[German Translation and Validation of the Scale for Evaluation of Neuropsychiatric Disorders in Parkinson's disease (SEND-PD)]

OBJECTIVE

The aim of the present study was to validate and provide a German version of the Scale for Evaluation of Neuropsychiatric Disorders in Parkinson's disease (SEND-PD) of Martínez-Martín et al. (2012).

METHOD

The German version of the SEND-PD was evaluated in a sample consisting of 96 patients with Parkinson's disease (PD) (mean age: 65.3 years ± 9.6, 29 female). This scale includes 12 items, representing the domains psychotic symptoms, mood/apathy and impulse control disorders. Reliability and validity analyses were conducted.

RESULTS

The examined patients presented a few neuropsychiatric symptoms. Explorative factor analyses identified the proposed three dimensions solution. The items of the mood/apathy domain were homogenous and selective, and the domain showed acceptable internal consistency. For the other two domains, the values were only partially acceptable. Convergent, discriminate and construct validity were shown.

CONCLUSION

The German version of the SEND-PD is sufficiently reliable and valid to be adopted in German speaking countries. However, since patients showed only a few symptoms in the dimensions of psychotic symptoms and impulse control disorders, these two domains can be evaluated only to a limited extent.

Assessing the opinions and experiences of German-speaking psychiatrists regarding necessary changes for the 11th revision of the mental disorders chapter of the International Classification of Disorders (ICD-11)

We performed an Internet-based questionnaire survey of the opinions of German-speaking psychiatrists regarding the experiences with the 10th revision of the international classification of mental disorders (chapter F of ICD-10). We received 304 completed questionnaires including more than 500 free-text comments. The responding group was characterized by professionally experienced middle-aged psychiatrists. German-speaking psychiatrists were comparatively content with ICD-10. Most diagnostic categories received a "satisfied" or "very satisfied" rating by the majority of respondents. Negative "goodness of fit" ratings--a possible indicator of the need for revision--were not higher than 50% for any category. Based on free-text entries, neurasthenia was the single diagnostic category most often suggested for deletion in ICD-11. Changes were considered necessary mainly for dementias and personality disorders. Adult attention deficit disorder and narcissistic personality disorder were the two diagnostic categories most frequently suggested to be added as new categories. This study provides valuable information related to perceived clinical utility of the classification, though with a narrow sample. Information about clinicians' experiences should be combined with scientific evidence for the revision process of ICD-11.

Neuroimaging predictors of transition to psychosis--a systematic review and meta-analysis

OBJECTIVES

In early stage psychosis research the identification of neurobiological correlates of vulnerability to schizophrenia is an important hurdle.

METHODS

We systematically reviewed the neuroimaging publications on high-risk subjects with subsequent transition to psychosis (HR-T) and conducted a meta-analysis calculating the effect size Cohen's d.

RESULTS

Out of 30 identified studies 25 met the inclusion criteria. Structural (s)MRI studies showed small to medium effect sizes of decreased prefrontal, cingulate, insular and cerebellar gray matter volume in HR-T compared to high-risk subjects without transition (HR-NT). Meta-analysis revealed relatively larger whole brain volumes in HR-T compared to HR-NT subjects (mean Cohen's d 0.36, 95% CI 0.27-0. 46). Compared to HR-NT, HR-T subjects showed in functional imaging studies reduced brain activation in prefrontal cortex, reduced neuronal density, and increased membrane turnover in frontal and cingulate cortex with medium to large effect sizes.

CONCLUSIONS

Despite methodological differences between studies, structural and neurochemical abnormalities in prefrontal, anterior cingulate, medial temporal and cerebellar cortex might be predictive for development of psychosis within HR subjects.

