Prodromal states in schizophrenia

The vulnerability-stress-coping (VSC) model is the most influential heuristic concept in understanding the course of schizophrenia, whose prodromal status still offers unsolved conceptual and methodological issues. Improved knowledge about the prodromal phase would provide a better understanding of the developing psychopathology and psychophysiology of schizophrenia and could also be of predictive value to attune therapeutic actions to the course of the illness more precisely. To shed more light on the characteristics of prodromal states, data from a German multicenter study on intermittent versus maintenance neuroleptic long-term treatment in schizophrenia (ANI study) were reanalyzed with respect to the prevalence and profile, nature, time course, and predictive value of prodromal symptoms in impending relapse. The results demonstrate that prodromes are a category of symptoms on their own, but they share variance with other symptom domains. Treatment side effects, psychotic symptoms, dysphoric mood, and social dysfunction are all associated with prodromal states--the direction of this association, however, is still to be clarified. Prodromal symptoms are also related to the neuroleptic treatment strategy and its relapse-preventive efficacy--findings that underscore neuroleptic maintenance medication in preventing both overt and subthreshold psychotic morbidity in schizophrenia.

Subthreshold disorders in psychiatry: clinical reality, methodological artifact, and the double-threshold problem

The introduction of modern operationalized classification systems for mental disorders has led to the issue of subthreshold disorders. Definitions for illness do not at the same time define health, e.g., in the sense of the World Health Organization (WHO) definition from 1947. The threshold not only to define disorders but also to define health is open to discussion. So-called subthreshold disorders require the definition of 2 thresholds. Empirical research has suggested that these "between-threshold disorders" are associated with increased disability and many other negative consequences. Part of the problem with subthreshold disorders is methodological in nature. Psychopathology and the Gestalt characteristic of psychopathological signs are ignored, and categorical instead of dimensional concepts are used. Thus, the distinction between syndromes and disorders, as well as the hierarchical structure of disorders, is not taken into account, and statistical problems with the prognostic power, which is dependent on the epidemiological distribution, are not solved. Variations in threshold definitions have important consequences for the individual and for society, be it because of the negative effects of "diagnostic labeling" or because of the costs to the health care system. Treatment options are presently rather insufficient, although modern sequential treatment algorithms and newer treatments (e.g., selective serotonin reuptake inhibitors [SSRIs] and Saint-John's-wort) promise interesting perspectives. Also in this context, self-help should become an important area of medical treatment research.

Suicidal behavior--symptom or disorder?

This article examines the diagnostic status of suicidal ideation with and without additional signs of defined or subthreshold mental disorders. Data from the World Health Organization (WHO) study on Psychological Problems in General Health Care (PPGHC) show that 8.8% of all general practice patients report that they recently had a wish to be dead. Among patients with acute depressive episodes, the rate is 34.5%, as compared with 1.3% in persons without any sign of mental disorder. Rates of suicidal ideation in persons with subthreshold disorders (10.4%) are similar to the rate in persons with other, nondepressed forms of mental disorders (12.9%). Still, 30.1% of all persons with suicidal ideation do not have a defined mental disorder, and 21.5% do not even have subthreshold disorders. But in these persons also, suicidal ideation is associated with an increased rate of depressive complaints. Suicidal ideation therefore, in any case, can be seen as an indicator of mental problems. But it seems impossible to lower the thresholds of defined mental disorders so that all forms of suicidal ideation will be covered. Instead, suicidal thoughts must be regarded as a symptom with the status of a disorder itself which should be handled as a comorbid condition if other mental disorders co-occur.

Anxiety and anxiety disorders in the old and very old--results from the Berlin Aging Study (BASE)

Within the context of the Berlin Aging Study, we examined the distribution of anxiety symptoms and disorders in a representative community sample. The participants were beyond the age of 70 years, thereby extending results from other studies not covering this age range. Additionally, we analyzed the distribution of anxiety symptoms and syndromes not fulfilling specified diagnostic criteria. A sample of 258 old (70 to 84 years) and 258 very old (85 to 103 years) subjects were examined. Anxiety disorders as defined in DSM-III-R and according to clinical judgment (diagnoses termed NOS) were assessed. In addition, items from the Geriatric Mental State-A (GMS-A) covering a wide range of symptoms of anxiety were subjected to factor analysis. The raw score distributions of anxiety subscales obtained by this procedure are examined by age, gender, education, personal living situation, and psychiatric comorbidity. The weighted overall prevalence of anxiety in the elderly community is 4.5% (n = 17), including specified (n = 8) anxiety disorders according to the DSM-III-R and unspecified (n = 9) disorders. Prevalence rates in the younger old were 4.3% and in the older old 2.3%. Weighted prevalence rates for males were 2.9% and for females 4.7%. The most common comorbid disorders were affective disorders in both age groups as well as both genders. Independently of the nosological level, 52.3% reported one or more symptoms of anxiety. Factor analysis of anxiety-related symptoms yielded 5 independent subscales, reflecting hypochondriasis, panic, phobia, worries, and vegetative anxiety. There were more phobic symptoms in the younger age group (P < .001). Except for worries and hypochondriac symptoms, females showed significantly higher anxiety in all other anxiety dimensions. There was no relation between anxiety and cognitive status or socioeconomic status (SES). Only for subjects living alone was more phobic-type anxiety found. Anxiety disorders in old and very old persons are less frequent than other psychiatric disorders of old age, and do not increase with age. Gender differences can still be observed. The symptomatic structure of anxiety seems similar to that found in younger cohorts. Thus, anxiety disorders in old age do not seem substantially different from those in younger age. Their relative contribution to the spectrum of mental disorders seems to decrease, rather than increase, with age, while at the same time anxiety symptoms are an almost daily experience.

A low-cost, portable system for the assessment of the postural response of wheelchair users to perturbations

Maintaining seated postural stability presents a serious challenge to wheelchair users in vehicles, even during normal driving conditions. The purpose of this research was to develop a system for the study of seated postural control in response to perturbations similar to those that might be experienced during vehicle turning and braking. A servo-controlled tilt platform was constructed to provide a low-cost, small, and easily transportable device for generating precise and repeatable perturbations. Tilt platform operation was examined for accuracy and reproducibility of a desired perturbation. Repeatability was high with a mean signal-to-noise ratio (SNR) of 45.4 for a given perturbation measured across 11 subjects. An initial comparison of stability results obtained on the tilt platform and in a vehicle showed a correspondence, although differences were apparent. The tilt platform has been used successfully to assess balance in spinal cord-injured subjects and to test wheelchair securement systems.

[Information the family physician gives his patients to take home. Utilization, contents and origin of printed information]

Providing the patient with information is one of the most important tasks of the family doctor, both for legal and medical reasons. Apart from verbal information, a wealth of printed material is also available. In a survey of 62 randomly selected general practices, the volume and nature of such information material was investigated, and its importance in practice established by means of an interview. 88.7% of the doctors interviewed stated that they handed out printed matter every day, and 96.8% considered the availability of such information to be an important aid in their daily work. Most of the printed information dealt with metabolic and cardiovascular disorders, and 93.5% of the material was supplied by the pharmaceutical industry. This means that other institutions which have a task to inform patients are virtually not represented in the doctor's office. Printed material providing health-promoting information, for example, on such topics as smoking, AIDS, exercise, healthy eating and suchlike, were lacking. The data point to an urgent need for additional information material in the doctor's office.

