwise dosage regimen is suggested, with an increase of dosage to upper limits in cases of non-response before discontinuation of treatment with venlafaxine.

Determinants of the quality of life (QoL) in patients with an implantable cardioverter/defibrillator (ICD)

OBJECTIVES

In high-risk cardiac patients the treatment of life-threatening arrhythmias with an implantable cardioverter/defibrillator (ICD) extends survival. Other important outcome criteria are treatment side effects especially the quality of life (QoL). Knowledge of the variables that influence QoL is important for therapy decisions in ICD patients.

METHODS

Ninety-three ICD patients evaluated their QoL by the SF-36 after 1-6 years of ICD implantation. The QoL was studied in relation to cardiac function (severity of heart failure, ejection fraction), treatment course (number of shocks), coping styles and psychiatric syndromes.

RESULTS

About 30% of the somatic QoL (physical role function, pain) is determined by the patients' somatization tendency, i.e. the extent to which they suffer from non-specific symptoms (sweating, weakness in the legs, nausea). The severity of heart failure had little influence on the physical QoL. The emotional QoL is primarily determined by phobic anxiety of ICD patients.

CONCLUSIONS

Psychiatric symptoms are the most important factors to determine the QoL in ICD patients. Behavioural treatment procedures of phobic anxieties and somatization could improve QoL in ICD patients.

Die posttraumatische Verbitterungsst�rung (PTED)

Adaptation disorders are a heterogeneous group of mental disorders. Although they play a major role in clinical practice, are difficult to treat, and often lead to chronicity and disability, diagnostic algorithms are vague and scientific research is rare. Clinical practice has shown a subtype of adaptation disorder that is characterized primarily by lasting embitterment after exceptional though normal life events which violate basic beliefs. This disorder can be called post-traumatic embitterment disorder (PTED). A case vignette and results of a pilot study are reported. Critical life events were found to be job loss in 38%, conflicts at work in 24%, death of a loved one in 14%, familial strain in 14%, and other events in 10%. When reminded of the critical event, patients report feelings of embitterment (85.7%), sadness (81.0%), anger (76.2%), or helplessness (75.0%). When standardized assessments are made, they fulfill criteria of various comorbid disorders such as GAD (38.1%), depression (33.3%) and dysthymia (33.3%), agoraphobia (28.6%), or panic (19.0%). Of the patients, 81% said they avoid places which remind them of the critical events. Impairments were suffered in work (70%), leisure (65%), and familial relations (57.1%).

Pathways to care and psychological problems of general practice patients in a "gate keeper" and an "open access" health care system: a comparison of Germany and the Netherlands

BACKGROUND

The comparison of different health care systems is one way to give empirical evidence to health care reform and policy. The differences between health care systems in which general practitioners serve as gate keepers in comparison to systems in which patients are free to contact every physician and specialist they like are a question of high interest.

METHOD

This study compares the Netherlands and Germany, two countries with very similar political, social, and health system structures, but different types of access to the health care system. While Germany offers unconstrained access to specialist ambulatory care, the Netherlands restricts health care utilization by giving primary care a 'gate keeper' function not allowing patients direct access to specialist care. Data from the WHO international collaborative study on psychological problems in general health care (Ustün and Sartorius 1995) were analysed with respect to pathways to care, treatment, and health status. In an initial cross-sectional assessment, in 3-month and 12-month follow-ups, contacts to physicians or hospital admission have also been monitored.

RESULTS

There were only marginal differences between the Dutch and the German sample in the sociodemographic characteristics as well as in the diagnostic status with respect to mental disorders. In the Netherlands, 95.5%, and in Germany, 68.8% of the patients presented their 'reason for visit' for the first time to any physician at this index contact with a general practitioner. During the following 3 months, 24% of the Dutch patients, but 60.2% of the German patients, additionally contacted other physicians ( P < 0.001). At 12 months, this rate was 62.9% vs. 78.6% ( P < 0.001). During the 12-month follow-up period, there were 15.7 0/00 hospital admissions in Germany vs. 25.4 0/00 in the Netherlands ( P < 0.005) [corrected].

CONCLUSIONS

Family physicians in a gate keeper system reduce the number of contacts to other physicians and the intensity of treatment, while at the same time the rate of hospital admissions is increased.

Mechanisms of mitochondria-neurofilament interactions

Mitochondria are localized to regions of the cell where ATP consumption is high and are dispersed according to changes in local energy needs. In addition to motion directed by molecular motors, mitochondrial distribution in neuronal cells appears to depend on the docking of mitochondria to microtubules and neurofilaments. We examined interactions between mitochondria and neurofilaments using fluorescence microscopy, dynamic light scattering, atomic force microscopy, and sedimentation assays. Mitochondria-neurofilament interactions depend on mitochondrial membrane potential, as revealed by staining with a membrane potential sensitive dye (JC-1) in the presence of substrates/ADP or uncouplers (valinomycin/carbonyl cyanide p-(trifluoromethoxy)phenylhydrazone) and are affected by the phosphorylation status of neurofilaments and neurofilament sidearms. Antibodies against the neurofilament heavy subunit disrupt binding between mitochondria and neurofilaments, and isolated neurofilament sidearms alone interact with mitochondria, suggesting that they mediate the interactions between the two structures. These data suggest that specific and regulated mitochondrial-neurofilament interactions occur in situ and may contribute to the dynamic distribution of these organelles within the cytoplasm of neurons.