The effects of antipsychotics on the brain: what have we learnt from structural imaging of schizophrenia?--a systematic review

Despite a large number of neuroimaging studies in schizophrenia reporting subtle brain abnormalities, we do not know to what extent such abnormalities reflect the effects of antipsychotic treatment on brain structure. We therefore systematically reviewed cross-sectional and follow-up structural brain imaging studies of patients with schizophrenia treated with antipsychotics. 30 magnetic resonance imaging (MRI) studies were identified, 24 of them being longitudinal and six cross-sectional structural imaging studies. In patients with schizophrenia treated with antipsychotics, reduced gray matter volume was described, particularly in the frontal and temporal lobes. Structural neuroimaging studies indicate that treatment with typical as well as atypical antipsychotics may affect regional gray matter (GM) volume. In particular, typical antipsychotics led to increased gray matter volume of the basal ganglia, while atypical antipsychotics reversed this effect after switching. Atypical antipsychotics, however, seem to have no effect on basal ganglia structure.

Screening Partnergewalt

Domestic violence is frequent. But up to now there is no screening instrument available in German which would allow a simple assessment. In this article a short screening interview is published that allows the identification of women who became victims of domestic violence. Such a screening interview has not been published in German speaking countries until now. A screening interview originally developed in English speaking countries called "Partner Violence Screen" (PVS) was translated, modified and validated in a population of female patients of a crisis intervention ward. The original version of the PVS consisted of 3 items which have been extended by two items, so that the modified version of the PVS is composed of 5 items now. In a validation study this instrument was compared to a much more detailed, 30 item self rating scale "Index of Spouse Abuse" (ISA). In addition to the validation of the PVS a life-time version of the PVS was developed which refers to the entire life period since the 18th birthday. The original version of the PVS showed a sensitivity of 0.79 and a specificity of 0.70. In the modified version "Screening Partner Violence" the sensitivity was 0.80 and the specificity 0.78. This screening instrument, which was translated and further developed by the authors, proved to be helpful for identifying domestic violence. With this instrument a screening interview is available for the first time in German speaking countries that can be accomplished with women in different institutions without losing much time.

[Psychological disorders after severe occupational accidents]

After severe accidents, a significant number of victims develop post-traumatic stress disorder (PTSD) and other psychiatric disorders, which lead to considerable impairment in work and daily life. Few studies exist which deal with the psychological consequences of industrial accidents. The Department of Psychiatry and Psychotherapy (University of Freiburg) in cooperation with the Department of Trauma Surgery (University of Freiburg) have therefore carried out a prospective study on the subject. 56 victims of an industrial accident were assessed immediately after the accident, and again six months later, using different instruments, e.g. structured clinical interviews (e.g. ADIS). The prevalence rates of psychiatric disorders in the follow-up assessment after six months were 12% PTSD, 11% subsyndromal PTSD (not all criteria of PTSD fulfilled) and 11% other psychiatric disorders. The patients with PTSD and subsyndromal PTSD were compared with the patients with other psychiatric disorders. The accidents of patients with PTSD/subsyndromal PTSD were more serious, and their injuries more severe. In addition, these patients reported that they had thought much more about their work before the accident and believed that their work was much more dangerous than that of patients with other psychiatric disorders. As early as the first day after the accident the patients with PTSD/subsyndromal PTSD were afraid of developing physical and work-related problems as a consequence of the accident. They also reported more symptoms of PTSD and depression and anxiety symptoms. Patients with PTSD/subsyndromal PTSD reported more limitations in daily life and that they were unfit for work for a longer period. After their return to work, they had more problems and were less resistant to stress.

[Differentiated short- and long-term effects of a "Training of Emotional Intelligence" and of the "Integrated Psychologic Therapy Program" for schizophrenic patients?]