Experimental common cold increases mucosal output of eotaxin in atopic individuals

BACKGROUND

In view of recent observations demonstrating that rhinovirus infections are associated with increased local activity of eosinophils, we hypothesized that eotaxin, a selective eosinophil chemoattractant, may be involved in eosinophil recruitment/activation in common cold infections.

METHODS

Twenty-three patients with seasonal allergic rhinitis were inoculated with human rhinovirus 16 (HRV 16) outside the pollen season. Sequential diluent and allergen (10(3) SQ-U) challenges, each followed by nasal lavage, were carried out about 3 months before and 4 days after virus inoculation.

RESULTS

Seventeen patients developed common cold and were further analyzed. Lavage fluid levels of eotaxin were increased at the height of active common cold (day 4 after inoculation) both at baseline (after diluent challenge) (P<0.01) and acutely after allergen challenge (P<0.05).

CONCLUSIONS

Common cold symptoms after nasal HRV 16 inoculation are associated with increased nasal mucosal output of eotaxin, suggesting that this chemokine is partly responsible for recruitment/activation of airway mucosal eosinophils in common cold infections.

Allergen-induced eosinophil cytolysis is a primary mechanism for granule protein release in human upper airways

Cytotoxic eosinophil granule proteins are considered important in the pathogenesis of allergic airway diseases such as rhinitis and asthma. To explore the cellular mechanisms behind eosinophil granule release in human allergic airways, 16 symptom-free patients with seasonal allergic rhinitis were challenged daily with allergen during 1 wk. Nasal lavage samples and biopsies, obtained before and 24 h after the last allergen exposure, were processed for immunohistochemical and electron microscopic analysis. The allergen challenges produced nasal symptoms, marked tissue eosinophilia, and an increase in lavage fluid levels of eosinophil cationic protein (ECP). The nasal mucosa areas with intense extracellular immunoreactivity for ECP were associated with abundant free eosinophil granules. Electron microscopy confirmed the free granules and revealed that all mucosal eosinophils were involved in granule release, either by cytolysis (33%) or piecemeal degranulation (PMD) (67%). Resting or apoptotic eosinophils were not observed. Cytolytic eosinophils had less signs of intracellular granule release (p < 0. 001) and a higher content of intact granules (p < 0.001) compared with viable eosinophils in the same tissue. This study demonstrates eosinophil cytolysis (ECL) as a distinct mechanism for granule mediator release in human allergic airway mucosa. The nature and extent of the ECL and its product (i.e., protein-laden extracellular granules) indicate that allergen-induced cytolysis is a primary and major mechanism for the release of eosinophil proteins in human allergic airway inflammation in vivo.

IL-2 and IL-4 counteract budesonide inhibition of GM-CSF and IL-10, but not of IL-8, IL-12 or TNF-alpha production by human mononuclear blood cells

1. The combination of interleukin-2 (IL-2) and IL-4 reduces the inhibitory effects of glucocorticoids on granulocyte-macrophage colony-stimulating factor (GM-CSF) production, in agreement with the hypothesis that this combination causes glucocorticoid resistance. Whether a general cytokine resistance to glucocorticoids is induced by IL-2 and IL-4 has not been reported. 2. Mononuclear blood cells from healthy individuals were pre-treated with IL-2, IL-4, or IL-2+ IL-4 (31.3-500 U ml(-1)) for 48 h, prior to lipopolysaccharide (LPS; 10 ng ml(-1); 20 h) and budesonide addition. Cytokine levels in the supernatants were analysed using specific immunoassays. DNA content was analysed to estimate cell numbers. 3. GM-CSF production was totally inhibited by budesonide at 10(-8) M in vehicle treated cultures, while IL-10 was inhibited to 33.4+/-4.3% of control. IL-2, IL-4, or IL-2 + IL-4 reduced the inhibitory effects of budesonide on GM-CSF to similar levels (23.7 6.7, 31.6+/-8.5 and 35.1+/-4.3% of control, respectively). IL-2, IL-4, or IL-2 + IL-4 also reduced the inhibitory effects of budesonide on IL-10 production (46.5+/-6.6, 55.9+/-7.3%, and 68.3+/-9.9% of control, respectively). In contrast, IL-8, IL-12 and TNF-alpha production did not become resistant to budesonide. 4. Thus, glucocorticoid resistance induced by IL-2 and IL-4 is not general at the cytokine production level. While the glucocorticoid sensitivity of GM-CSF and IL-10 production decreased, the sensitivity of IL-8, IL-12 or TNF-alpha production was unchanged. Also, the mixture of IL-2 and IL-4 is not crucial for induction of glucocorticoid resistance of GM-CSF production.

Theory and practice in the management of depressive disorders

Scientific, professional, and governmental bodies have in recent years intensified efforts to formulate guidelines for the treatment of depression with the goal that medical practice should comply with these standards and thus improve patient care. 'Evidence-based medicine' demands that medical practice should explicitly refer to the best available scientific knowledge. Empirical data on the epidemiology of care suggest that there are major differences between guidelines and routine practice. Failure to detect mental disorders range from 45 to 90%. Only 1 in 10 of those suffering from depression receive adequate treatment. Treatment is insufficient as prescribed dosages are routinely too low, as up to 50% of treatments are ended prematurely and because patient non-compliance interferes with proper treatment application. Psychological treatment is provided only in 60% of cases in need and is mostly unspecific, i.e. listening or giving advice. Furthermore, there are large regional variations in prescribing patterns which show that treatment is influenced by many non-medical factors. Empirical studies show that giving information to physicians or even measures to improve recognition alone are not sufficient to make changes in treatment behaviour. Only if measures are taken to improve treatment interventions directly then, at least for more severe cases, could better illness outcome be shown. If one wants to understand therapist non-compliance with treatment guidelines then one first has to understand the process of medical decision making. Action theory provides a model which brings together theoretical and experimental knowledge, goal setting, medical and emotional assessment, and operational procedures. On the basis of this theory, future guidelines should specify the setting for which they claim to be valid, they should be empirically tested for their feasibility and effects on patient outcome, and they should give proper attention to non-medical factors which have major impact on medical practice.

Postural stability of wheelchair users exposed to sustained, external perturbations

The postural stability of wheelchair users experiencing external perturbations was examined. Rotation of a tilt platform generated moments in the trunks of subjects seated in a manual wheelchair on the platform. The magnitude and duration of the moments were on the order of those that might be encountered in the sagittal plane during controlled braking maneuvers in a vehicle. Four subjects with tetraplegia, four with paraplegia, and five controls participated in experimental trials on the platform. As input, four different Disturbance profiles with either a 0.2 g (gravitational acceleration) or 0.4 g maximal level were imposed. The majority of the subjects with spinal cord injury lost balance at Disturbance levels below 0.2 g. The results suggest that the rate of change of the applied perturbation may also affect stability. The use of a stability index based on normalized motion of the center of pressure with respect to the seat showed efficacy in characterizing the response.