[Finding the reasons for "workplace phobia". Sick leave can cause damage]

Anxiety engendered by the workplace leads to an inability to work and earn one's living. The term workplace phobia is applied when anxiety leads to avoidance of the workplace. As in the case of school phobia, a range of differential diagnoses may be involved, requiring careful clarification. Such may include post-traumatic stress disease, posttraumatic embitterment, social phobia, personality disorders, depression and organic brain disease. The treatment of workplace-related phobia differs from that of other phobias because of the peculiarities of the workplace. Simply giving the patient sick leave may do more harm than good, and as such needs to be carefully weighed up.

Is interval medication a successful treatment regimen for schizophrenic patients with critical attitudes towards treatment?

In neuroleptic long-term medication, only part of the patients accept regular intake of neuroleptic drugs. The question is whether an interval medication regimen as opposed to continuous medication can help to reduce drop outs in patients with critical attitudes towards long-term medication. In a 2-year prospective study, 122 patients were randomised to an interval and 164 to a continuous neuroleptic medication regimen. The drop out rates were 62.5% in the interval and 53.7% in the continuous medication group. Drop outs generally show more negative attitudes towards treatment. Patients with negative attitudes do not do better under interval medication. Moreover, this regimen even requires more cooperation and trust in terms of the necessity of medication on the part of the patient compared to the continuous medication regimen. Interval medication therefore is a strategy which can only be successful in highly cooperative, but not in treatment-reluctant patients.

A comparison of GMS-A/AGECAT, DSM-III-R for dementia and depression, including subthreshold depression (SD)--results from the Berlin Aging Study (BASE)

BACKGROUND

Empirical evaluation of the agreement between different diagnostic approaches is crucial for the understanding of epidemiological results in geriatric psychiatry.

OBJECTIVES

In this paper, we analyse differences between widely used diagnostic approaches of dementia and depression and offer evidence that diagnostic thresholds vary substantially on quantitative dimensions, but that conceptual and other differences between approaches must also been taken into account.

METHODS

In an epidemiological study of n = 516 persons, aged 70-103 years, we compared psychiatric diagnoses of dementia and depression obtained by GMS-A/HAS-AGECAT, DSM-III-R and clinician's diagnoses of subthreshold depression (SD).

RESULTS

For depression, cumulative prevalence of clinician's diagnosis (including SD, GMS-A/HAS-AGECAT and DSM-III-R defined forms) was highest, followed by GMS-A/HAS-AGECAT-diagnosis and DSM-III-R, while for dementia DSM-III-R was followed by GMS-A/HAS-AGECAT. Overall agreement between DSM-III-R and GMS-A/HAS-AGECAT was moderate. Adapting thresholds for AGECAT resulted in slightly better diagnostic efficiency. Diagnostic disagreement was found predominantly for cases with intermediate symptom severity, supporting the hypothesis of differing thresholds between DSM-III-R and GMS-A/HAS-AGECAT, while cases with lower or higher symptom severity were similarly seen as cases or non-cases.

CONCLUSION

Disagreement is not only caused by conceptual differences, but also different thresholds of diagnostic algorithms. Adaptation of threshold levels should be feasible, depending on the purpose of the analysis.

Correlates of suicidal ideation in general healthcare patients - Results of the WHO Collaborative Study on Psychological Problems in General Health Care (WHO-PPGHC)

In the WHO study on Psychological Problems in General Health Care (WHO-PPGHC), a random sample of 5438 patients from 15 international centres were investigated to study prevalence and type of mental disorders by use of standardized methods. Using the General Health Questionnaire, 9.7% of the practice attenders admitted that they have or recently had suicidal ideations. In a logistic regression analysis, predictors of suicidal ideation were hopelessness, presence of an ICD-10 diagnosis, social disability in terms of occupational role functioning and daily routine, and lack of social adaptation in terms of lower age and being less educated. The predictors are discussed in an explanatory model of suicidal ideation in general healthcare. Implications for patient care in general healthcare are discussed.

Effects of rhinovirus-induced common colds on granulocyte activity in allergic rhinitis

OBJECTIVE

To explore the activities of mast cells, eosinophils, and neutrophils in patients with allergic rhinitis developing common colds and increased responsiveness to allergen following nasal rhinovirus inoculation.

METHODS

We have revisited a nasal lavage material obtained from 17 patients who were successfully inoculated with rhinovirus outside the pollen season and received nasal allergen challenges before and after inoculation. We have examined indices of mast cell activity (tryptase), eosinophil degranulation (eosinophil peroxidase; EPO), and neutrophil activation (myeloperoxidase; MPO).

RESULTS

Allergen challenges performed before rhinovirus inoculation increased the nasal output of EPO. Notably, this response was significantly greater after rhinovirus inoculation (cf. before inoculation). The output of MPO was also increased following allergen challenge after, but not before, rhinovirus inoculation. Nasal lavage fluid levels of tryptase were increased following allergen challenge similarly before and after rhinovirus inoculation. Also, the viral infection did not affect the baseline levels of tryptase.

CONCLUSIONS

The present data demonstrate that rhinovirus infections activate both eosinophils and neutrophils, but that they may not affect mast cell activity. We suggest that common colds in part through stimulation of granulocyte activity potentiate the airway inflammation in allergic diseases.

