[Transition psychiatry - challenges and solutions]

Disruptions in psychiatric care delivery during the transition from adolescence to adulthood frequently lead - particularly in the case of severe mental illness - to a considerable treatment delay and an especially high rate of treatment dropout with a high risk of early chronification. The joint Task Force Transition, of the German Society of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP) and the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN), therefore analyzed general, sector-specific and disorder-specific gaps in the German psychiatric care system which obstruct a successful transition to the adult psychiatric care system. The article summarizes the results of the Task Force, outlines the aims and challenges of transition-psychiatric treatment models, and addresses their structural and professional prerequisites. The requirements and recommendations derived from this are transferred to psychiatric planning, health and research policy as well as education, training and professional development in order to optimally shape the transition from adolescent-centered to adult-oriented psychiatric care in the future.

[Trauma and posttraumatic stress symptoms in patients in German primary care settings]

BACKGROUND

Primary care settings have an important gatekeeping function to detect mental diseases, including trauma and posttraumatic stress disorders.

OBJECTIVES

To assess the prevalence of trauma and posttraumatic symptoms in a first sample of northeast German primary care patients and to evaluate the diagnostic sensitivity and specificity of the general practitioners.

MATERIAL AND METHODS

Traumatic experiences and posttraumatic stress disorders (PTSD) were assessed with self-rating questionnaires in a sample of N = 400 patients from 3 primary care facilities. Additionally, knowledge and diagnostic accuracy of the general practitioners were evaluated.

RESULTS

According to the results of the patient health questionnaire (PHQ-15) data from all patients, the majority of patients questioned showed slight to moderate stress from somatic symptoms. Of the patients with complete data 7 % (n = 25) had a complete PTSD according to the results of the questionnaire, which was also identified in the medical assessment with a sensitivity of 40 %. The stress resulting from posttraumatic symptoms was closely associated with the extent of somatic complaints.

CONCLUSION

Patients with a history of trauma and posttraumatic symptoms are prevalent in primary care settings. An early diagnosis by the general practitioner can help patients to receive adequate treatment. Patients with somatoform disorders in particular should be screened for trauma and posttraumatic symptoms.

[Psychometric evaluation of the Dissociative Experiences Scale-Taxon (DES-T)]

Current refinements of the dissociation concept have arrived at the distinction between a dimensional, non-pathological type and a discontinuous, pathological class of dissociation, which can be identified by a subset of 8 items of the Dissociative Experiences Scale, the DES-Taxon (DES-T). This study reports on the psychometric evaluation of the German version of the DES-T in a large general population sample (n = 2,359). The distributions of all items and the total score of the DES-T emerged to be non-normal and right-skewed with a sharp peak. The internal consistency proved to be high (Cronbach's α = 0.92), and all items discriminated well with item-total correlations above 0.65. An explorative factor analysis revealed that all items loaded on the first, unrotated factor with loadings of a ≥ 0.7 (explained variance 64%). The DES-T is a one-dimensional measure as indicated by confirmatory factor analysis. There were no relevant associations between the DES-T, sociodemographic characteristics, depression or anxiety. The prevalence of pathological dissociation was 1.6% in the general population. The DES-T proved to be an economic and psychometrically sound self-report measure for the assessment of pathological dissociative phenomena.

[High utilisers with affective and schizophrenic disorders in the psychiatric health care system: a comparison between Eastern and Western Germany]

OBJECTIVE

High utilisers of psychiatric services are defined as a group of patients showing a great amount of service use, especially inpatient care, consequently causing immense costs. There is a lack of studies investigating differences between East and West Germany.

METHODS

Service use and psychopathology were examined in 350 high utilisers receiving inpatient treatment in one East German and three West German psychiatric hospitals.

RESULTS

Whereas current length of stay was higher in participants from West Germany, readmissions were more frequent in the East German participants who also exhibited higher psychopathology.

CONCLUSION

Presumably, the deficient situation of outpatient health care in East Germany is compensated by increased stationary admission, consequently leading to a structural promotion of high utilisation.

