A mild case of SMVT deficiency illustrating the importance of treatment response in variant classification

Introduction Sodium-dependent multivitamin transporter (SMVT) deficiency is a recently described multivitamin-responsive IMD of which the phenotypic spectrum and response to treatment remains to be elucidated. So far, four pediatric patients have been described in three case reports with symptoms ranging from severe neurodevelopmental delay to feeding problems and failure to thrive, who demonstrated significant improvement after initiation of enhancement of targeted multivitamin treatment (biotin, pantothenic acid and lipoic acid). Case vignette of SMVT deficiency We describe a fifth case of a patient presenting at the relatively mild end of the phenotypic spectrum with failure to thrive, frequent vomiting and metabolic acidosis with hypoglycemia, and mild osteopenia, who was diagnosed with SMVT deficiency due to compound heterozygous variants in SLC5A6. Additional genetic testing of variants of unknown significance (VUS) as well as the clinical improvement in all aspects of the patients disease upon initiation of treatment with biotin and pantothenic acid (plus lipoate as anti-oxidant) aided in the confirmation of this diagnosis. Discussion This case report aims to enhance recognition of the broad phenotypic spectrum of SMVT deficiency due to SLC5A6 mutations, and discusses the different treatment strategies. It demonstrates how combining biochemical and genetic testing with the evaluation of (early) treatment response (i.e. using a diagnostic therapeuticum), can influence confirmation of pathogenicity of genomic variants.

Effect of standardized post-coercion review on subjective coercion: Results of a randomized-controlled trial

Background

Post-coercion review has been increasingly regarded as a useful intervention in psychiatric inpatient setting. However, little is known about its effect on perceived coercion.

Methods

A multicenter, two-armed, randomized controlled trial was conducted, aiming at analyzing the effect of post-coercion review on perceived coercion. People with severe mental disorders, who experienced at least one coercive measure during inpatient treatment, were randomized using Zelen’s design to an intervention group receiving standardized post-coercion review, or a control group treated as usual. The MacArthur admission experience scale (AES) and the coercion ladder (CL) were used to assess perceived coercion during inpatient treatment. The coercion experience scale (CES) measured experienced coercion during the coercive intervention. Analyses of covariance were performed to determine group differences.

Results

Of 422 randomized participants, n = 109 consented to participate in the trial. A restricted intention-to-treat analysis of all individuals who consented revealed no significant effect of the intervention on perceived coercion. A significant interaction effect between the factors gender and intervention on the AES scores was found. Sensitivity analysis revealed significant effects of the intervention on both AES and CL scores and an interaction effect between intervention and gender, indicating a higher efficacy in women. No effect of the intervention on CES scores was found.

Conclusions

Standardized post-coercion review sessions did not alleviate the subjective perception of coercion in the total sample. However, post hoc analysis revealed a significant effect of the intervention in women. Results indicate the need to further address gender-specific issues related to coercion.

[Personnel assessment in psychiatry and psychotherapy : Results of a feasibility study on the platform model]

The topic of personnel assessment in psychiatry, psychotherapy and psychosomatics is currently of great importance in terms of health policy. Sufficient empirical evidence for the development of a comprehensive system for staffing is not yet available. The platform model developed by the psychiatric psychosomatic societies and associations pursues a combined empirical normative approach for a future-oriented assessment instrument for the various professional groups. The concept presented has been proven in the health policy discussion as a sensible system of comprehensive personnel assessment; however, an empirically sound control is still lacking as to whether this system can be used practically for the task described and thus can withstand the task of a resilient and future-proof measurement instrument for the necessary personnel. The task of the present study was to examine the extent to which the assumptions of the platform model are confirmed, whether methodological indications can be identified and whether there are limitations of the study that can be used in the validation and foundation of the model. The study confirmed the feasibility of the model and refers to a number of methodological findings and limitations that can be used for the further development of the model. The developed model allows the necessary staffing to be derived and justified, regardless of diagnoses and settings. It is future-oriented and dynamic.

[Religious beliefs and spirituality in medical residency : A survey among physicians in charge of training psychiatry and psychotherapy]

Religion and spirituality (R/S) as empirically measurable and treatment-relevant variables are growing in significance in psychiatry and psychotherapy worldwide. In a survey conducted among physicians in charge of psychiatric residency training in Germany respondents were asked about the integration of R/S in their curricula. Data suggest that subjects (n = 285) attach considerable importance to R/S and especially to existential issues. The importance of R/S in psychiatric training is essentially linked to the trainers' personal views of the world and the corporate culture of the training centers. A possible selection bias and the need to integrate R/S in psychiatric training on the basis of scientific evidence and ethical considerations are discussed.