A prospective study of factors influencing adherence to a continuous neuroleptic treatment program in schizophrenia patients during 2 years

Dropout from prophylactic neuroleptic treatment is one major reason for relapse in schizophrenia patients. There is a lack of prospective studies on factors that predict medication adherence. We investigated factors suspected to predict dropout from continuous neuroleptic treatment in a 2-year prospective study involving 122 outpatients with a DSM-III-R diagnosis of schizophrenia. Forty-two (34.4%) were classified as patient-related dropouts. No significant difference between compliant patients and dropouts was found with regard to sociodemographic variables, except that compliant patients were significantly older. Also, no differences in psychopathology were seen at the beginning of treatment, but compliant patients had a longer duration of illness. Compliant patients had higher doses of neuroleptics in the initial stabilization phase and correspondingly showed more extrapyramidal signs. Physicians rated compliant patients from the beginning as more cooperative. These patients also showed significantly higher scores in positive treatment expectations. In a stepwise regression analysis, positive illness concepts, the global assessment of functioning (GAF), and the physicians' view of patients' cooperation predicted 19 percent of the variance. We concluded that the prediction of dropouts is insufficient and remains largely an unsolved problem. Future research should focus more on context factors in the search for clinically meaningful explanations of patient dropout from treatment.

[ICD-10 primary health care. WHO support for family practice psychotherapy]

In the year 2001, The World Health Organization (WHO) published a special edition of the International Classification of Mental Disorders (ICD-10, Chapter F) for use by general practitioners (ICD-10 PHC-Primary Health Care). In this GP version of the ICD-10, diagnostic categorizations and algorithms serving treatment requirements are summarized in simplified form. Unlike the general ICD-10 guidelines, this version also contains management guidelines for each disease category. These include information for the patient and family, advice on counseling, description of treatment methods, and indications for specialist referral. The treatment guidelines are differentiated, concrete and suitable for use in the doctor's office, and concise (in each case not more than a single page). The WHO also offers an education program to enable the interested GP to deepen his knowledge of the treatment guidelines and their theoretical basis. A particular feature of this program are patient information leaflets that guide the physician on what the patient needs to be told. The physician can use these as a basis for his talks with the patient, or give them to the patient for home study.

[Chronic course and psychosocial disability caused by depressive illnesses in general practice patients during a one year period. Results of a study by the World Health Organization]

As part of an international WHO study on psychological disorders in primary health care, patients were examined for mental disorders and especially depression and social disability in the course of 1 year. Depression is common in primary care (8.6%) and frequently associated with recurring or chronic courses (33.3%). Depression at baseline leads to a 100% increase of lost working days (3.2 per month) 1 year later as compared to patients without depression (1.7). The diagnosis of depression at baseline poses a greater risk for a relevant and lasting psychosocial disability (28.2%) than e.g. chronic somatic illnesses (8.6%). Even the diagnosis of a subthreshold depression leads comparatively to a higher degree of psychosocial disability (15.6% of patients) and days of absenteeism at work during the last month (2.9 days).

[Vagus nerve stimulation. A potential therapy for chronic/recurrent depression?]

Vagus Nerve Stimulation (VNS) is since the 1990 a clinically useful anticonvulsant therapy for treatment-resistant epilepsy. Open acute and longer term data suggest the potential clinical utility of VNS as an antidepressant therapy especially in treatment refractory depression. The vagus nerve has connections to the limbic system and other brain structures which modulate affect. PET studies showed functional changes under VNS in such critical areas, which can explain the mechanisms of action of VMS. Ongoing studies will have to better establish its acute and longer-term efficacy, and specific indications in the treatment of depression.

[Do old persons wish to die? Suicidal tendencies and weariness of life in old age. Results of the Berlin Aging Study (BASE)]

On the basis of the results of the Berlin Aging Study (BASE), some 15% of persons aged 70 years and older confess to being tired of life, 5% express a wish to die, and 0.5-1% entertain thoughts of suicide. Women express a wish to die or have thoughts of suicide approximately 1.5 to 3 times more frequently than men. Depending on the severity of the suicidal tendency, more than 80% of such patients, and all of these entertaining thoughts of suicide, suffer from acute psychiatric disorders. Death wishes and thoughts of suicide must therefore always prompt an intensive psychiatric diagnostic work-up, and initiation of suitable and rigorous treatment, and must not be mistaken for the expression of understandable attitudes towards aging.

[Generalized anxiety disorders (GAD)--a neglected illness? Background und aims of the GAD-P study]

In the past Generalized anxiety disorder (GAD)--previously classified as anxiety neurosis--was regarded as not being a separate diagnostic entity. On the basis of new explicit criteria for GAD in the 90ies, GAD-specific pharmacological (i.e. SNRI) and psychological treatments with improved efficacy have become available. The Generalized Anxiety and Depression in Primary care study (GAD-P) investigates the prevalence of GAD in primary care settings and evaluates the patterns of care provided. Aims, methods and findings of the GAD-P study are described in this supplement.

[Psychosocial Risk Factors of the Wish to be Dead in the Elderly]

BACKGROUND

Suicidal ideation is a common phenomenon in the elderly. The purpose of this report is to reveal the influence of psychosocial risk factors and psychiatric disorders on the wish to die in the elderly.

METHOD

We compared the data of 54 persons (age 70+) who said that they wished to die with 462 persons without death wishes according to several psychosocial risk factors, physical health and psychiatric diagnoses. The data come from the Berlin Aging Study, an interdisciplinary assessment of an epidemiological random sample of 516 citizens in Germany.

RESULTS

Using a MANOVA and logistic regression analysis the data indicated that the wish to be dead, even in these very old persons, was mostly associated with the occurrence of a major depression, self rated higher depressivity, higher age, female gender, and negative life conditions such as living in a nursing home.

CONCLUSION

The results of this study support that the wish to be dead in the very old is very likely to be associated with the occurrence of a psychiatric disorder, especially major depression and the higher probability of negative life conditions. Thus, we emphasize the requirement of psychiatric assessment as well as treatment of those older people who want to die.