[A needs-oriented discharge planning intervention for high utilisers of psychiatric services: quality of the implementation and opportunities for improvement]

OBJECTIVE

Process evaluation of a needs-oriented discharge planning and monitoring (NODPAM) intervention for patients with severe mental illness with high utilisation of inpatient psychiatric care (within a RCT showing lack of evidence of superiority over treatment as usual).

METHODS

Analysis of intervention drop-outs vs. intervention group patients participating in the intervention; analysis of the impact of intervention characteristics on unmet needs over time.

RESULTS

Patients with more severe forms of illness were more likely to be among intervention drop-outs, a relatively high proportion of unmet needs persisted in patients participating in the intervention. Good intervention implementation and high patient satisfaction with the intervention were associated with a reduction of unmet needs.

CONCLUSIONS

The NODPAM intervention failed to reach patients with high service use and more severe forms of illness; quality of intervention implementation might have contributed to the lack of superiority over treatment as usual. The intervention might not have been well integrated in routine treatment and was therefore experienced as extraneous to routine care.

[The specific role of medical psychotherapy as seen by somatic physicians in general hospitals]

OBJECTIVES

We examined the attitude towards the importance of medical psychotherapy among physicians working in a hospital. We focused on their opinion about the general role of medical psychotherapy within the health care system as well as on their opinion about the importance of medical psychotherapy in different clinical situations.

METHOD

105 physicians with various clinical specialties were interviewed using a questionnaire designed for this purpose.

RESULTS

From the point of view of the interviewed physicians, medical psychotherapy plays an important role. Especially medical psychotherapists are considered to be competent in cases of life-threatening situations resulting from mental disorders (such as suicide, anorexia nervosa), in psychopharmacological treatment as well as in cases of medically unexplained physical symptoms. Furthermore, medical competence in psychotherapy is requested wherever there is close connection to physical illness (such as stressful events in medical contexts).

CONCLUSIONS

Especially in times of increasing specialization of physicians there is a need for medical psychotherapy in inpatient health care and clinical consultation.

Psychometric Properties of the German Version of the Scale to Assess the Therapeutic Relationship in Community Mental Health Care (D-STAR)

Objective: There are presently no instruments available in German language to assess the therapeutic relationship in psychiatric care. This study validates the German version of the Scale to Assess the Therapeutic Relationship in Community Mental Health Care (D-STAR). Method: 460 persons with severe mental illness and 154 clinicians who had participated in a multicenter RCT testing a discharge planning intervention completed the D-STAR. Psychometric properties were established via item analysis, analyses of missing values, internal consistency, and confirmatory factor analysis. Furthermore, convergent validity was scrutinized via calculating correlations of the D-STAR scales with two measures of treatment satisfaction. Results: As in the original English version, fit indices of a 3-factor model of the therapeutic relationship were only moderate. However, the feasibility and internal consistency of the D-STAR was good, and correlations with other measures suggested reasonable convergent validity. Conclusions: The psychometric properties of the D-STAR are acceptable. Its use can be recommended in German-speaking countries to assess the therapeutic relationship in both routine care and research.

[RCT on discharge planning for high utilisers of mental health care: conduct and quality of the intervention]

OBJECTIVE

To evaluate feasibility of a structured discharge planning intervention for high utilisers of mental health care developed in a multicentre RCT.

METHODS

Data of N = 241 participants (discharge and 3-month follow-up) allocated to the intervention group are analysed with regard to the intervention's quality of implementation, acceptance, and changes in needs.

RESULTS

The intervention was well accepted among patients and staff. However, a subgroup of participants showed manual violations. Total and unmet needs could be reduced between baseline and follow-up. Amount and change of needs substantially varied by centre and there was a trend towards variation by dose.

CONCLUSIONS

The intervention was feasible. Further analyses are needed to explore differential efficacy.

Needs-oriented discharge planning and monitoring for high utilisers of psychiatric services (NODPAM): design and methods

Background

Attempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare.

Methods

This paper presents design and methods of the study "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM), a multicentre RCT conducted in five psychiatric hospitals in Germany. Inclusion criteria are receipt of inpatient psychiatric care, adult age, diagnosis of schizophrenia or affective disorder, defined high utilisation of psychiatric care during two years prior to the current admission, and given informed consent. Consecutive recruitment started in April 2006. Since then, during a period of 18 months, comprehensive outcome data of 490 participants is being collected at baseline and during three follow-up measurement points.