[The German Association for Psychiatry, Psychotherapy and Psychosomatics participation compass II : Implementation of social participation for people with mental illnesses]

For most people living with mental illnesses, participating in society is of existential importance; however, psychosocial care often fails to recognize its significance and therefore rarely includes the patient's interaction with society in the course of treatment. The reasons for this are both substantial and organizational in nature. The endless opportunities for participating in society, current areas as well as ways of taking part in social life even beyond the terms of the social legislative definition are, in addition to institutional variety and regional differences, all too often barriers to providing the very urgently needed support. Further aspects are insufficient knowledge of therapists about established options of rehabilitative treatment and about responsibilities related to participation in specialized training and further education for professional caregivers. The presented compass of participation for social integration of persons with mental illnesses starts at this point: it provides guidelines for psychiatric and psychotherapeutic practitioners, general practitioners as well as for physicians working in residential or day care institutions with a psychiatric and psychotherapeutic background. Both this article and planned online versions should help professionals to timely and successfully assist people, particularly those with severe mental illnesses, to navigate the broad spectrum of services for social and vocational integration in Germany.

[DGPPN recommendations on quality indicators for schizophrenia]

BACKGROUND

In Germany, several quality indicators have been proposed for the measurement of quality of mental healthcare. Some of these quality indicators have been tested in feasibility studies. The German Association for Psychiatry and Psychotherapy (DGPPN) established the "Task Force Quality Indicators (QI)" that, based on previous experience in the development and pilot testing of indicators, considered the further development and practical realization of QI for schizophrenia.

AIM

The aim was to select a set of QI for schizophrenia that can also be applied to other diagnoses or used in generic measurements. Another goal was to focus on high feasibility of indicators.

METHODS

In a multistage selection process, the DGPPN Task Force selected QI that focus on essential quality aspects from an inventory of 161 existing QI developed by national and international research groups. Indicators were adapted in consultation with the "trialogic forum" of the DGPPN.

RESULTS

The DGPPN proposes the following ten indicators for quality measurement in mental healthcare for schizophrenia: QI1 Long-term treatment/Monitoring of side effects, QI2 Seclusion and restraint, QI3 Number of suicides, QI4 Psychoeducational-oriented intervention for significant others, QI5 Timely beginning of outpatient treatment after discharge from inpatient treatment, QI6 Aggression management - inpatient treatment, QI7 Diagnostic procedures/Physical examination, QI8 Antipsychotic polypharmacy, QI9 Rehabilitation/Vocational rehabilitation, QI10 Diagnostic procedures/Psychosocial functioning.

DISCUSSION

Most of our proposed QI have to be measured by means of additional data documentation. Based on prior experience in the pilot testing of QI, the DGPPN estimates that the additional efforts in data documentation would be manageable, but have to be refinanced. The indicators will be tested in feasibility studies in different mental healthcare hospitals in Germany.

[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]

BACKGROUND

Mental disorders are frequently not or only insufficiently treated. Internet-based interventions offer the potential of closing the existing gaps in the treatment of mental disorders; however, it is very difficult for patients and providers to choose from the numerous interventions available.

OBJECTIVE

The aim of this study was to develop a set of quality criteria that can help patients and care providers to identify recommendable internet-based interventions.

METHODS

A selective literature search was carried out and the existing evidence on internet-based interventions in the treatment of mental disorders was collated. A panel of experts then developed quality criteria based on existing models for the systematic assessment of telemedicine applications.

RESULTS

Internet-based interventions are effective in the treatment of a broad range of mental disorders. The best evidence is available for depression and anxiety disorders. A set of criteria is proposed for the evaluation of available internet-based interventions using a checklist. These criteria have to be developed further with input from other stakeholders.

DISCUSSION

When taking these quality criteria into account, evidence-based interventions available on the internet can make an important contribution to improvement of the care of patients with mental disorders.

[On the legalization debate of non-medical cannabis consumption : Position paper of the German Association for Psychiatry, Psychotherapy and Psychosomatics]

Calls are increasing for the legalization of cannabis. Some legal experts, various politicians, political parties and associations are demanding a change in drug policy. The legalization debate is lively and receiving wide coverage in the media. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) comments on the most important questions from a medical scientific perspective: can cannabis consumption trigger mental illnesses, what consequences would legalization have for the healthcare system and where is more research needed?

[Treatment pathways in the care of patients with schizophrenia and depression]

BACKGROUND

In mental healthcare the concept of pathways addresses diverse issues and problem areas, such as heterogeneous health service offers, the regional variability of treatment concepts and clear-cut guidelines on how and where to obtain treatment for a particular mental disorder. The ambiguous aspects of the concept require international and national definitions and consensus which must also cover quality criteria.