Social cognition was shown as a rate limiting factor for both psychosocial outcome and response to psychosocial intervention in schizophrenia. In a randomized controlled trial a new cognitive-behavioral group treatment for schizophrenic inpatients (the "Training of Emotional Intelligence", TEI) was tested against the well evaluated "Integrated Psychological Therapy Program" (IPT) of H. Brenner. Within the framework of P. Salovey's work the Training of Emotional Intelligence focussed on three domains of deficits in schizophrenia: emotional perception, emotional understanding and emotional management. In the randomized controlled trial with 41 DSM-IV schizophrenic inpatients no differences were found in problem-solving and negative symptoms, both post treatment and in the 12 months-follow up. Additionally there was a better outcome in affect decoding capacity post treatment, and a progess in regulation of negative affects in the follow up. Emotional role taking behavior and social anxiety returned to baseline level, perhaps by reasons of no "booster sessions" in the follow up. Unfortunately in contrast to our hypotheses we failed to show treatment-specific effects, which may be due to an underpowered statistical testing. There was only one exception of this: While the Integrated Psychological Therapy Program showed a greater reduction of global psychopathology after treatment, the Training of Emotional Intelligence reduced psychopathology in the follow up more strongly. Possible reasons for these results are discussed.

Evaluation of the German version of the PTSD Symptom Scale (PSS)

The psychometric properties of the PTSD Symptom Scale (PSS) were evaluated in a clinical sample of severely injured in-patients after a traffic accident (n = 123). The PSS contains 17 items which were derived from the DSM-III-R criteria of posttraumatic stress disorder (PTSD). The results indicate that the PSS has satisfactory reliability and validity (internal and external). The results are in correspondence with the results of Foa et al. using a sample of rape and non-sexual-assault patients.

[Development of the Borderline Symptom List]

The categorical diagnosis of borderline personality disorder (BPD) is currently discussed as sufficiently reliable and valid. However, specific standardized instruments to measure the degree of the symptomatology are currently not available. Based on the criteria of DSM-IV, the Diagnostic Interview for Borderlines (DIB-R) and the opinion of clinical experts and borderline-patients, a self-rating scale was developed to quantify the intrapsychic strain of patients with BPD. 308 female borderline-patients scored the 99 items. Factor analyses revealed seven factors: self-image, affect regulation, autoaggression, dysthymia, social isolation, intrusions and hostility. Analyses of reliability and validity revealed promising results.

Experience of aversive tension and dissociation in female patients with borderline personality disorder -- a controlled study

Assuming that the experience of strong aversive tension might be an indicator of the extent of affect dysregulation within patients with borderline personality disorder (BPD), we sought to operationalize the duration and intensity of these phenomena. In addition we studied the relationship between aversive tension and the experience of dissociative features. Seventy-two female patients with BPD, together with 55 healthy controls, completed a self-rating questionnaire covering the previous 24 h. Substantial and highly significant differences with regard to the duration and intensity of the subjectively perceived states of aversive tension were found. Amongst patients with BPD there was a strong correlation between duration and intensity of tension, and experience of dissociative features, both somatoform and psychological. The findings underline the clinical importance of states of aversive tension in BPD particularly with regard to stress-related induction of dissociative features.

[The concept of "evidence-based medicine" in psychiatry. A path to a more rational psychiatry?]

Many of the diagnostic and therapeutic procedures in psychiatry and psychotherapy are based on opinion rather than evidence. The concept of evidence-based medicine aims to bridge the gap between clinical research and clinical decision-making by integrating the best available external evidence with personal expertise. In this article, we demonstrate several examples of the non-evidence-based medicine paradigm. Then we show the usefulness and practicability of the new evidence-based medicine paradigm by using a clinical example. Finally, we discuss the consequences, chances, and limitations of this new model. We also examine the role of the individual clinician's viewpoint as well as the need of institutional re-engineering and the possible restructuring of the entire health care system towards evidence-based methods.

[Cognitive remediation. A new chance in rehabilitation of schizophrenic disorders?]

A critical review of current approaches and principles of cognitive remediation strategies in rehabilitation of schizophrenia is given. Selection of cognitive functions targeted in compensatory training programs could be based on results of neuropsychological predictor research on social and vocational functioning in community and neuropsychological rate limiting factors in rehabilitation. Methodological flaws in data base, missing of task analysis of more complex skills like social perception, social skills and interpersonal problem solving and the lack of evaluation of training generalization on work performance are discussed. Finally the cognitive remediation program developed in the Department of General Psychiatry and Psychotherapy/University of Freiburg, Germany is proposed. The components focused on training in attention, memory, and executive function (decision making, planning). Compensatory strategy building, and computer-mediated automatization are integrated in a group setting.