The manualised intervention applies principles of needs-led care and focuses on the inpatient-outpatient transition. A trained intervention worker provides two intervention sessions: (a) Discharge planning: Just before discharge with the patient and responsible clinician at the inpatient service; (b) Monitoring: Three months after discharge with the patient and outpatient clinician. A written treatment plan is signed by all participants after each session.

Primary endpoints are whether participants in the intervention group will show fewer hospital days and readmissions to hospital. Secondary endpoints are better compliance with aftercare, better clinical outcome and quality of life, as well as cost-effectiveness and cost-utility.

Discussion

If a needs-oriented discharge planning and monitoring proves to be successful in this RCT, a tool will be at hand to improve patient outcome and reduce costs via harmonising fragmented mental health service provision.

Trial Registration

ISRCTN59603527

Social and health adjustment of bulimic women 7-9 years following therapy

OBJECTIVE

To examine the long-term social adaptation and long-term follow-up of bulimic women after therapy.

METHOD

Eighty women with bulimia nervosa were investigated 7-9 years after the beginning of either conflict-oriented in-patient therapy or systemic out-patient therapy. Data was gathered through interviews and patient questionnaires.

RESULTS

At the time of follow-up, 28.9% still had DSM-III-R bulimia, 10.1% suffered from subthreshold bulimia or anorexia (EDNOS), 61.2% did not suffer from any DSM-III-R eating disorder. Compared with statistics on the normal population, the social adaptation of the women was quite good with regard to work, household and living conditions. Some dimensions representing probable aetiological factors (i.e. restrictions of intake, feelings of ineffectiveness) showed a delayed reaction to therapy.

CONCLUSION

Long-term outcome of bulimia nervosa may be expected to be moderately good. During therapy, greater attention should be paid to characteristics of the disorder less responsive to treatment.

Increased levels of platelet-derived growth factor in vitreous fluid of patients with proliferative diabetic retinopathy

It is generally accepted that growth factors play an important role in the pathogenesis of proliferative diabetic retinopathy. Since platelet-derived growth factor AB (PDGF AB) is known to be involved in many angiogenetic and proliferative processes, it was the aim of our study to elucidate the role of PDGF AB in the angiogenetic process in proliferative diabetic retinopathy. We measured PDGF AB concentrations in the vitreous of 23 patients with proliferative diabetic retinopathy, 4 of them with additional rubeosis iridis as an indicator of very high vasoproliferative activity. Control measurements were done in 19 patients without diabetic or ischemic eye diseases and also in 4 non-diabetic patients with ischemic proliferative retinopathy with rubeosis iridis. To exclude PDGF remnants in the vitreous due to vitreous bleeding we additionally measured platelet factor 4 concentrations as a stable marker of activated thrombocytes in the vitreous.

RESULTS

Significantly elevated concentrations of PDGF AB were found in the vitreous of patients with proliferative diabetic retinopathy, with higher levels in individuals with additional rubeosis iridis compared to controls. However, concentrations of PDGF AB were also elevated in ischemic non-diabetic retinopathy, supporting the concept that ischemia might be a strong stimulator of growth factor production in the retina. Platelet factor 4 was not detectable in any of the vitreous samples included in the study. In summary, our results indicate that the growth factor PDGF plays an important role in the pathogenesis of proliferative diabetic retinopathy, probably in synergistic action with other growth factors like IGF I, IGF II, VEGF and TNF alpha.

Entwicklung und erste Evaluierungen der Achse Krankheitserleben und Behandlungsvoraussetzungen der Operationalisierten Psychodynamischen Diagnostik (OPD)