METHODS

This article gives an overview of currently available evidence for the analysis of clinical pathways and pathways to care in international mental healthcare, covering studies on schizophrenia and depression from 2010 to 2014.

RESULTS AND DISCUSSION

The ambiguity of the concept impedes the overview and does not provide unequivocal results. The development, implementation and analyses of guidelines or clear-cut clinical and pathways to care must consider individual, clinical and care system aspects as well as the interplay of these factors. Results suggest that system aspects tend to dominate over clinical factors of schizophrenia and depression. As a consequence, the definition, implementation and evaluation of clinical pathways or pathways to mental healthcare is first and foremost a responsibility of the respective national mental healthcare system and must be understood on that level, before findings are summarized internationally and models of best practice are debated.

[Reality of treatment in psychotherapy: Results of a survey of German psychiatric hospitals]

OBJECTIVES

Since the introduction of the qualification as specialist for psychiatry and psychotherapy, in addition to psychopharmacotherapy psychotherapy is an integral component of the treatment of mentally ill people. A survey was carried out to evaluate the reality of clinical routine use of psychotherapy in German psychiatric hospitals.

METHODS

Between October 2011 and March 2012 German hospitals of psychiatry and psychotherapy were contacted by the head organization, the conference of national directors (Bundesdirektorenkonferenz), to participate in a survey regarding the application of psychotherapy in the real clinical world of daily treatment. With an anonymous questionnaire, data were requested as either a printed form or online version.

RESULTS

Data from 25 psychiatric hospitals in the year 2010 could be analysed (average number of beds 300 of which 53 were for psychosomatic/psychotherapeutic patients) and a total of 87,000 inpatients were treated whereby 34 % were diagnosed as F1 addictive disorders and 24 % as F3 affective disorders. More than 80 % of the hospitals applied group therapies of relaxation, cognitive behavior therapy, social competence training and specific techniques, such as dialectic-behavior therapy. As individual treatment methods, patients with depressive disorders were treated with cognitive behavior therapy, interpersonal psychotherapy or psychodynamic therapy in more than 50 % of the cases. Relaxation techniques were offered in most cases by the nursing staff, behavior therapy by psychologists and physicians and psychodynamic therapy mainly by psychiatrists.

Testing the extreme male brain theory of autism spectrum disorder in a familial design

Autism Spectrum Disorder (ASD) may be an extreme manifestation of some male-typical traits in both neuroanatomy and cognition. Using the ratio of the second to fourth digit (2D:4D) and digit length as biomarkers of (pre- and postnatal) testosterone levels, examined was whether hypermasculinized digit ratios and/or lengths were familial traits in ASD and investigated their relation to sexually dimorphic cognitive abilities. 2D:4D ratios and digit lengths of 216 children with ASD, 202 unaffected siblings, and 360 parents were compared with those of 174 control children and their 146 parents. Generalized Estimation Equations, Generalized Linear Models, and Linear Mixed Models were used to investigate parent-offspring relationships and group differences. In ASD probands and their relatives alike, digit length relative to overall height was significantly increased in comparison to controls. No significant group differences were found between affected and unaffected subjects, or between males and females. Additionally, 2D:4D ratios increased with age. No (consistent) associations were found between 2D:4D ratio or digit lengths and systemizing and empathizing skills. The findings emphasize the role of familially based elevated pre- and postnatal testosterone levels in the liability for ASD, but challenge the use of 2D:4D ratio as a proxy of prenatal testosterone exposure solely. Given that many genes influence digit length, the exact mechanisms underlying a familial predisposition toward increased digit length in ASD are as yet unknown and needs to be explored in future studies.

[Lump sum payment system in psychiatry and psychosomatics: concomitant research - quo vadis?]

The new lump sum payment scheme for psychiatric and psychosomatic services is coming into force in 2013. This constitutes another step on the way to performance-based financial compensation of inpatient and day hospital treatment in psychiatric and psychosomatic hospitals in Germany. This fundamental change needs to be accompanied by scientific evaluation with regards to its effects. This article reflects on the legal foundations of such evaluations and the current progress of preparation. Furthermore, own approaches for analysing the effects of the new finance scheme are presented.

[Guideline compliance in the treatment of schizophrenic patients. Introduction of a computer-assisted treatment pathway]

BACKGROUND

The goal of S3 Guidelines for the Treatment of Schizophrenia was to improve the care of patients with schizophrenic psychoses. However, the publication of guidelines alone does not ensure their consistent implementation. The use of treatment pathways represents one possible approach to help implement the complex treatment recommendations contained in the S3 Guidelines. The first computer-assisted treatment pathway for patients with schizophrenic psychoses was successfully incorporated into the everyday routine of psychiatric hospitals. The aim of the present study was to systematically analyse the impact of this measure on guideline compliance.