On the validity of the Bech-Rafaelsen Melancholia Scale (BRMS)

BACKGROUND

The findings published to date on convergent validity of the BRMS are mainly concerned with the correlation with other observer-rating scales for depression. In many studies on the evaluation of therapeutic interventions self-rating scales are used in connection with observer-rating scales. Therefore, findings on the relations among instruments of both groups are necessary in order to justify the combination of a particular observer-rating scale with a particular self-rating scale. In the ICD-10 three different degrees of severity of depressive episodes are distinguished. No data on the discriminant validity of the BRMS with respect to this new diagnostic classification are available till now.

METHODS

45 depressed inpatients were assessed with two observer-rating scales (BRMS and DEPRES of the AMDP system) and two self-rating scales (BDI and DS).

RESULTS

The discriminant validity with reference to the three degrees of severity of depressive episodes as defined in ICD-10 is at r = 0.80 very high. The convergent validity of the BRMS is high at r = 0.70, related to the DEPRES. The correlations between the BRMS and the BDI as well as the DS were clearly lower, at 0.53 and 0.32 each.

CONCLUSIONS

The only moderate convergent validity between self-rating and observer-rating scales is a strong argument for a multi-methodological approach in the context of therapy evaluation.

[Pharmacologic and cognitive therapy treatment strategies in in persistent negative schizophrenic symptoms]

Negative symptoms are a cofeature of schizophrenia which constitute a severe burden on relatives as well as on the patient himself. Novel (atypical) antipsychotic drugs unlike conventional antipsychotics cause substantial progress in the treatment of negative symptoms. Methodological flaws in recent studies which evaluate the effectiveness of neuroleptics in negative symptoms are being discussed critically. Especially the needs for differentiation of primary and secondary negative symptoms are underlined. Cognitive behavioural rehabilitation strategies are also reviewed. A newly developed cognitive behavioural approach in the treatment of negative symptoms developed by the "Research Group for Rehabilitation in Schizophrenia" of the Department of Psychiatry at the Freiburg University is proposed. A framework is discussed in which neuroleptic treatment optimalization and enhancement of coping strategies by psychosocial approaches are integrated. The need for integrating the patient in rehabilitation and treatment planning is underlined. Despite the limitations of methodology of most studies the findings of research reviewed here could be able to stimulate the optimalization of rehabilitation with these patients. It is necessary to ensure that all patients--especially those with high risk for deteriorating outcome--receive optimal treatment at the earliest possible stage in the course of their schizophrenic disorder. Progress in early intervention strategies [42] are therefore of outstanding interest. Main barriers to effective treatment have to be considered: noncompliance (and side-effects) of medication, repeated relapse, "treatment resistance", negative symptoms, and neurocognitive deficits. These factors indicate the need to favour integrated treatment approaches in which drugs and psychosocial strategies can be combined in a manner that maximizes the potential synergism.

Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy

BACKGROUND

Fatigue is a common and often severe problem in cancer patients undergoing chemotherapy. The authors postulated that physical activity training can reduce the intensity of fatigue in this group of patients.

METHODS

A group of cancer patients receiving high dose chemotherapy followed by autologous peripheral blood stem cell transplantation (training group; n = 27) followed an exercise program during hospitalization. The program was comprised of biking on an ergometer in the supine position following an interval training pattern for 30 minutes daily. Patients in the control group (n = 32) did not train. Psychologic distress was assessed at hospital admission and discharge with the Profile of Mood States and Symptom Check List 90.

RESULTS

By the time of hospital discharge, fatigue and somatic complaints had increased significantly in the control group (P for both < 0.01) but not in the training group. Furthermore, by the time of hospital discharge, the training group had a significant improvement in several scores of psychologic distress (obsessive-compulsive traits, fear, interpersonal sensitivity, and phobic anxiety) (P value for all scores < 0.05); this outcome was not observed in the control group.