Zusammenfassung. In der Operationalisierten Psychodynamischen Diagnostik (OPD) können auf 5 Achsen relevante psychodynamische Konstrukte erfaßt werden. Die Achse I bezieht sich dabei auf Krankheitserleben und Behandlungsvoraussetzungen des Patienten und erfaßt u. a. Schweregrade der Befunde, Aspekte der Krankheitsverarbeitung, Behandlungsmotivation und Ressourcen des Patienten. Zur weiteren Überprüfung der Achse I wurden die Daten von 449 Patienten aus der psychosomatischen Ambulanz erhoben. Es zeigte sich, daß die vorgegebenen Abstufungen gut genutzt wurden. Die OPD-Items korrelierten nicht mit dem Alter, ein Geschlechterunterschied in einigen Items ließ sich am ehesten auf die unterschiedlichen Geschlechterverteilungen in den untersuchten Diagnosegruppen zurückführen. Zwischen den erfaßten Diagnosen gab es signifikante Unterschiede, die zeigten, daß die OPD-Items eine gute Ergänzung zur Diagnostik nach ICD-10 darstellen. Die OPD-Items korrelierten in mittlerer Höhe mit den Skalen des Fragebogens zur Psychotherapiemotivation. Insgesamt können die berichteten Ergebnisse als Hinweise für inhaltliche Validität und Praktikabilität der Achse I verstanden werden.

[Regression of hard exudates in diabetic background retinopathy in therapy with etofibrate antilipemic agent]

BACKGROUND

The aim of this pilot study was to investigate the influence of a lipid lowering therapy with etofibrate on the progression of diabetic background retinopathy in patients with diabetes mellitus and combined hyperlipoproteinemia. In addition to the well known correlation between the duration of diabetes and the quality of blood glucose control, a correlation between diabetic microangiopathy and elevated triglyceride levels is discussed for many years. The most important pathogenic mechanisms in this respect seem to be an elevation of blood viscosity and alterations in the fibrinolytic system. Fibrinogen and triglycerides are the main determinants of plasma viscosity. As lipid lowering drugs containing fibrates and nicotinic acid are able to lower triglycerides and fibrinogen effectively, a favourable therapeutic effect on the progression of diabetic retinopathy may be expected.

PATIENTS AND METHOD

11 type II diabetics with combined hyperlipoproteinemia (Fredrickson type IIb) and mild to moderate background retinopathy detected by fundus photography were treated with etofibrate (2 x 500 mg/day) for a period of 6 months.

RESULTS

In 7 of 10 patients hard exudates, which had been present at the beginning of treatment, showed clear regression at the end of the treatment period. Among the laboratory test parameters a significant 30% reduction of triglycerides (p < 0.010) was observed. There was also a clear 25% increase in HDL cholesterol and a 12% fibrinogen reduction. Considerable changes of the quality of blood glucose control were not evident during the treatment period.

CONCLUSION

Treatment with the lipid lowering drug etofibrate seems to produce favourable therapeutic effects on hard exudates in diabetic background retinopathy in patients with diabetes mellitus and combined hyperlipoproteinemia. The mechanisms of this effect are not yet clearly understood, in addition to positive effects on the microcirculation of the retina by lowering blood viscosity there is a direct lipolytic effect in the area of hard exudates to be discussed, too. It is important to point out that we did not see any positive effect of etofibrate therapy concerning other morphological changes of diabetic background retinopathy, i.e. microaneurysms or hemorrhages in our pilot study.

Supportive psychotherapy

By way of introduction the concepts 'helpful-supportive' (in analytical psychotherapy) and 'exclusive-supportive' psychotherapy are defined. Then the indications and the patients' characteristics (marked ego weakness, dependency wishes) concerning exclusive-supportive psychotherapy in psychosomatic medicine are outlined. After this we describe the three interview and treatment steps of supportive psychotherapy in psychosomatic patients which particularly include the patients' motivation for conflict-enlightenment psychotherapy. Furthermore some effectiveness criteria are presented. Apart from this motivation work, there exists an indication for supportive long-term psychotherapy in psychosomatic patients. Exclusive-supportive psychotherapy in chronically medically ill patients is founded upon the instability of the psychic adaptation processes (particularly the labilized denial work) following the manifestation of chronic disease. The characteristic intervention techniques deal with the patient's secondary frustration-aggression following, on the one hand, his idea 'Why am I so ill and not the others'. On the other hand, supportive-psychotherapeutic handling of the patient's acute or long-lasting handling of the patient's acute or long-lasting conflict situations prevails. Additional systemic psychotherapeutic procedures are highly recommended in psychosomatic and chronically ill patients, for these procedures are well suited to promoting the effectiveness of individual supportive psychotherapy.