MATERIALS AND METHODS

Based on the S3 Guidelines for the Treatment of Schizophrenia developed by the German Association of Psychiatry, Psychotherapy and Neurology (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde; DGPPN), diagnostic and treatment procedures were defined by a multiprofessional working group with members from five different hospitals and subsequently incorporated into an existing hospital information system. In one of the five hospitals, the impact of this measure was analysed in a pilot study in a systematic manner. In the year 2007, approximately 100 patients in each of two wards in the hospital received in a parallel group design either standard care or care based on a computer-assisted treatment pathway. Based on their place of residence, patients were assigned to the two units consecutively. Both groups were analysed to determine the extent to which the care they received conformed to treatment guidelines. Data available from the years 2004 and 2005 served as a historical comparison to the present results.

RESULTS

The differences in guideline compliance between the two wards were heterogeneous and, in certain respects, counterintuitive. As expected, the treatment pathway group showed an increased number of laboratory tests, more frequent drug screening at hospital admission and more appropriate dosing of neuroleptics. However, the rate of participation in psychoeducational interventions was disappointing. A conspicuous finding was the negative relationship between initial disease severity and compliance with guidelines on psychopharmacological treatment. In contrast, the historical comparison revealed that guideline compliance had increased slightly in both the treatment pathway and standard treatment groups.

CONCLUSION

Developing computer-assisted treatment pathways based on S3 Guidelines and incorporating them into existing hospital information systems is feasible and well accepted by users. The initial effects on guideline compliance are mostly positive, but not strongly so. Moreover, there was a reduction in duration of hospital stay. Disease-related factors such as disease severity appear to compromise guideline compliance.

[Patients of immigrant origin in inpatient psychiatric facilities. Differences between first and second generation: nationwide questionnaire of the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors]

In a representative nationwide survey, the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors examined the use of inpatient psychiatric and psychotherapeutic services in Germany by patients of immigrant origin. Questionnaires were sent to a total of 350 general hospital psychiatric clinics throughout Germany and 131 responded by the specified deadline (19 July 2006). In our study, persons of immigrant origin comprised 17% of patients in the responding facilities, which confirmed the results of the pilot study in 2004 of 17.4%. This indicates that the percentage of inpatient psychiatric services used by patients of immigrant origin is almost proportionate to these patients' percentage of the general population (18.6%, Microcensus 2005). In this main study patients of immigrant origin were significantly more likely to receive an ICD-10 F2 diagnosis, and it was precisely patients with this diagnosis who were observed to experience difficulties in communication with caregivers. With reference to the F2 diagnoses there were no noticeable differences between first generation of inpatients with migration history and second generation of inpatients with migration history. There were however more first generation of inpatients with migration history diagnosed with affective disorders whereas more second generation of inpatients with migration history were diagnosed with personality and behavioural disorders. Such differences were not found in the group of patients without immigrant origin. Whilst first generation of inpatients with migration history demonstrated higher educational levels, second generation of inpatients with migration history showed fewer linguistic difficulties.

Psychodynamic vulnerability factors in the development of panic disorders--a prospective trial in patients after vestibular neuritis

BACKGROUND

In our 2-year prospective study of 80 patients admitted consecutively to our clinic with an episode of acute vestibular neuritis, a total of 8 patients later developed a panic disorder according to DSM-III-R criteria. The goal of our analysis was to determine whether certain conflict patterns (e.g. in the area of autonomy vs. dependence) or deficient psychological structure could predict later panic disorder, as might be expected based on psychodynamic theory.

SAMPLING AND METHODS

Between 4 and 8 weeks after the acute vestibular episode, we evaluated all patients using operationalized psychodynamic diagnostics (OPD). With the different axes of the OPD system, we were able to assess patients' experience of illness (Axis I), potential conflicts (Axis III), and psychological structure (Axis IV) in a semiquantitative manner.

RESULTS AND CONCLUSIONS

Poor psychosocial integration, a lack of social support, a high burden of suffering, and moderate to severe impairment of self-experience were able to account for 32.1% (Nagelkerkes R(2)=0.321) of variance in the development of panic disorder over the course of 2 years. However, contrary to what might have been expected based on psychodynamic theory, patients who later developed a panic disorder did not exhibit any differences in their Axis III or IV scores compared to patients who remained psychologically healthy.