Cross-cultural comparison of depressive symptoms in Europe does not support stereotypes of ageing

BACKGROUND

Stereotypes of older people suggest that they are depressed.

AIMS

To examine depression symptoms among people aged > or = 65 in the general population and to ask the following questions. Are there high proportions of depressive symptoms among otherwise well people? Do these levels reflect the prevalence of depression? Do key symptoms vary with age and do they confirm stereotypes?

METHOD

Nine centres contributed data from community-based random samples, using standardised methods (GMS-AGECAT package).

RESULTS

Proportions of depressive symptoms varied between centres. Some often associated with ageing were rare. Many were more common in women. Low-prevalence centres tended to have fewer symptoms among 'well' people, but there were inconsistencies. Low levels of symptoms among the well population of a centre did not necessarily predict lower levels in the depressed.

CONCLUSIONS

Variations in the prevalence of depressive symptoms occurred between centres, not always related to levels of illness. There was no consistent relationship between proportions of symptoms in well persons and cases for all centres. Few symptoms were present in > 60% of the older population--stereotypes of old age were not upheld.

Psychological distress and psychiatric disorders in primary health care patients in East and West Germany 1 year after the fall of the Berlin Wall

BACKGROUND

The reunification of Germany confronted citizens in East and West Germany with many changes in their lives. These changes may be considered as critical life events. Especially for those in East Germany, life circumstances drastically changed, and individuals were increasingly required to adopt and develop coping capabilities. In addition to new opportunities and freedom, there was threatening uncertainty about the future. Theories of life events and stress postulate that threat events have an impact on human well-being. It was expected that there would be an increased rate of psychiatric morbidity after unification, especially in the eastern part of Germany.

METHOD

An international study by the WHO on psychiatric disorders in general health care was carried out in 1990, 1 year after the opening of the Berlin Wall, in both parts of Berlin and in Mainz, West Germany. This allowed for a comparison of the prevalence rates of psychiatric disorders among general health care patients in the East and West, after the euphoria immediately following unification had subsided.

RESULTS

The prevalence rates of current ICD-10 diagnoses and of subthreshold disorders in East Berlin were similar to the rates in West Berlin and Mainz. The recognition rate of psychiatric disorders by physicians did not differ in East Berlin as compared to West Berlin and Mainz.

CONCLUSION

Contrary to the prediction expected from the literature on individual negative life events, major changes in life circumstances and stressful life events on a societal level within 1 year did not have a major impact on psychological function.

The prescribing of psychotropic drugs by primary care physicians: an international collaborative study

Psychotropic drugs play a major role in primary care management of mental disorders. This study expands the existing data on prescribing practices using data from a 15-center, primary care epidemiologic survey. Questions to be addressed include the following: Which clinical and nonclinical factors are related to the prescribing of psychotropic drugs by primary care physicians? How do prescribing patterns vary across primary care centers? At each center, primary care patients were screened using the General Health Questionnaire, and a stratified random sample completed a standardized diagnostic assessment. For each patient completing the diagnostic assessment, the treating primary care physician provided data on clinical diagnosis and medications prescribed. Study results indicated that 11.5% of all practice attenders, 51.7% of cases who received a diagnosis of mental disorders by a physician, and 27.6% of cases who received a diagnosis using the Composite International Diagnostic Interview were treated with psychotropic medication because of their psychologic problems. Anxiolytics, hypnotics, and antidepressants each accounted for approximately 20% of all prescriptions. Prescription rates increased with the prominence of psychologic complaints, severity of mental disorder, severity of social disability, female gender, age older than 40 years, lower education, unemployment, and marital separation. Rates and type of drugs also varied among specific mental disorders; 19.3% of patients with brief recurrent depression but 55.0% with agoraphobia got any psychotropic drug. Antidepressant drugs were prescribed in 7.7% of anxiety disorders compared with 31.9% of depressive disorders. There were large differences between international centers. When comparing client-type centers with clinic-type centers, overall prescription rates were similar (51.2 vs. 52.9%), but significant differences were observed with respect to psychotropic polypharmacy (12.6% client, 6.3% clinic), tranquilizer medication (24.2 client, 32.9% clinic), and antidepressant medication (17.3 client, 8.9% clinic). Psychotropic drugs have an important role in the treatment of mental disorders by general practitioners. Prescription is associated with a number of clinical but also nonclinical factors that must be recognized when guidelines for international use are to be published. Recognition of mental disorders and selection of specific drug classes are important areas in which medical practice needs improvement.

Circulating eosinophil/basophil progenitors and nasal mucosal cytokines in seasonal allergic rhinitis

Accumulation of eosinophils in the airways is characteristic of allergic rhinitis and asthma. The tissue eosinophilia may involve both recruitment of mature eosinophils and proliferation of their progenitors. This study examines mature eosinophils (nasal and circulating), their circulating progenitors, and a potential role of granulocyte-macrophage colony-stimulating factor (GM-CSF) in stimulating these progenitors. Twelve subjects with a history of seasonal allergic rhinitis and positive skin prick test for birch pollen were studied during four periods: shortly before, in the early and intense phase, at the end, and well after the Swedish birch-pollen season. Nasal mucosal and circulating eosinophils were examined in both nasal brushings and peripheral blood samples. Eosinophil/basophil progenitors were determined by counting colony-forming units in nonadherent mononuclear blood-cell cultures in methylcellulose at 14 days. The nasal mucosal cytokines GM-CSF, interleukin (IL)-1beta, IL-3, IL-5, IL-6, IL-8, and RANTES were analyzed (ELISA) in nasal lavage (NAL) fluids. All patients developed severe symptoms of rhinitis at the height of the season, with increased numbers of eosinophils in the nasal mucosa (P<0.05) and in the circulation (P<0.05). At this time point, the number of circulating progenitors (P<0.05) and the NAL fluid level of GM-CSF (P<0.05) were also increased. In contrast, there was no change in the NAL fluid levels of IL-1beta, IL-3, IL-6, or IL-8. Neither IL-5 nor RANTES could be detected in any of the NAL fluids. At the end of or after the season, there was no increase in nasal eosinophils or circulating eosinophils or progenitors (P>0.05). Ex vivo addition of GM-CSF (10-100 U) increased the number of blood progenitors grown before (P<0.01) and after (P<0.05) the season, compared with during the season. The in vitro GM-CSF responsiveness of progenitors may be related to whether or not these already have been stimulated endogenously by GM-CSF. Taken together, our data thus suggest that GM-CSF may play a role in vivo to increase production of eosinophilic progenitors in allergic airway disease.