Vitreous levels of the insulin-like growth factors I and II, and the insulin-like growth factor binding proteins 2 and 3, increase in neovascular eye disease. Studies in nondiabetic and diabetic subjects

Retinal capillary nonperfusion results in neovascularization of the eye, which is restricted to the retina in less severe cases and progresses to the anterior chamber and the iris angle in the most advanced case, called rubeosis. This angioneogenesis may be induced by the release of retinal growth factors into the vitreous. This study compared levels of the IGF-I and IGF-II, and of the IGF binding protein-2 (IGFBP-2) and IGFBP-3 in vitreous from three groups with different degrees of retinal ischemia, as judged by the extent of neovascularization: a control group without new vessel formation, retinal neovascularization in patients with proliferative diabetic retinopathy, and massive ischemia of various causes resulting in rubeosis. IGF-I and IGFBP-3 were increased 10- and 13-fold in rubeosis (P << 0.01) compared with no ischemia (n = 10), while IGF-II and IGFBP-2 were elevated 2.7- and 4.3-fold (P < 0.01). Within the rubeosis group similar changes were observed independently of the cause of ischemia, which was central vein occlusion, ischemic ophthalmopathy, or intraocular tumor in seven cases and diabetic retinopathy in three samples from two patients. Vitreous from patients with proliferative diabetic retinopathy but without rubeosis (n = 16) contained 2.5- and 2.2-fold elevated levels of IGF-I and of IGFBP-2 (P < 0.05), while IGF-II and IGFBP-3 were increased 1.4- and 1.6-fold, which was not significant. We conclude that: (a) ischemia appears to be a strong stimulus for the local production of IGF-I and -II and of IGFBP-2 and -3 in the eye. (b) Changes in IGF-I and IGFBP-2 in proliferative diabetic retinopathy may be secondary to local ischemia rather than being specific for diabetic retinopathy. (c) IGF-I and IGFBP-3 may play a role in mediating angioneogenesis in the eye.

Quality of life in patients with inflammatory bowel disease

The term 'quality of life' is defined as the result of objective circumstances of life and subjective perceptions of patients. Health-related quality of life is a dynamic concept which changes during an adaptational process interacting with illness condition during the course of chronic inflammatory bowel disease. In a review on the research in this field, it is shown that quality-of-life assessment may be an important adjunct to the evaluation and treatment of patients with inflammatory bowel disease. The comparative evaluation of quality of life in patients treated medically and surgically may offer important information for decision making.

Therapy outcome of two treatment models for bulimia nervosa: preliminary results of a controlled study

Beyond the reduction of the core symptoms, different modification patterns are expected due to differing emphases in two alternative types of treatment for bulimia nervosa: inpatient analytic and outpatient systemic therapy. The initial results of a study with a waiting-list control group are reported. Eating disorders of the bulimic women definitely improved in both therapy groups, the results for the inpatient group (n = 27) indicate a basic change in the attitude towards eating.

[Inhalation therapy with selective beta 2-sympathomimetic drugs. Effect of pirbuterol administered via the Autohaler and salbutamol administered via the Diskhaler in obstructive respiratory tract disease]

The therapeutic success of salbutamol inhalation with the powder inhalator (Diskhaler) and of pirbuterol with an inhalation-triggered metered aerosol (Autohaler) was determined by comparing the degrees of bronchodilation in 13 patients suffering from chronic obstructive airways disease. Rt and IGV were determined by whole-body plethysmography and FEV1, peak flow and MEF50 by spirometry, and pulse rates were also measured. On average, Rt values decreased by 40 per cent; the other lung function parameters responded correspondingly. Duration of action extended to 4 hours after dosage. Pulse rates and lung functions measured after administration of the products did not differ, either. In such studies as this, whole-body plethysmographic results are superior to those obtained by spirometry.

Quality of life in patients with inflammatory bowel disease

The term 'quality of life' is defined as the result of objective circumstances of life and subjective perceptions of patients. Health-related quality of life is a dynamic concept which changes during an adaptational process interacting with illness condition during the course of chronic inflammatory bowel disease. In a review on the research in this field, it is shown that quality-of-life assessment may be an important adjunct to the evaluation and treatment of patients with inflammatory bowel disease. The comparative evaluation of quality of life in patients treated medically and surgically may offer important information for decision making.