Cognitive impairment in depressed outpatients as measured with the Dementia Checklist: a simple method for primary care and in field research

The Dementia Checklist is a 12-item dementia rating scale for physicians who, for whatever reason, cannot be specifically trained. It addresses symptoms of cognitive decline that can easily be identified, and that are typical for different stages of cognitive impairment. This allows an easy classification of the severity of dementia. In a first study, the dementia checklist was used in 937 geriatric outpatients who were treated by neuropsychiatrists for depression. All items contribute to the accuracy of measurement (Cronbach's alpha = 0.84). Differences in cognitive impairment depending on age (chi 2 = 51.7; p < or = 0.001) and depression (chi 2 = 47.6; p < or = 0.001) indicate external validity of the dementia checklist and 5.7% of the outpatients were rated as demented. The Dementia Checklist provides a very economical and easy-to-use assessment of cognitive decline.

Mucosal output of eotaxin in allergic rhinitis and its attenuation by topical glucocorticosteroid treatment

BACKGROUND

Eotaxin is a chemokine that attracts and activates eosinophils. The present study examines the occurrence of eotaxin in nasal mucosal surface liquids in patients with seasonal allergic rhinitis without allergen exposure and during repeat allergen challenge with and without topical glucocorticosteroid treatment. The number of subepithelial eosinophils and mucosal outputs of bulk plasma (alpha2-macroglobulin) and eosinophil cationic protein (ECP) are also examined.

METHODS

Twelve patients underwent daily allergen challenges for 6 days. Separately, 14 patients, who were receiving budesonide and placebo in a parallel group design, also underwent allergen challenge for 6 days. Nasal biopsies were obtained before and 24 h after the allergen challenge series, and lavages were carried out before and 15 min after selected allergen challenges.

RESULTS

At baseline nasal lavage fluid levels of eotaxin correlated to levels of alpha2-macroglobulin and ECP. After the first allergen challenge there was a correlation between nasal lavage fluid levels of eotaxin and ECP. Repeat allergen exposure increased the mucosal output of eotaxin (P <0.05) and ECP (P <0.01) as well as eosinophil numbers (P <0.01), but no correlation was found between increased eosinophil numbers and eotaxin. Budesonide reduced eotaxin levels during repeat allergen challenge (P <0.05).

CONCLUSIONS

Repeat allergen exposure in allergic rhinitis is associated with increased mucosal output of eotaxin. Topical budesonide attenuates this effect, suggesting the possibility that inhibitory effects on mucosal eotaxin may contribute to anti-eosinophilic actions of topical glucocorticosteroids.

Epidemiology and psychiatric morbidity of suicidal ideation among the elderly

This study investigates the epidemiology and psychiatric morbidity of the wish to be dead, suicidal ideation, and suicidal intent in a group of elderly persons (> 70 years). A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview GMS-A and various other self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R and clinical judgment. In a cross-section of this population, we found the following prevalence rates: At the time of the study, 14.7% of the elderly community had symptoms of tiredness of life, 5.4% wished to die, and 1% showed suicidal ideation or gestures. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as suffering from psychiatric disorders and 50-75% showed symptoms fulfilling the criteria of at least one specific psychiatric diagnosis. Further, logistic regression analysis showed a significant influence of major depression and specific DSM-III-R diagnosis on suicidality in old age. Our conclusion is that suicidal ideation in the elderly is usually a sign of a mental illness warranting diagnosis and treatment rather than assisted suicide.

Epidemiology and psychiatric morbidity of suicidal ideation among the elderly

This study investigates the epidemiology and psychiatric morbidity of the wish to be dead, suicidal ideation, and suicidal intent in a group of elderly persons (> 70 years). A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview GMS-A and various other self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R and clinical judgment. In a cross-section of this population, we found the following prevalence rates: At the time of the study, 14.7% of the elderly community had symptoms of tiredness of life, 5.4% wished to die, and 1% showed suicidal ideation or gestures. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as suffering from psychiatric disorders and 50-75% showed symptoms fulfilling the criteria of at least one specific psychiatric diagnosis. Further, logistic regression analysis showed a significant influence of major depression and specific DSM-III-R diagnosis on suicidality in old age. Our conclusion is that suicidal ideation in the elderly is usually a sign of a mental illness warranting diagnosis and treatment rather than assisted suicide.

[Depressive disorders and antidepressive therapy. A comparison of neurology practice and psychiatric clinic]

It is a question of great importance when psychiatric patients should be treated as inpatients or as outpatients. This decision depends on therapeutic as well as economic considerations. However in depression, as in other mental illnesses, many cases could reasonably be treated as in- or outpatients alike. Despite the importance of this question, there is to our knowledge no epidemiological study which compares patients in inpatient and outpatient settings within the current German medical system. 1300 inpatients and 5376 outpatients were investigated using identical methodologies within a drug utilization study of the antidepressant venlafaxine. Inpatients were found to be more severely ill and have a recurrent course of illness and higher rates of comorbidity. Outpatients more often had a chronic course. Inpatients were treated more often and with a wider variety of medication than outpatients, with the exception of phytopharmaceuticals. Venlafaxine was given in higher doses in the inpatient setting and combined more often with other psychotropic medications. Complaints of adverse drug reactions were comparable in both groups. Nausea was the most frequent, reported by 9.7% of inpatients and 15.2% of outpatients. The data show that the distribution of patients in outpatient and inpatient settings corresponds to the stepwise structure of the German health care system.