Alpha2-macroglobulin and eosinophil cationic protein in the allergic airway mucosa in seasonal allergic rhinitis

As previously demonstrated in seasonal allergic rhinitis, increased microvascular permeability and eosinophil activation are key features of allergic airway inflammation. In the present study, the hypothesis that exudation of alpha2-macroglobulin may cause the appearance of eosinophil cationic protein (ECP) in the airway lumen was explored. Nasal lavages were carried out using the nasal pool device before and during the pollen season both at baseline and after histamine challenge in 10 children with allergic rhinitis. Nasal lavage fluid levels of alpha2-macroglobulin and ECP were determined. All patients experienced nasal symptoms of allergic rhinitis during the pollen season (p<0.01-0.05). Baseline nasal lavage fluid levels of alpha2-macroglobulin and ECP were increased during the season (p<0.01-0.05) and were found to be well correlated (p<0.0001). Histamine produced concentration-dependent plasma exudation before and during the pollen season, but it was only during the pollen season that this caused an increase in the lavage fluid levels of ECP (p<0.05). These data suggest that exudation of plasma and increased tissue levels and output of eosinophil cationic protein characterize nasal mucosal inflammation in children with seasonal allergic rhinitis. The plasma exudation process in part may account for lumenal entry of eosinophil cationic protein molecules that have been released in mucosal tissue compartments. A combination of induced exudation and nasal lavage may improve the yield of important markers of inflammation in studies of nasal diseases.

Demonstration of bronchial eosinophil activity in seasonal allergic rhinitis by induced plasma exudation combined with induced sputum

BACKGROUND

Patients with seasonal allergic rhinitis may develop bronchial hyperresponsiveness during the active disease period. Eosinophil activation may occur in the bronchial mucosa and may be reflected by increased sputum levels of eosinophil cationic protein (ECP), especially when ECP binding proteins such as alpha 2-macroglobulin pass through the lamina propria and across the epithelium into the airway lumen. A study was therefore undertaken to determine histamine airway responsiveness (FEV1) and bronchovascular responsiveness (exudation of alpha 2-macroglobulin) to histamine in subjects with seasonal allergic rhinitis, and to explore whether sputum ECP levels are increased by the use of induced exudation followed by induced sputum.

METHODS

Eleven patients with seasonal allergic rhinitis were examined before and during a birch pollen season. Sputum was induced by inhalation of 4.5% saline twice before and twice during the pollen season. Histamine inhalations were given before the second of each pair of sputum inductions at increasing concentrations until FEV1 was reduced by 20%. Sputum levels of alpha 2-macroglobulin and ECP were determined as indices of bronchial exudation of plasma and activation of bronchial eosinophils, respectively.

RESULTS

Bronchomotor responsiveness increased during the pollen season (median difference in the reduction of FEV1 9% (95% confidence interval (CI) -3 to 26)) but histamine induced exudation of plasma was not increased. Baseline sputum levels of alpha 2-macroglobulin and ECP did not increase. Histamine induced exudation of alpha 2-macroglobulin was associated with increased sputum levels of ECP exclusively during the pollen season (median difference 8.2 ng/ml (95% CI 0.4 to 562.0)).

CONCLUSION

Bronchial hyperresponsiveness in seasonal allergic rhinitis may not be associated with bronchovascular exudative hyperresponsiveness. Sputum levels of ECP were increased only during the season, and only after induced exudation (potentially moving ECP to the mucosal surface). It is suggested that the combined method of induced exudation and induced sputum may significantly improve the yield of some markers of inflammation in sputum samples.

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 alpha2-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 alpha2-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 (alpha2-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.

The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities

BACKGROUND

This study reports the responses of patients with confirmed depressive illnesses to different treatments in the WHO Mental Disorders in General Health Care study, conducted in 15 cities around the world.

AIM

To discover how depressions recognized by the doctor compare with unrecognized depressions, both in terms of the initial illnesses and their outcomes, and to compare the outcomes of those depressions treated with antidepressants with those treated with daytime sedatives.

METHOD

The design of the study was naturalistic, in that physicians were free to treat patients however they wished. Patients with confirmed depressive illnesses were assigned to four groups: treatment with an antidepressant; treatment with a daytime sedative (usually a benzodiazepine); patients recognized as having depression by the physician but were not offered drug treatment; and patients unrecognized as having depression by their physician.

RESULTS

Both groups receiving drugs had illnesses of equal severity, were demographically similar to one another, and had similar previous histories of depression. Those receiving antidepressants had significantly fewer overall symptoms and fewer suicidal thoughts than those treated with sedatives. By the end of one year, differences between the groups had disappeared: patients not given drugs had milder illnesses but did significantly better than those receiving drugs, both in terms of symptoms lost and their diagnostic status. Unrecognized depressions were less severe than recognized depressions, and had a similar course over the year.

CONCLUSIONS

Patients receiving antidepressants were better in terms of overall symptoms and suicidal thoughts than those treated with sedatives at three months, but this advantage does not persist. Depression emerges as a chronic disorder at one-year follow-up--about 60% of those treated with drugs, and 50% of the milder depressions, still meet criteria for caseness. The study does not support the view that failure to recognize depression has serious adverse consequences, but, in view of the poor prognosis of depression, measures to improve compliance with treatment would appear to be indicated.

Classification of observational data with artificial neural networks versus discriminant analysis in pharmacoepidemiological studies--can outcome of fluoxetine treatment be predicted?

For several years, there has been an ongoing discussion about appropriate methodological tools to be applied to observational data in pharmacoepidemiological studies. It is now suggested by our research group that artificial neural networks (ANN) might be advantageous in some cases for classification purposes when compared with discriminant analysis. This is due to their inherent capability to detect complex linear and nonlinear functions in multivariate data sets, the possibility of including data on different scales in the same model, as well as their relative resistance to "noisy" input. In this paper, a short introduction is given to the basics of neural networks and possible applications. For demonstration, a comparison between artificial neural networks and discriminant analysis was performed on a multivariate data set, consisting of observational data of 19738 patients treated with fluoxetine. It was tested, which of the two statistical tools outperforms the two other in regard to the therapeutic response prediction from the clinical input data. Essentially, it was found that neither discriminant analysis nor ANN are able to predict the clinical outcome on the basis of the employed clinical variables. Applying ANN, we were able to rule out the possibility of undetected suppressor effects to a greater extent than would have been possible by the exclusive application of discriminant analysis.

Effects of beta2-agonists and budesonide on interleukin-1beta and leukotriene B4 secretion: studies of human monocytes and alveolar macrophages

The aims of the present study were to determine whether beta2-agonists (short- and long-acting) and a glucocorticoid (budesonide) influence the secretion of a pro-inflammatory cytokine (interleukin-1, [IL-1]) and a granulocyte attractant (leukotriene B4 [LTB4]) and to compare these effects on blood monocyte and alveolar macrophages. Alveolar macrophages (obtained by bronchoalveolar lavage) and blood monocytes from 26 healthy nonsmokers were stimulated with lipopolysaccharide or human serum opsonized zymosan. The influence of four beta2-agonists (salbutamol, terbutaline, formoterol, and salmeterol) and a corticosteroid (budesonide) on the release of interleukin-1beta (IL-1beta) and LTB4 was studied in a dose-response manner (10(-8)-10(-5) mol/L for beta2-agonists and 10(-10)-10(-6) mol/ L for budesonide). The stimulated IL-1beta secretion was significantly greater in blood monocytes than in alveolar macrophages (p < 0.05), but alveolar macrophages were much more capable of secreting LTB4 than were blood monocytes (p < 0.001). Budesonide significantly inhibited the release of IL-1beta from blood monocytes (p < 0.001), but no such effect was observed in alveolar macrophages. Budesonide did not influence the release of LTB4 in either cell type. The beta2-agonists neither influenced the LTB4 nor the IL-beta secretion in either cell type with the exception of formoterol, which stimulated IL-1beta secretion at the highest concentration (10(-5) mol/L, p < 0.05). In conclusion, beta2-agonists exhibited only minor effects on IL-1beta secretion from blood monocytes and no effect on LTB4-secretion from either cell type, and budesonide effectively inhibited the IL-1beta release in blood monocytes, but not in alveolar macrophages. Thus, induced secretion of LTB4 and IL-1beta , and the sensitivity to corticosteroids with regard to IL-1beta secretion, change during the transformation from blood monocytes to alveolar macrophages.