CONCLUSIONS

The current study found that aerobic exercise can reduce fatigue and improve psychologic distress in cancer patients undergoing chemotherapy.

The concept of "sense of coherence" and the development of posttraumatic stress disorder in traffic accident victims

According to the "sense of coherence" concept, those subjects who can give meaning to a traumatic event can comprehend what has happened and have a sense of manageability of the sequelae, are able to cope better with the traumatic event itself. In the present study, this concept was applied to traffic accident victims. Severely injured traffic accident victims were assessed a few days after the accident and at 6-month follow-up. At follow-up, patients filled in the 29-item version of the Sense of Coherence (SOC) self-rating scale. The results show that the SOC total score correlated negatively with the development of: (i) posttraumatic psychopathology; (ii) psychological disorders (i.e., posttraumatic stress disorder after the accident); and (iii) anxious cognitions. The personality trait of neuroticism correlated negatively and extraversion and frustration tolerance correlated positively with SOC total score. Previous hypotheses are supported by our findings.

Prediction of posttraumatic stress disorder by immediate reactions to trauma: a prospective study in road traffic accident victims

Road traffic accidents often cause serious physical and psychological sequelae. Specialists of various medical faculties are involved in the treatment of accident victims. Little is known about the factors which might predict psychiatric disorders, e.g. Posttraumatic Stress Disorder (PTSD) after accidents and how psychological problems influence physical treatment. In a prospective study 179 unselected, consecutively admitted road traffic accident victims were assessed a few days after the accident for psychiatric diagnoses, severity of injury and psychopathology. All were inpatients and had to be treated for bone fractures. At 6-months follow-up assessment 152 (85%) of the patients were interviewed again. Of the patients, 18.4% fulfilled the criteria for Posttraumatic Stress Disorder (DSM-III-R) within 6 months after the accident. Patients who developed PTSD were injured more severely and showed more symptoms of anxiety, depression and PTSD a few days after the accident than patients with no psychiatric diagnosis. Patients with PTSD stayed significantly longer in the hospital than the other patients. Multiple regression analysis revealed that the length of hospitalization was due mainly to a diversity of factors such as severity of injury, severity of accident, premorbid personality and psychopathology. Posttraumatic stress disorder is common after road traffic accidents. Patients with PTSD at follow-up can be identified by findings from early assessment. Untreated psychological sequelae such as PTSD cause longer hospitalization and therefore more costs than in non-PTSD patients.

[Quality of life. Construct validation and the development of a modular system]

The construct Quality of Life (QoL) is investigated by metaanalysis of eight (inter)nationally validated questionnaires in a multicenter study. Data have been collected in a mentally healthy (n = 479), a depressed (n = 171) and a schizophrenic (n = 139) sample. Conventional psychometric criteria and a facet analytical methodology have been applied. The resulting questionnaire "Modular System for Quality of Life" (MSQoL) consists of a core module with 47 items (one "G-factor" and six subdimensions), which is sufficiently valid for all three samples. Additionally, there are four specific modules (demography, family, partnership, profession). No specific modules can be identified for the psychopathological subgroups. The validated radex structure for subjective QoL offers the opportunity for a cumulative research design and for adaptations to the actual setting.

Adaptation and psychometric properties of the German version of the Dissociative Experience Scale

We introduce the 'Fragebogen zu Dissoziativen Symptomen' (FDS), a German adaptation of the Dissociative Experience Scale (DES) which was developed to screen for dissociation within an ICD-10 framework. In addition to the original 28 DES items, the FDS contains 16 items covering dissociative phenomena included in the ICD-10, particularly pseudoneurological conversion symptoms. The psychometric properties of the FDS were studied in 927 clinical and nonclinical subjects from different diagnostic groups and compared to results of American studies. The scale had good test-retest reliability of .88, high internal consistency (split-half = .90, Cronbach's alpha = .94) and good construct validity. These results indicate that the FDS may be a valuable screen for dissociative psychopathology in German-speaking countries.