Epidemiology of prescriptions for neuroleptic drugs: tranquilizers rather than antipsychotics

BACKGROUND

The pharmacology of neuroleptics as well as epidemiological and clinical observations of prescriptions of these drugs give the impression that they are and can be used for indications other than schizophrenia to a considerable degree.

METHOD

We analyzed pharmacoepidemiological data on neuroleptic prescriptions in Germany. We used the following criteria: numbers of defined daily doses (DDDs) per annum, diagnoses for which they were prescribed, patient age, specialist medical training of the prescribing physician, and indicators that neuroleptics were used instead of other psychotropic drugs such as minor tranquilizers.

RESULTS

Only 14% of the prescriptions for neuroleptic drugs were for schizophrenic psychoses, 18% for other paranoid psychoses and 5% for affective disorders. 63% were prescribed for neurotic disorders, sleep disorders, or dementia. Almost half of the neuroleptic prescriptions were given for patients aged 65 years or over. Only 40% were prescribed by psychiatrists or neurologists. Throughout the period from 1986 to 1995, neuroleptic prescriptions increased steadily, which was paralleled by a decrease in the prescription rates for benzodiazepines.

CONCLUSIONS

Evaluation is urgently needed for those uses of neuroleptic drugs that, from a pharmacoepidemiological perspective, must be seen as their primary indication.

Clinical skin temperature measurement to predict incipient pressure ulcers

OBJECTIVE

To evaluate temperature differences between areas of erythema and surrounding healthy tissue to determine whether clinical temperature measurement of sites at risk for pressure ulcer development could be used to indicate tissue damage. To validate the temperature portion of the National Pressure Ulcer Advisory Panel's new Stage I pressure ulcer definition.

DESIGN

Repeated measures design.

SETTING

Acute rehabilitation hospital.

SUBJECTS

65 outpatients and inpatients presenting with pressure-induced erythema at areas at risk for pressure ulcer development. The subjects were primarily non-ambulatory and exhibited a range of skin pigmentation and disabilities, including spinal injury, multiple sclerosis, and lower-limb amputations.

MAIN RESULTS

The temperature and appearance of 80 pairs of erythematic and control sites were documented. Sites were considered to have equal temperatures if the difference was within plus or minus 1.0 degree F. Fifteen percent (n = 12) of the erythematic sites were the same temperature as the surrounding tissue, 23% (n = 18) of the erythematic sites were cooler than the control sites, and 63% (n = 50) were warmer.

CONCLUSION

Both increased and decreased temperature differences can be used to indicate reactive hyperemia or a Stage I pressure ulcer, but a tissue integrity problem may still exist despite the absence of a temperature difference.

The development of a quantitative electroencephalographic scanning process for attention deficit-hyperactivity disorder: reliability and validity studies

The development of a quantitative electroencephalographic (QEEG)-based procedure for use in the assessment of attention deficit-hyperactivity disorder (ADHD) was examined through a series of studies investigating test reliability and validation issues. This process, involving a spectral analysis of the electrophysiological power output from a single, midline, central location (the vertex), was conducted in 469 participants, 6 to 20 years of age, classified as ADHD, inattentive type; ADHD, combined type; or control. The results indicated that the QEEG scanning procedure was reliable (r = .96), was consistent with the Attention Deficit Disorders Evaluation Scale (S. B. McCarney, 1995) and the Test of Variables of Attention (L. M. Greenberg, 1994; chi-square, p < .01), and differentiated participants with ADHD from a nonclinical control group (p < .001). The sensitivity of the QEEG-derived attentional index was 90%; the specificity was 94%.

Classic conditioning and dysfunctional cognitions in patients with panic disorder and agoraphobia treated with an implantable cardioverter/defibrillator

OBJECTIVE

A model for the development of anxiety disorders (panic disorder with or without agoraphobia) is needed. Patients with an implantable cardioverter/defibrillator (ICD) are exposed to repeated electric shocks. If the theory of anxiety development by aversive classic conditioning processes is valid, these repeated shocks should lead to an increased risk of anxiety disorders. To study this hypothesis, we retrospectively studied 72 patients after implantation of an automatic ICD.

METHODS

Patients were assessed with the semistructured Diagnostic Interview of Psychiatric Disease 1 to 6 years after implantation of an automatic ICD. Panic disorder and/or agoraphobia was diagnosed in patients who fulfilled all DSM-III-R criteria for those conditions.

RESULTS

Anxiety disorder developed in 15.9% of patients after ICD implantation. This was significantly related to the frequency of repeated defibrillation (shocks) to stop malignant ventricular arrhythmias. Dysfunctional cognitions are an additional vulnerability factor.

CONCLUSIONS

The data support both the conditioning hypothesis and the cognitive model of anxiety development. These findings suggest that ICD patients are an appropriate risk population for a prospective study of the development of anxiety disorders.