Effects of a corticosteroid, budesonide, on production of bioactive IL-12 by human monocytes

Interleukin 12 (IL-12) has a key role during the initial phase of the immune response, favouring development of T helper class 1 (Th1) cells. IL-12 is composed of two subunits, p35 and p40, which are both needed for bioactivity. The level of p35 expression determines the level of bioactive IL-12 (p70), while the p40 subunit is produced in excess. In the present study we examined the sensitivity of bioactive IL-12 production by human monocytes to a corticosteroid, budesonide. We also compared the corticosteroid sensitivity of IL-12 and two other cytokines, interleukin 1beta and granulocyte-macrophage colony-stimulating factor (GM-CSF). Monocytes obtained from peripheral blood of healthy donors (n=12) were stimulated with lipopolysaccharide (LPS; 10 microg/ml; 20 h) in the presence or absence of budesonide (10(-11)-10(-7) M). The supernatants were assayed for IL-12 (p70), IL-1beta and GM-CSF concentrations using specific immunoassays. Budesonide potently inhibited the production of bioactive IL-12. A significant suppression was obtained by treatment with even very low budesonide concentrations; even 10(-11) M budesonide significantly inhibited IL-12 to 81.6+/-7.6% of the control level (P<0.05). The maximal inhibitory effect of budesonide was seen at 10(-8) M. The inhibition of IL-12 production was significantly higher than the inhibition of GM-CSF (P<0.01) or IL-1beta (P<0.001). Whereas IL-12 production was totally inhibited, GM-CSF production was inhibited to 16.4+/-3.7 and IL-1beta production to 43.1+/-7.3% of control, respectively. The dramatic capacity of corticosteroids to modulate production of IL-12 as well as other cytokines may be a major mechanism underlying the effectiveness of these drugs in a broad spectrum of inflammatory diseases.

Effects of orally inhaled budesonide in seasonal allergic rhinitis

It has previously been demonstrated that topical nasal treatment with glucocorticosteroids has significant effects on the bronchial airways. Less is known about effects on nasal disease by topical bronchial treatment with these drugs. The present study examined effects on nasal allergic disease of inhaled budesonide (avoiding nasal deposition of the drug). Patients with seasonal allergic rhinitis, but without asthma, were thus given inhalations of budesonide (600 microg b.i.d.) or placebo. The aim of the design was to allow the study of eosinophilic airway disease in a part of the airway other than the directly treated locus. Moderate to high birch pollen levels were recorded during the study season, and nasal symptoms were significantly increased in both treatment groups, although they were milder in patients receiving budesonide than in the placebo group (p<0.05). Nasal brush eosinophils and nasal lavage fluid levels of eosinophil cationic protein as well as blood eosinophils were increased during the season (p<0.05), but these increases were prevented by the inhaled budesonide. Nasal lavage fluid levels of alpha2-macroglobulin were particularly elevated in the placebo group but did not differ between patients receiving placebo and budesonide. Budesonide prevented the seasonal development of increased bronchoconstrictor responses to methacholine challenge (p<0.05). In conclusion, budesonide reduced the seasonal eosinophilia both in the circulation and in the nose along with an attenuation of seasonal nasal symptoms. Hence, at a daily dose of 600 microg b.i.d., known to cause no, or minimal, adverse effects, inhaled budesonide produces clinically significant anti-inflammatory effects in the entire airways, including the nasal mucosa, which is not exposed topically to the drug. We suggest that nasal and systemic anti-eosinophil actions are produced at commonly employed dose levels of orally inhaled budesonide.

[Brief scale for assessment of need for care and provision of care]

In accordance with the German law on care for helpless persons, an observer rating scale has been developed to allow a staging of need of care. Construction of the scale, item descriptions, definitions, algorithms for sum score and inter-rater reliability data are reported. The scale can reliably measure the need of care, quality of care, and who is the care provider.

Patient treatment insistence and medication craving in long-term low-dosage benzodiazepine prescriptions

BACKGROUND

Long-term low-dosage dependence on benzodiazepines in traditionally explained by withdrawal symptoms. Previous research has not given much attention to reports that suggest that many patients oppose stopping benzodiazepines long before withdrawal symptoms have developed. This study investigates the scope of and factors associated with this pre-withdrawal treatment insistence.

METHODS

Patients receiving long-term low-dosage benzodiazepines in primary care were asked to take a drug-holiday of at least 3 weeks. Sociodemographic, medication, morbidity and attitudinal variables were assessed in addition to the GPs' perceptions of their patients.

RESULTS

Two-thirds of the patients rejected the drug-holiday proposal. Patients who refused a drug-holiday were less educated and were using a higher percentage of long-acting benzodiazepines than patients who accepted the drug-holiday proposal. Those who refused were seen by their GPs as being more complaining, harder to satisfy and less co-operative.

CONCLUSIONS

These results provide evidence for drug-seeking or craving behaviour of patients who receive low-dosage benzodiazepine prescriptions. A major problem in benzodiazepine withdrawal occurs before the withdrawal programme has even begun. These data show that benzodiazepine low-dosage dependence should be considered a real form of dependence.

Fluoxetine treatment and single psychotropic comedication: is there an increase in adverse event rates?

After the market launch of fluoxetine (Flx) in Germany in 1990 several series of drug utilization observation studies were carried out under naturalistic conditions (approximately 19,000 patients). This paper focuses on 3158 patients from neuropsychiatric practices comparing adverse event rates plus additional variables in patient groups treated with Flx monotherapy (n=1571) versus those receiving comedication with a single psychotropic (n=737), or those subgroups receiving a single antidepressant (n=222) or antipsychotic drug (n=128). Compared to the monotherapy group, both the comedicated group as a whole and the antidepressant subgroup did not show significant changes in adverse event rates. The subgroup with antipsychotic comedication revealed somewhat higher adverse event rates; the pattern of adverse events, however, was largely comparable, and extrapyramidal symptoms were reported for only a few isolated cases. Thus, these findings suggest that--under naturalistic conditions--comedication of Flx with psychotropic drugs (a commonly used treatment strategy for various reasons) is feasible and does not generally increase patient risk.