[Follow-up assessment of mood in depressive patients]

Three short, respectively promising self-rating scales used for the assessment of emotional states, especially depression, were examined: a visual analogue scale with only five items, a short version of the so-called "adjectives list" and a differentiated scale for recording current emotions, possible susceptibility to them and the ability to express them. We checked statistical parameters of item analysis, reliability, validity and time course measurement. This study was carried out with depressive inpatients (n = 35) at the time of admission and 4 weeks later in beginning remission. All three scales proved to be reliable (Cronbach-alpha between 0.48 and 0.97) and partially very valid instruments (concurrent validity between 0.04 and 0.87). In order to improve the documentation of a beginning response to therapeutic efforts, separate recordings of depressive subsyndromes such as "impetus" or "positive emotionality" seem to be quite promising approaches.

[Questionnaire on dissociative symptoms. German adaptation, reliability and validity of the American Dissociative Experience Scale (DES)]

The "Fragebogen zu dissoziativen Symptomen (FDS)" represents the authorised German translation and adaptation of the "Dissociative Experience Scale" (DES; Bernstein and Putnam 1986). The original scale comprises 28 items covering dissociative experiences with regard to memory, identity, awareness and cognition according to DSM-III-R and DSM-IV. For the German version, 16 items were added to cover dissociative phenomena according to ICD-10, mainly pseudoneurological conversion symptoms. Reliability and validity of the German version were studied in a total sample of 813 persons and were compared to the results of the original version. Test-retest reliability of the FDS was rtt = 0.88 and Cronbach's consistency coefficient was alpha = 0.93, which is comparable to the results of the DES. The instrument differentiates between different samples (healthy control subjects, students, unselected neurological and psychiatric inpatients, neurological and psychiatric patients with a dissociative disorder and schizophrenics). The FDS is an easily applicable, reliable and valid measure to quantify dissociative experiences.

[Children of mentally ill parents. A study of problem awareness in clinical routine practice]

The risk of developing clinically relevant psychiatric disorders in the lifetime course is significantly greater among children of mentally ill parents. A child-adapted programme of information concerning the nature and symptomatology of parental illness is considered to be an important preventive factor, and lies within the domain of the psychiatrist's or therapist's responsibilities. During the developmental phase of a prevention project at Freiburg University's Department of Psychiatry and Psychotherapy, both clinical practice and the level of problem awareness among patients and the therapists were evaluated. Over a period of one year, consecutive interviews involving 114 patients with children under 18 years of age, as well as their respective therapists, were conducted. The results showed that: scarcely any exchanges between children and therapists took place; the extent to which children are informed about parental illness must be considered as small; a high percentage of such children are already evaluated by their parents as disturbed, and the pressing need for support exists.

Psychopathological assessment and diagnosis. A study of specificity of single symptoms

The importance of single symptoms in the diagnostic process has not been adequately studied, mainly because of the complexity of the information involved. The aim of the present study is to investigate the interconnection between psychopathological assessment and diagnostic classification, with the aid of a nonparametric, inductive pattern recognition method. Using the concept of inductive logic and a theory of inductive knowledge acquisition, a model has been developed to describe psychopathological assessment and diagnostic classification. Based on a comprehensive psychopathological assessment in 837 patients with 14 different diagnoses, classification values were calculated for specific symptoms in different diagnostic groups. Furthermore, nonparametric statistical procedures have advantages over discriminant analytic approaches: more information is utilized in differentiating the groups and differentiations can be made between more groups, whereby the rate of correctly classified cases is comparable with discriminant analytic approaches. The pattern recognition method appears to illustrate the multidimensional, medical decision-making in a comprehensible way.

[Inpatient treatment of depressed patents. Conceptual considerations and results of a pilot project for quality assurance in Baden-Württemberg]

Quality-assurance activities will become more important in psychiatry during the next few years. In relation to other medical disciplines, some special aspects concerning structure, process and outcome quality as well as practical realization and methodologic aspects must be considered. These specific issues were the focus of a study dealing with the treatment of depressed inpatients. The experiences and results as well as considerations concerning future quality-assurance projects are discussed.