Ranges of psychiatric morbidity in the old and the very old--results from the Berlin Aging Study (BASE)

The purpose of this study was to determine prevalence rates of psychiatric morbidity in the elderly, distinguishing different levels of psychiatric caseness as compared to the diagnoses of the DSM-III-R. In a cross-sectional population-based study in Berlin (West), Germany, 516 people aged 70 to 95+ were randomly selected from the obligatory city registry (1990-1993) and stratified by age and gender (N = 43 men and N = 43 women in each of six 5-year age groups). Psychiatric and physical examinations were carried out in an extensive standardized assessment. Distinct psychopathological syndromes occurred in 72.7% of the elderly (54.6% of the men, 79.1% of the women). A clinically defined psychiatric disorder was found in 49.4% of the elderly (95% confidence interval 43.9%- 54.9%; 36.4% of the men, 54.0% of the women). Excluding insomnia, the overall psychiatric morbidity was 40.4% (30.9% m, 43.8% w). Excluding clinical diagnoses that were not otherwise specified in the DSM-III-R, the overall prevalence of specified DSM-III-R diagnoses was 23.5% (16.3% m, 26.0% w). Excluding dementia, which is known to be age-related, the prevalence was 11.3% (8.5% m, 12.2% w) and no significant effect between the age groups was seen. A considerable proportion of clinically relevant psychiatric morbidity in the elderly does not meet the criteria of specified DSM-III-R diagnoses, although these cases are in need of care. The data show that the threshold and severity of caseness accounts for important differences when overall psychiatric morbidity is assessed.

Efficacy and safety findings from naturalistic fluoxetine drug treatment in adolescent and young adult patients

This article reports on the efficacy and safety of the selective serotonin reuptake inhibitor, fluoxetine, in 213 patients (ages 11-23 years) treated by psychiatrists/neurologists (PN) or general practitioners/internists (GPI). Data were derived from naturalistic drug utilization observation (DUO) studies with fluoxetine (n = 18,759 patients). Data collection--at the start and the end of the observation period (< or =6 weeks)--included patient characteristics, diagnoses, medication, co-medication, efficacy, and adverse events (AEs). Nonparametric statistics and descriptive p values (two-tailed) were used. Analyses revealed various differences between PN (n = 56) and GPI (n = 157) samples as to patient and treatment characteristics (p < 0.001-0.08). Based on both Clinical Global Impression (CGI; all p < 0.001) and self-assessment (total n = 47; Zung SDS, all p < or = 0.003), both PN and GPI patients showed improvements in their symptomatology over time, including suicidality (all p < 0.001; there were no group differences). Overall AE rates were higher in PN patients (p < 0.01; 17.9% vs. 4.5%); the frequency and type of AEs in both subgroups were typical for fluoxetine and the total DUO samples. In fact, AE rates were lower compared to controlled trials. Findings suggest that PN patients were more severely ill at observation start and suffered a more complicated treatment course. However, clinical efficacy showed highly significant improvements in both subgroups; AE rates were low in both--although higher in PN patients. Thus, results support a positive benefit/risk ratio of fluoxetine use for this young patient population.

Testing the validity of erythema detection algorithms

Dermatology has quantified skin color for monitoring progress of treatments. The most common and effective means of erythema detection is visual inspection of the skin. However, for people with darkly pigmented skin, erythema can be masked by melanin. Tissue Reflectance Spectroscopy (TRS) is a noninvasive method of quantifying skin color. Most commonly, TRS quantifies erythema caused by cosmetics, topical ointments, UV light, or other irritants. Recently, TRS has been used to characterize the presence of erythema due to reactive hyperemia or Stage I pressure ulcers. The objective of this study was to compare the reliability and validity of erythema detection algorithms by determining their sensitivity and specificity. Two algorithms, Diffey and Helen Hayes Hospital (HHH), had sensitivity exceeding 85% and specificity exceeding 75%, but most algorithms demonstrated adequate validity across all subjects. The validity of the HHH algorithm did not change with the skin pigmentation of the subject. The results of this comparison will be useful to researchers interested in using TRS to detect erythema in people with different skin pigment levels.

The development of a quantitative electroencephalographic scanning process for attention deficit-hyperactivity disorder: reliability and validity studies

The development of a quantitative electroencephalographic (QEEG)-based procedure for use in the assessment of attention deficit-hyperactivity disorder (ADHD) was examined through a series of studies investigating test reliability and validation issues. This process, involving a spectral analysis of the electrophysiological power output from a single, midline, central location (the vertex), was conducted in 469 participants, 6 to 20 years of age, classified as ADHD, inattentive type; ADHD, combined type; or control. The results indicated that the QEEG scanning procedure was reliable (r = .96), was consistent with the Attention Deficit Disorders Evaluation Scale (S. B. McCarney, 1995) and the Test of Variables of Attention (L. M. Greenberg, 1994; chi-square, p < .01), and differentiated participants with ADHD from a nonclinical control group (p < .001). The sensitivity of the QEEG-derived attentional index was 90%; the specificity was 94%.

Psychiatrists' diagnoses of subthreshold depression in old age: frequency and correlates

BACKGROUND

Depressive syndromes not fulfilling the criteria for specified disorders (subthreshold depression, SD) may be clinically important. We aimed to study SD in old and very old age, in comparison with subjects with no depressive symptoms (NDS) and subjects with major depression (MD).

METHODS

A community-based random sample of 516 subjects, age 70 to 100 years and over, stratified by age and sex, was examined. All participants were investigated by psychiatrists and by geriatricians independently.

RESULTS

In 16.5% (N = 85) of the study subjects SD was identified. Study subjects with SD had, similarly to the subjects with MD, significantly more somatic diagnoses and used more somatic as well as psychotropic medications than the subjects with NDS. Self-ratings and observer ratings of depression indicated that SD was a milder depressive state than MD.

CONCLUSIONS

Compared with MD, SD is probably a milder form of depression. The increased use of psychotropic medications indicates that at least a portion of these individuals have a disorder requiring treatment. One of the characteristics of SD is co-morbidity with somatic illnesses and physical disability.