Plasma-derived proteins in airway defence, disease and repair of epithelial injury

One significant characteristic of the airway mucosa in vivo, that cannot easily be mimicked in vitro, is its microcirculation, which generates a highly dynamic, biologically active milieu of plasma-derived molecules that may pass to the airway lumen in vivo. New data on the mechanisms of airway mucosal exudation indicate that the protein systems of circulating plasma may contribute significantly to the biology and immunology of the lamina propria, its surface epithelium and the luminal surface, not only in injured airways, but also in airways that are activated but display no sign of oedema, epithelial disruption, or increased absorption capacity. We suggest that present knowledge of the mechanisms of plasma exudation, together with rapidly emerging information (not detailed herein) on receptors, target cells and cellular responses to the plasma-derived molecules, must be considered in any realistic model that investigates "immuno-inflammatory" mechanisms of the airway mucosa.

Contribution of plasma-derived molecules to mucosal immune defence, disease and repair in the airways

This review discusses recent observations, in health and disease, on the release and distribution of plasma-derived molecules in the airway mucosa. Briefly, the new data on airway mucosal exudation mechanisms suggest that the protein systems of plasma contribute significantly to the mucosal biology, not only in injured airways but also in such mildly inflamed airways that lack oedema and exhibit no sign of epithelial derangement. Plasma as a source of pluripotent growth factor, adhesive, leucocyte-activating, etc., molecules may deserve a prominent position in schemes that claim to illustrate immunological and inflammatory mechanisms of the airway mucosa in vivo.

Predictors of relapse and rehospitalization in schizophrenia and schizoaffective disorder

In a German multicenter treatment study, 354 patients with schizophrenia and schizoaffective disorder were followed for 2 years. The data collected were taken as a basis for the present predictor study. For the first time, the technique of classification and regression tree (CART) analysis has been employed for this purpose. CART yielded informative data and appeared to be a useful instrument in predictor research. On the outcome variables "relapse" and "rehospitalization," significant predictor variables were found in several areas: neuroleptic treatment, onset and previous course (precipitating factors, first manifestation, hospitalization in the preceding year, suicide attempts), psychopathology (residual type, schizoaffective disorder), social adjustment (marital status, employment, intensity of life, Phillips score), previous life experiences (traumatic experiences and psychiatric or developmental disturbances in childhood), and biology (gender, age). Our investigation confirmed the generally prevalent views regarding the value of neuroleptic treatment, the multifactorial etiology, and the vulnerability stress model of schizophrenia.

[The social status of schizophrenic patients]

In the German multicenter ANI study comparing continuous prophylactic treatment with intermittent medication, the social situation of a large sample of 364 schizophrenic patients was investigated and followed up over a 2-year period of outpatient aftercare. Effective therapy and prophylaxis substantially reduced relapses and rehospitalization. On the other hand, the psychosocial situation still showed considerable disadvantages. Of the patients (35 years old on average), 60% were still unmarried. Almost one-half of the patients still lived alone or with their parents, and one-third lived a very solitary life. At the end of the 2-year aftercare period, one-third was able to earn their own living. Almost one-half retired early from their occupations. Predictors and intervening variables are presented in order to stimulate early rehabilitation approaches. Schizophrenics are particularly placed at a disadvantage by tighter competition in the employment market, even though the course of illness can be improve. Social psychiatry must to be involved in helping to improve social contacts, accommodation and employment in order to prevent major distress.

Specialty training and the personal use of benzodiazepines by physicians affect their proneness to prescribe tranquilizers

The decision on how to treat a patient does not depend on clinical matters or illness characteristics alone, but also on patient, physician and setting variables such as personality, training, or reimbursement. No research has yet been carried out to answer the question whether personal experience with medications also influences prescribing behavior. In this study, 124 physicians stratified according to specialty (neuropsychiatrists vs. general practitioners), type of institution (private practice vs. hospital), years of professional experience (young vs. old), and region (rural vs. urban) participated in a structured interview to evaluate their proneness to prescribe benzodiazepines for sleep disorders as well as their personal experience in taking benzodiazepines for their own sleep problems. Both specialty and personal experience were significantly related to proneness to prescribe. Other variables tested (region, institution, age, gender) did not help to explain the variance in benzodiazepine prescribing practice. Thus physician variables and, importantly, their own personal experience in taking the medication significantly influence treatment choice. Rational medical decision making and treatment guidelines must therefore take into account medical knowledge as well as knowledge of personal treatment preferences and professional biases.

Differences in self-reported sleep complaints in elderly persons living in the community who do or do not take sleep medication

BACKGROUND

Sleep disorders and the use of sleep medication are major health issues. Since complaints about sleep disturbances are subjective phenomena, the aim of the present study was to investigate which sleep complaints and self-reported disturbances of sleep behavior are connected with the utilization of sleep medication.

METHOD

In the Berlin Aging Study, a random sample of 516 persons aged 70 to over 100 underwent extensive psychiatric and medical examinations including several medication assessments and a special interview on sleep complaints and sleep behavior.

RESULTS

19.1% of the elderly were taking some form of sleep medication. Univariate and discriminant analyses showed that neither self-reported duration of sleep time nor difficulties with sleeping through the night but complaints about difficulties initiating sleep and global complaints about disturbed sleep differentiated between those who do or do not take sleep medication.

CONCLUSION

Persons taking sleep medication nevertheless have a higher rate of sleep-related complaints than those who take no medication. Waking up in the night per se does not discriminate between drug users and controls. Instead, it is the inability to fall asleep or fall back into sleep after waking and global discontent with subjective sleep quality that make a difference.

Antioxidative properties of organotellurium compounds in cell systems

The protective/antioxidative properties of diaryl tellurides were demonstrated in cellular systems of increasing complexity. In the presence of glutathione, bis(4-hydroxyphenyl) telluride (1a), bis(4-aminophenyl) telluride (1d) and bis(2-carboxyphenyl) telluride (1h) reduced by more than 50% t-butyl hydroperoxide-induced cell death in lung fibroblast cultures at concentrations below 2 microM. Bis(2,6-dimethyl-4-hydroxyphenyl) telluride (2b) reduced by more than 50% leukocyte-mediated and phorbol-12-myristate-13-acetate-stimulated damage to Caco-2 cells at 0.1 microM concentration. As judged by their abilities to reduce formation of thiobarbituric acid reactive substances at concentrations close to 1 microM, diaryl tellurides 1a, 1d and 2b protected rat kidney tissue against oxidative damage caused by anoxia and reoxygenation. The organotellurium compounds also offered protection after systemic administration. In the presence of diaryl telluride 2b (0.1-1 microM), the ischemia/reperfusion-induced vascular permeability increase in the hamster cheek pouch was significantly reduced as compared with the control. Some of the most active organotellurium cell protectants were evaluated for their ability to inhibit formation of the inflammatory mediators leukotriene B4 and interleukin-1beta. An inhibitory effect on the secretion of these species was seen for compounds 1a and 2b at or above 10 microM concentrations. The protective effects of diaryl tellurides against t-butyl hydroperoxide-induced cell injury can be ascribed mainly to the peroxide-decomposing, glutathione peroxidase-like capacity of the compounds. The chain-breaking, electron- or hydrogen atom-donating ability of diaryl tellurides seems to be the main reason for their protection against leukocyte-mediated cell damage in Caco-2 cells and in the oxidatively challenged rat kidney and hamster cheek pouch.