Follow-up results from a psychosomatic outpatient clinic

On the background of the German situation of psychosomatic medicine as an independent department beside the psychiatric clinic, we describe the theoretical issues, organizational structure and functioning of a psychosomatic outpatient clinic. 186 consecutive referrals were analyzed. The ratio of man to woman was 1:2, mean age was 32 years (range 17-58). About half of the patients suffered from psychogenic disorders (according DSM-III criteria subsumed to the category of 'psychological factors affecting physical condition'), 21% had anxiety disturbances, and of the remaining patients 15% had affective illnesses and 13% somatoform disorders. There were three treatment conditions: inpatient psychotherapy, outpatient individual or group psychotherapy and family therapy. Follow-up results (2 years after the first contact) give some hints on the effectiveness of the different treatment procedures. The results show that the psychosomatic outpatient clinic may offer treatment for a specific patient population whose characteristics differ significantly from those of patients treated in consultation liaison services as well as by practicing psychotherapists.

Psychotherapeutic interventions in alexithymic patients. With special regard to ulcerative colitis and Crohn patients

Starting from the psychosomatic patients in clinico-medical wards and the inherent two primary alexithymic features "highly limited introspective capacity' and "very low motivation concerning dynamic psychotherapy', which we proved empirically, we describe the therapist's attitude and the three steps of supportive psychotherapy which initially represent the most indicated procedure in this patient group. In Hannover, this supportive psychotherapeutic procedure is applied by student auxiliary therapists. On the basis of our empirical findings, the effectivity of supportive psychotherapy, accomplished by students, in the alexithymic psychosomatic clinico-medical inpatients could be clearly demonstrated. Furthermore, we comment on some previous psychotherapeutic findings with regard to Crohn patients. Starting from our pretreatment and our follow-up measurements, we were able to prove that patients who were treated by both supportive psychotherapy and psychoanalytically orientated inpatient ward psychotherapy, showed remarkable improvements at all levels of the measurement techniques. Finally, we outline some clinico-psychosomatic aspects with regard to secondary alexithymia.

The Hannover Consultation Liaison model: some empirical findings

Starting from the definitions concerning the concepts 'Liaison medicine' and 'Consultative Psychiatry' we begin with remarks with regard to the Consultation Liaison-Situation in West Germany on the basis of the key-words 'Brief history', 'Independent university units with regard to Psychotherapy and Psychosomatics as well as the connected organization' and 'Teaching procedures'. Following it the Hannover Consultation Liaison model is presented particularly with regard to both the psychosomatic inpatient ward including the functional organization and psychotherapeutic processes as well as the so-called 'Innere Ambulanz' which includes the consultation liaison services in the clinico-medical departments outside Psychiatry and Psychosomatics. Within the 'Innere Ambulanz', which is closely connected to our psychosomatic inpatient ward, the consultation liaison activities and the resulting supportive psychotherapeutic strategies are performed by student auxiliary therapists who are interested in completing their 4-5 months internship-time in our department. We describe both the three supportive psychotherapeutic steps, which may last months to years including subsequent dynamically psychotherapeutic strategies as well as the reactions of the auxiliary therapist function on the students. Furthermore, we may state that there exists no one more optional education procedure of graduate students than the student's confrontation with his partial self-responsibility vis-à-vis a patient who is being supportive-psychotherapeutically treated by him. Specific empirical proofs concerning our patient oriented consultation liaison activities are demonstrated on the basis of previous psychotherapeutic findings in Crohn patients. Here we are able to demonstrate the effectivity of psychotherapy in the case of the supplementarily psychotherapeutically treated patients in comparison to the patients who received medical therapy only. Finally we are able to present quantitative clinico-medical inpatient needs with regard to consultation liaison activities starting from our 'Innere Ambulanz'. On the basis of our conservative estimate, 31-42% of patients showed severe psychosomatic or psychic symptoms who should be treated by psychological means in addition to the medical treatment.