In vitro bioactivity of aerosol-gel deposited TiO(2) thin coatings

Bioactive, pure, and Ca- or P-doped TiO(2) thin coatings on Ti metal and Si wafers were prepared by the aerosol-gel technique. The coatings were characterized by X-ray photoelectron spectroscopy, atomic force microscopy, Fourier transform infrared spectroscopy, and scanning electron microscopy. Bioactivity was determined in vitro in a simulated body fluid and was shown to be fully comparable to sol gel-derived TiO(2) coatings prepared by dip-coating. However, the formation rate of carbonate containing apatite decreased with increasing dopant concentration, which was related to changes in chemical composition and topology of the coatings.

Induced kappa receptor editing shows no allelic preference in a mouse pre-B cell line

B cell Ag receptor editing is a process that can change kappa antigen recognition specificity of a B cell receptor through secondary gene rearrangements on the same allele. In this study we used a model mouse pre-B cell line (38B9) to examine factors that might affect allelic targeting of secondary rearrangements of the kappa locus. We isolated clones that showed both productive and nonproductive rearrangements of one kappa allele, while retaining the other kappa allele in the germline configuration (kappa(+)/kappa degrees or kappa(-)/kappa degrees ). In the absence of any selective pressures, subsequent rearrangement of the germline alleles occurred at the same frequency as secondary rearrangement of the productive or nonproductive rearranged alleles. Because 38B9 cells lack Ig heavy chains, we stably expressed mu heavy chain protein in 38B9 cells to determine whether heavy-light pairing might affect allelic targeting of secondary kappa rearrangements. Although the expression of heavy chain was found to both pair with and stabilize kappa protein in these cells, it had no effect on preferential targeting Vkappa-Jkappa receptor editing compared with rearrangement of a germline allele. These studies suggest that in the absence of selection to eliminate autoreactive Vkappa-Jkappa genes, there is no allelic preference for secondary rearrangement events in 38B9 cells.

[Comparison of the responsibility spectrum of a community psychiatric emergency service and outpatient emergency care in a psychiatric clinic]

PURPOSE

The need for psychiatric crisis services is generally accepted. Additional to traditional crisis clinics which are located in general or psychiatric hospitals in recent years also special community crisis services were implemented. The question is whether there are differences in patients and type of care between traditional and new services.

METHODS

In this study empirical data are reported on reasons for contact, on patients and on interventions for a hospital based crisis clinic and a community crisis service. 132 service and 364 clinic contacts were recorded.

RESULTS

There were more neurotic patients in the community service and more psychotic patients in the clinic. In both services inpatient care had to be arranged in one third of the cases. In the hospital based crisis service fewer legal commitments were necessary. A speciality of the community crisis service is the possibility to look after patients in their homes.

CONCLUSION

Both services have similar features, but there are also differences which show that the new service offers new possibilities of care.

Immediate effect of topical budesonide on allergen challenge-induced nasal mucosal fluid levels of granulocyte-macrophage colony-stimulating factor and interleukin-5

The nasal antiinflammatory effects produced by maintenance treatment with topical steroids include reduced production of cytokines. The present study explored nasal mucosal effects induced during the first 9 h after a single dose of topical budesonide. Nine subjects with allergic rhinitis due to birch or timothy pollen were given budesonide (256 microg; Rhinocort Aqua) or placebo in a double-blind, randomized, crossover (4 wk washout) manner. Nasal allergen challenges were performed 30 min after the steroid/placebo pretreatment. Before and 30 min, 1, 3, 5, 7, and 9 h after challenge, filter paper strips were placed on the nasal septum and inferior turbinates for 10 min to sample undiluted mucosal fluids. Strips were then extracted in 1 ml buffer for cytokine analysis (ELISA). Allergen challenge produced acute nasal symptoms that peaked at 30 min and then tapered off. Conversely, both GM-CSF and IL-5 were increased only at 3, 5, 7 and 9 h (p < 0.05 compared with baseline). Budesonide did not affect the nasal symptoms but inhibited (p < 0. 05; compared with placebo treatment) the allergen challenge-induced mucosal output of GM-CSF and IL-5. These data demonstrate that GM-CSF and IL-5 are induced in a nonsymptomatic, late phase response to nasal allergen challenge, and that this cytokine response is prevented by single dose budesonide pretreatment.

Early termination of antidepressant drug treatment

Guidelines for antidepressant drug therapy recommend continuing treatment for several months, even after recovery. Premature termination of medication is viewed as a significant reason for chronicity in depressive disorders. To study the scope and type of this problem, routine treatment cases must be observed in sufficient numbers. In four subsequent drug utilization observation studies, the time course and reasons for early termination (i.e., during the first weeks of fluoxetine treatment for depression) were investigated in (1) 15,601 patients of 4,696 general practitioners; (2) 2,401 patients of all ages treated by 479 neuropsychiatrists from 1990 to 1991; (3) 757 patients of all ages treated by 213 neuropsychiatrists from 1992 to 1993; and (4) in 977 geriatric subjects treated by 216 neuropsychiatrists. In study 1, treatment was terminated during the first 10 weeks in 32.9% of cases; in study 2, in 48.0%; in study C, in 31.2%; and in study D, in 31.0%. When treatment was discontinued because of adverse events, the median of treatment duration was approximately 15 days; in cases of clinical deterioration, 20 days; in cases of poor response, 40 days; and when the reason was good response, the median of treatment duration was approximately 43 days. This is the largest field study on early termination of antidepressant treatment available to date. The consistency of results, which were collected from a large number of patients of different ages and from specialists as well as general practitioners, speaks for the validity and stability of the observed phenomena. The different forms of early treatment termination are discussed and addressed separately because they each have special risks and are differently associated with treatment failure.