[Depression in the very elderly]

In the Berlin Aging Study (BASE) an age and gender stratified sample of 516 persons aged 70 to over 100 was assessed by means of the semi-structured GMS-A interview, the CES-D-self-rating scale and the Hamiltion-Depression-observer-rating scale. Prevalence rates were 4.8% for Major Depression, 9.1% for all DSM III-R specified depressive disorders and 26.9% of subthreshold depression was included. There was no increase in prevalence rates with age but an increase in scores on the self rating CES-D. The prevalence rates for DSM III-R specified depression in females was 10.3% and almost double that of men (5.6%). Depressed persons do not show significant cognitive impairment as measured with the MMSE in comparison to controls. As compared to the total sample higher prevalence rates of overall depression were seen in persons with multimorbidity (36.8%) and lower rates in married persons. 13.2% of the elderly talked about feeling tired with life, 7.9% had thoughts about death and 1.2% reported suicidal ideation, which was closely linked to depressive disorders. In 44% of depressed cases undertreatment was observed. Only 6% got Antidepressants but 40% benzodiazepines.

Interleukin-2 and -4 induce resistance of granulocyte-macrophage colony-stimulating factor to corticosteroids

In vitro pretreatment of human mononuclear blood cells with a combination of interleukin-2 and interleukin-4 decreases corticosteroid receptor affinity and reduces the anti-proliferative effects of corticosteroids. Similar abnormalities have been observed in mononuclear blood cells of steroid-resistant asthmatics. In vitro steroid resistance was induced by 48 h pretreatment of mononuclear blood cells from healthy individuals (n = 10) with interleukin-2 and interleukin-4 (500 Units (U)/ml). The effects of three structurally different corticosteroids (10(-7)-10(-11) M) on lipopolysaccharide-stimulated (10 ng/ml; 20 h) production of granulocyte-macrophage colony-stimulating factor (GM-CSF) were examined. GM-CSF production was efficiently inhibited by all three corticosteroids in the control cultures. Cortivazol was significantly more potent (IC50 = 3 x 10(-11) M) than budesonide and tipredane (IC50 = 2.5 x 10(-10) M and IC50 = 2 x 10(-10) M, respectively). However. interleukin-2 and interleukin-4 pretreatment counteracted the inhibitory effects of all three corticosteroids to a similar degree. The results highlight the importance of interleukin-2 and interleukin-4 in the induction of steroid resistance, since pretreatment of mononuclear blood cells with these cytokines impaired corticosteroid inhibition of GM-CSF production.

Tenascin is increased in airway basement membrane of asthmatics and decreased by an inhaled steroid

Tenascin and fibronectin are extracellular matrix glycoproteins expressed during morphogenesis and tissue repair. In the present study bronchial biopsies were studied by the morphometric method of immunocytochemistry to reveal the distribution of different tenascin and fibronectin isoforms as well as the presence of inflammatory cells in the airway mucosa of patients with chronic asthma (n = 32) and those with seasonal birch-pollen-sensitive asthma out of season (n = 17), both in comparison with healthy control subjects (n = 12). The results showed an increase in tenascin immunoreactivity in the bronchial subepithelial reticular basement membrane layer in patients with chronic asthma (p < 0.0001) and in those with seasonal asthma (p < 0.01) compared with control subjects. The tenascin immunoreactivity, appearing as an intense wide subepithelial band in asthma, was seen only occasionally in the basement membrane of control specimens. Instead, a diffuse immunoreaction against both total fibronectin and locally produced extradomain A fibronectin was similarly visible in the airway mucosa of both patients and control subjects. Despite the significant increase in the airway mucosa of eosinophils and lymphocytes in patients with chronic asthma (p < 0.0001 and p < 0.0001, respectively) and of eosinophils in patients with seasonal asthma (p < 0.001), there was no correlation between the number of these cell types and level of tenascin expression. In patients with birch-pollen-sensitive asthma during the birch-pollen season, inhaled corticosteroid treatment, budesonide 400 micrograms twice daily, decreased tenascin immunoreactivity, in comparison with effects of placebo (p = 0.01). Our results suggest that the higher amount of tenascin reflects disease activity in asthma and may be an indicator of a remodeling process rather than of injury itself.

1997 IPA/Bayer Research Awards in Psychogeriatrics. The wish to die in very old persons near the end of life: a psychiatric problem? Results from the Berlin Aging Study

The wish to die in elderly persons is currently under debate. Experts are questioning whether it is natural for these individuals to show a wish to die, whether the right to eventually kill oneself should be respected, or whether suicidal intentions in old age are expressions of mental disorders that need intensive, professional care. A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview Geriatric Mental State Examination-Version A (GMS-A) and several self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R criteria and by clinical judgment. The goal of the study was to find examples of "pathology-free wishes to kill oneself." A total of 115 out of 516 very old (70 to 105 years) persons, which represents 21.1% of the community population, said at the time of investigation that they wanted to die or felt life was not worth living (Hamilton Depression Rating Scale [HAMD] score 1, 2, or 3). Forty-three very old persons (6% of the community population) had the wish to be dead according to the HAMD or the GMS-A, and 11 persons (2% of the community population) had suicidal intentions. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as having psychiatric disorders and half to three quarters showed symptoms fulfilling the criteria of at least one specified psychiatric diagnosis. Acute suicidal intentions were in all cases associated with at least one specified diagnosis according to DSM-III-R. Thirteen persons out of 54 who actually wanted to die (GMS-A category 4, 5, 6 or HAMD category 2, 3) did not fulfill criteria for specified diagnoses. Seven individuals showed scores in self-rating and observer-rating scales that speak for mental disorders apart from pure suicidality. Six remaining persons are described in greater detail in short case vignettes. They showed either mild but chronic psychiatric disorders, fluctuating courses, or an atypical phenomenology of psychiatric disorders. The results of this study strongly suggest that the wish to be dead in the very old is most probable, and suicidal intentions are definitely associated with psychiatric disorders.

The impact of psychosocial and clinical variables on duration of inpatient treatment for depression

The duration of psychiatric hospital stays becomes increasingly important as economic pressures on medicine mount. Psychiatric hospitals, in particular, search for ways to cut costs without sacrificing efficiency. There is no doubt that clinical depression is one of the most important cost factors in psychiatry. Former studies have concentrated mainly on the influence of clinical variables such as the severity or subtype of depression on the length of stay (LOS). However, it can also be assumed that life situations or psychosocial variables in general might influence LOS. Data from 736 admissions between January 1983 and 1991 with a diagnosis of depression were examined to test the hypothesis that psychosocial and clinical variables influence LOS. Results showed a significant influence of age, marital status and gender, as well as severity and type of depression, on duration of inpatient treatment. Age, female gender, being widowed or divorced, the diagnosis of "endogenous depression" and severity were all associated with longer LOS. There was an interaction of gender, marital status and perceived loneliness, as well as an interaction of severity of depression with gender, both of which were associated with LOS.