Correlation between physical performance and fatigue in cancer patients

BACKGROUND

Fatigue and a reduction in physical ability are common and often severe problems of cancer patients regardless of disease stage and modality of treatment. However, while physical performance can be assessed objectively with laboratory tests, fatigue is a subjective phenomenon whose perception is influenced by past experience and expectations for the future.

PATIENTS AND METHODS

To evaluate the correlation between fatigue and physical impairment, we assessed maximal physical performance with a treadmill test, and mental state with two questionnaires, the Profile of Mood States (POMS) and the Symptom Check List (SCL-90-R), in a successive series of 78 cancer patients with solid tumors or hematological malignancies.

RESULTS

A weak association between fatigue and maximal physical performance was found (r = -0.30; P < 0.01). However, intensity of fatigue showed a strong correlation with several indicators of psychological distress such as depression (r = 0.68), somatization (r = 0.64) and anxiety (r = 0.63; P for all < 0.001). Furthermore, patients with lower levels of physical performance had significantly higher scores for depression (P = 0.005), somatization (P = 0.03) and anxiety (P = 0.08), and significantly lower scores for vigor (P = 0.05) than their counterparts whose physical performance was higher.

CONCLUSIONS

We conclude that fatigue in cancer patients may be related to mood disturbance but appears to be independent of physical performance. Moreover, low physical performance can be viewed as an independent predictor of mental distress in cancer patients.

[Quality assurance in inpatient treatment of depression. Aspects of quality monitoring and external quality assurance exemplified by a pilot project of inpatient treatment of depression]

Aspects of a Pilot Study on Depression Treatment According to Quality Monitoring and External Quality Assurance: Experiences and results of a pilot study on quality of the treatment of depressed inpatients in 4 different psychiatric hospitals (2 state mental hospitals, 1 university clinic, 1 psychiatric clinic at a city general hospital) according to so-called process and outcome quality, are reported. Outcome data (self-ratings, observer rating, clinical global impression admission versus discharge, patient satisfaction with treatment, duration of inpatient stay/and patient data are reported while comparing the 4 hospitals. Difficulties and problems of data collection, assessments and comparison of 4 different hospitals are discussed.

Serum concentrations of thyroid hormones in patients with nonseasonal affective disorders during treatment with bright and dim light

Serum concentrations of thyroxine (T4), triiodothyronine (T3), and thyrotropine were measured in 34 patients with nonseasonal affective disorders before and after 1 week of light treatment. Nineteen of these patients received bright white light (2500 lx) and 15 dim red light (50 lx) for 2 hours daily in the mornings over a 1-week period. Slight but significant reductions in the rating scores for the depressive symptomatology were found for both the bright-and dim-light groups, but there were no significant differences between the two groups. The improvement is thus most likely a placebo effect. Surprisingly, the small changes in the severity of the depressive symptoms in the group as a whole were significantly correlated to the changes in the serum levels of T4 during the weeks of bright- and dim-light treatment, respectively. The more a patient improved, the further his or her T4 level fell and vice versa. The fluctuations in the concentrations of T4 during light treatment were significantly greater in the depressed patients than in a group of 12 healthy controls who also received bright or dim light, whereas the changes in T3 were significantly smaller than those of the healthy controls. The pronounced fluctuations in T4 levels were probably not secondary to changes in mood. Rather, they are likely to reflect changes in tissue (intracellular) metabolism of T4, which may be involved in the mechanisms underlying the fluctuations in mood in these patients.