Why are patients prescribed psychotropic drugs by general practitioners? Results of an international study

BACKGROUND

There has been growing interest in factors that might influence the prescription of psychotropic drugs in general practice.

METHOD

This was a multi-centre study using a two-phase stratified sampling strategy in primary care facilities from 14 different countries to determine factors associated with the prescription of psychotropic drugs.

RESULTS

A total of 1763 consecutive GP attenders aged between 16 and 65 years of age were recruited. Although antidepressants were used more for depressive disorders and anxiolytics for patients with anxiety, the differential diagnosis was otherwise not an important factor in prescribing behaviour. Antidepressants and anxiolytics were prescribed twice as frequently in client centred clinics following a 'personal physician model' as opposed to non-client centred settings, where care was less personalized. The reverse was true of hypnotics (adjusted odds ratio of 0.5). General practitioners with a positive view of their undergraduate psychiatric training and who had had further postgraduate experience in the speciality were significantly less likely to prescribe medication, and if they did they were more likely to use antidepressants. Older patients were significantly more likely to be prescribed psychotropic medication. Several other patient factors emerged when individual classes of medication were considered; these included the loss of a spouse and the absence of physical ill health in the case of antidepressants, and female sex, fewer years of schooling and unemployment in the case of anxiolytics.

CONCLUSIONS

Social, health care and GP factors are at least as important as clinical features in the prescription and choice of psychotropic medication.

Allergen challenge-induced acute exudation of IL-8, ECP and alpha2-macroglobulin in human rhinovirus-induced common colds

Rhinovirus infections cause exacerbations of eosinophilic airway disease. The acute effects of allergen‐challenge on nasal interleukin‐8 (IL‐8), eosinophil cationic protein (ECP), and α₂‐macroglobulin were examined in atopic subjects with common cold symptoms.

Twenty‐three patients with seasonal allergic rhinitis were inoculated with human rhinovirus 16 outside the pollen season. Diluent and allergen challenges, followed by nasal lavages, were carried out about 3 months before and 4 days after virus inoculation.

Seventeen patients developed significant common cold symptoms with increased nasal lavage fluid levels of α₂‐macroglobulin, IL‐8, and ECP at baseline (p<0.001–0.05 versus before inoculation), and were further increased by allergen challenge (p<0.001–0.05); IL‐8 and ECP levels were correlated (r=0.63, p<0.001). Before inoculation, the six patients who later did not develop common cold symptoms had high levels of IL‐8 and myeloperoxidase (MPO), and exhibited strong allergen‐induced plasma exudation responses (α₂‐macroglobulin). After inoculation, IL‐8 and ECP did not increase in these symptomless subjects.

In conclusion, high nasal interleukin‐8 and myeloperoxidase levels and exudative hyperresponsiveness may protect against infection. The association between nasal interleukin‐8 and eosinophil cationic protein in common cold, particularly that observed in nasal lavage fluids after allergen‐induced acute exudation of plasma, suggests the involvement of interleukin‐8 in exacerbation of airway mucosal eosinophil activity.

Selective localization of Bcl-2 to the inner mitochondrial and smooth endoplasmic reticulum membranes in mammalian cells

Bcl-2, an anti-apoptotic protein, is believed to be localized in the outer mitochondrial membrane, endoplasmic reticulum, and nuclear envelope. However, Bcl-2 has also been suggested as playing a role in the maintenance of mitochondrial membrane potential, indicating its possible association with the inner mitochondrial membrane. We therefore further examined the exact localization of Bcl-2 in mitochondria purified from wild-type and bcl-2-transfected PC12 cells and pre- and postnatal rat brains. Double immunostaining demonstrated that Bcl-2 was co-localized with subunit beta of F1F0ATPase in the inner mitochondrial membrane. Biochemical analysis of isolated mitochondria using digitonin and trypsin suggests an association of Bcl-2 with the inner mitochondrial membrane. More interestingly, the majority of Bcl-2 disappeared from the inner membrane of mitochondria when cultured under serum deprivation. These results suggest that Bcl-2 acts as an anti-apoptotic regulator by localizing mainly to the inner mitochondrial and smooth ER membranes.

Corticosteroids and interferons inhibit cytokine-induced production of IL-8 by human endothelial cells

IL-8, secreted by endothelial cells at the site of inflammation, participates in recruitment and transmigration of leukocytes. IL-8 may also have pathophysiological consequences in inflammatory and immunological disorders. We have investigated the effect of interferons (IFNs) and glucocorticosteroids (GCs) on cytokine induced secretion and production of IL-8 by human umbilical endothelial cells (HUVEC). There was a low spontaneous secretion of IL-8 by unstimulated HUVEC which increased after 6 or 24 h of stimulation with the pro-inflammatory cytokines TNF-alpha or IL-1beta. IFN-gamma as well as the GCs, Dexamethasone and Budesonide, inhibited TNF-alpha induced IL-8 secretion in a dose-dependent manner. IFNs may have a general modulating effect, since IFN-alpha also inhibited the TNF-alpha-induced IL-8 secretion. There was a slight, but significant, increase in the content of intracellular IL-8 in stimulated HUVEC. However, there was no difference between stimulation with IL-1beta or TNF-alpha alone or in combination with IFNs or GCs, whereas inhibition of IL-8 secretion with monensin increased IL-8 content suggesting that IFNs and GCs inhibit synthesis rather than secretion of IL-8. In conclusion, IFNs or GCs may be useful for inhibiting IL-8 production by endothelial cells and could thus be used for therapeutic modulation of the inflammatory response.