Predicting health care utilization in the very old. The role of physical health, mental health, attitudinal and social factors

The purpose of this paper is to predict health care utilization in the very old from a combination of individual-based factors such as physical and mental health, health attitudes and beliefs, sociodemographic characteristics, and life circumstances. This study was conducted within the context of the Berlin Aging Study (BASE). Higher use of medications was most strongly predicted by more medical diagnoses, better cognitive status, and health attitudes. Physician contact was only weakly predicted by physical health variables, hypochondriasis, and living alone. In contrast, living alone was the greatest predictor of the utilization of increased levels of caregiving services, while having children nearby served as a protective factor against the need for more formal caregiving services. These results show that utilization of health care depends on interaction between physical and mental health, attitudinal, and social factors.

An investigation of the representativity of neuropsychiatrists and their patients in a drug utilization observation study on fluoxetine

This study presents a methodological approach to an expost facto investigation of sample bias in drug utilization observation (DUO) studies using the example of a DUO with the nontricyclic antidepressant fluoxetine. A total of 479 psychiatrists and neurologists and 2,401 patients were investigated. The purpose of the study was to judge the representativeness of our DUO sample for two populations: first, for all psychiatrics and neurologists prescribing fluoxetine or all patients being treated with fluoxetine in Germany and, second, for all psychiatrists and neurologists prescribing antidepressants or all patients being treated with antidepressants in Germany. Criteria for the representativeness test were physician variables (gender, size of community where practicing, federal state, age, volume of prescriptions) and patient variables (gender, age, prescription-related diagnosis, concurrent illnesses, concomitant medications). The study shows that the DUO sample can rightfully claim representativeness in the majority of parameters for the psychiatrists and neurologists prescribing fluoxetine and for the patients being treated with fluoxetine. There are more noticeable discrepancies with regard to the psychiatrists and neurologists in general and to the patients being treated with antidepressants in general. The methodological problems of pharmacoepidemiological investigation of representativeness are discussed.

What happens to patients after the end of a clinical trial? Systematic follow-up observational study of an open moclobemide trial in major depression

Controlled clinical drug trials typically last several weeks. At the end of this fixed time period approximately two-thirds of the patients in trials with antidepressant drugs are classified as responders, i.e. the initial severity score is reduced by about fifty percent. In a clinical perspective this means that many patients, even among the responders, are still quite ill and require further treatment. Nevertheless, to date there do not appear to have been any studies on treatment and course of illness after the termination of controlled clinical trials. In a "naturalistic" follow-up surveillance study of 202 patients who had taken part in a controlled trial with the antidepressant moclobemide for six weeks, treatment and clinical status were monitored through questionnaires sent out to their treating physicians (n = 78) at two assessment points four weeks and six months later. Results showed that sixty percent of patients continued to receive the study drug moclobemide after the completion of the clinical trial. Twenty percent were switched to other antidepressants and twelve percent received no further psychotropic drugs. In the course of six months a considerable variation in treatment modes could be observed. Patients under ongoing active treatment made considerable additional progress. A correlation was found between insufficient response and repeated switching of medication. Patients who had been taken off antidepressant medication because of early good response did not experience early relapse after the end of treatment.

Guidelines for the implementation of drug utilization observation (DUO) studies in psychopharmacological therapy. The "Phase IV Research" Task-Force of the Association for Neuropsychopharmacology and Pharmacopsychiatry (AGNP)

The task-force on Phase-IV-Research of the Association for Neuropharmacology and Pharmacopsychiatry (AGNP) has developed guidelines for the implementation of scientifically sound drug utilisation observation studies (DUO studies). These guidelines have been adopted by the executive committee as the position of the association. DUO studies are prospective pharmacoepidemiological studies, by which prescription, illness, and patient data of individual patients are collected without interference with the routine course of treatment. They can answer questions on the interaction of treatment modalities with positive and negative treatment outcome. Scientific standards require that there is a study protocol which describes the epidemiological, statistical, procedural, and quality assurance methodology and states who is responsible for what. As such studies can violate data protection regulations or can be used for sales instead of scientific purposes, consultation of an ethics committee is recommended.

Antidepressant drug use: differences between psychiatrists and general practitioners. Results from a drug utilization observation study with fluoxetine

Between 1990 and 1993, a series of drug utilization observation studies with fluoxetine (Flx) were conducted in Germany in several waves. 3,158 patients treated by psychiatrists/neurologists (PN) and 15,601 patients treated by general practitioners/internists (GPI) were included; data collection at start and end of treatment focussed on diagnoses, symptoms, prescription, comedication, efficacy (CGI, Zung scale), and adverse events. Differences between PN and GPI patients were of major interest. For more than 90% of both the PN and the GPI cases. Fix was used for the indication of "depression", with a dosis of 20 mg/day. More PN patients (47%) than GPI patients (28%) were diagnosed as "endogenous"; GPI patients more often presented with first episodes (36 vs. 24%). "suicidal ideation" was less prominent compared to PN subjects (17 vs. 28%). Psychotropic comedication was regarded as necessary in 39% (PN) and 10% (GPI) of the cases. Early treatment termination because of "remission/major improvement" was observed in 13% (PN) vs. 21% (GPI) and because of "adverse events" in 11% (PN) vs. 3% (GPI) of the patients. At observation end, 53% (PN) vs. 74% (GPI) were rated as "symptom-free/markedly improved" (CGI); self-ratings reflected comparable results, marked improvements over time, but still PN/GPI differences at the end. "Suicidality" related to depression was more pronounced in the PN group at both points in time. 24% (PN) vs. 6% (GPI) of the cases reported "routine" adverse events, while in 2% (PN) and 1% (GPI) "serious" adverse events were observed. (For all the above comparisons p < 0.001 to < 0.0001.) These findings reveal that-under routine conditions handled by PNs and GPIs-Fix shows an efficacy and safety consistent with clinical trial data. The body of data suggests that PN patients present with more severe depression and more suicidality, require more comedication, and end up with a poorer outcome. Differences in the physicians' perception of psychiatric and somatic symptomatology and their treatment routines may also have something to do with the PN/GPI group differences observed.

Dysthymia in neurological disorders

Dysthymia is characterized by long-lasting periods of lowered mood. Epidemiological studies in the USA and Europe have demonstrated that the prevalence of dysthymia is at least 3% of the general population. Its pervasive occurrence makes dysthymia a public health problem worldwide. One feature of this disorder is its co-occurrence with medical and neurological disorders. A World Health Organization meeting on dysthymia in neurological disorders was held in Geneva, 1-3 July 1996 to address this topic. Some of the major goals of this meeting were to clarify the definition of dysthymia in the presence of neurological disorders and to evaluate current research in the field, to point out new areas for investigation, and to discuss current psychological and pharmacological treatments for dysthymia in neurological disorders. The potential roles of neuroendocrine and molecular mechanisms in dysthymia were identified through specific problems related to dysthymia occurring in disorders such as Parkinson's disease, Alzheimer's disease, stroke, multiple sclerosis and epilepsy. This meeting provided direction and opportunity for future studies in the under-recognized and under-investigated relationship between dysthymia and neurological disorders.