The multiaxial system of ICD-10: evaluation of a preliminary draft in a multicentric field trial

The multiaxial system (MAS) of ICD-10, chapter V (F) consists of three axes: axis I, clinical syndromes (psychiatric disorders including personality disorders and somatic diseases); axis II, disabilities; axis III, environmental/circumstantial and personal life-style/life management factors. Results of a multicentric field trial evaluating a preliminary draft of the MAS are presented. 45 raters in seven German centers made 488 ratings on 12 written case histories. With a mean kappa of 0.50 for 3-character diagnoses interrater reliability for axis I was moderate although lower than expected from previous field trials. On axis II the WHO Disability Diagnostic Scale (WHO-DDS) was compared to the Global Assessment of Functioning (GAF) used in DSM-III-R and DSM-IV. For both scales the intraclass correlation coefficient showed a moderate interrater reliability (WHO-DDS = 0.62; GAF = 0.65). On axis III the number of relevant psychosocial circumstances coded by the different raters varied greatly. Interrater reliability was very poor with kappa values ranging from 0.03 to 0.55 for the different categories and an overall kappa of 0.16.

Schizophrenia, schizotypal and delusional disorders (F2). Results from the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries

The results of the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries concerning section F2, "Schizophrenia, schizotypal and delusional disorders', are presented. From a total of 39 cases (written case reports and video tapes) 5 met the criteria for schizophrenia (F20) with 201 ratings. The majority of clinicians rated the ease of diagnosis, confidence of diagnosis, and goodness of fit positive. The reliability of the 2-character diagnoses was excellent (F2; kappa = 0.88), as was the case for the category schizophrenia (F20; kappa = 0.89) and was higher than in the comparable study concerning the Clinical Diagnostic Guidelines.

Design of the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries

The design of the international multicentric field trial on ICD-10, chapter V (F) "Mental and Behavioural Disorders (including disorders of psychological development): Diagnostic Criteria for Research' including some modifications for the study in German-speaking countries is described. The different stages of the study, the assessment instruments, and the database are presented.

Instruments in the assessment of psychosomatic and neurotic disorders

The introduction of DSM-III/DSM-III-R and ICD-10 implies fundamental innovations to the diagnostic process. The changes relate both to formal aspects (e.g. symptom and time-related criteria) and to content (e.g. the abandonment of the concept of neurosis). Additionally, specific assessment instruments are introduced. However, other aspects important for the description and treatment of patients easily become neglected when concentrating on a system of diagnoses which aim at the classification of patients by groups of disorders. The present article will present instruments which make it possible to do justice to both points of view.

[Suicidal behavior of depressed patients at inpatient admission]

Early recognition of suicidal behavior is of extreme importance for avoidance of this cause of death. The risk of suicide attempts is particularly high in psychiatric illness, and among hospital in-patients especially in those with depression. Thus, the risk of suicide should be estimated in the first interview after admission to a psychiatric hospital. Our study analysed the routine documentation of such interviews on admission to the Psychiatrische Klinik der Freien Universität in Berlin: 41% of all depressive patients were suicidal. Suicidal and non-suicidal depressive patients could be differentiated by the following traits: suicidal patients were younger, had been younger at the initial onset of depressive illness, had made more suicide attempts in the past, and had a greater number of relatives who had committed suicide or made suicide attempts. They were more often single or divorced, and had fewer children of their own. Their psychopathology was characterized by a more strongly developed syndrome of depression, hostility and apathy. These findings point to a pattern of characteristics that are linked with suicidal behavior, which can be used to estimate the risk of suicide right at the beginning of a stay in hospital.

Somatoform disorders--diagnostic concept, controlled clinical trials, and methodological issues

The paper summarizes the concept of somatoform disorders, which was first introduced in the Diagnostic and Statistical Manual of Mental Disorders in its third edition in 1980. The relevant clinical trials related to this concept are reviewed. On the basis of this experience, the present study discusses methodological requirements for clinical trials, including inclusion and exclusion criteria, measurements of efficacy and safety, and statistical considerations, in the hope that this will stimulate the use of this diagnostic entity in the future.

Implications of the concepts "coping" and "quality of life" for criteria of course and outcome

The Berlin Coping Study is a prospective longitudinal project with schizophrenic patients investigating the relationship between coping strategies and course and outcome. We find that some psychological issues relevant for both clinical practice and psychiatric research, and especially for pharmacological therapy, have been rather neglected up to now. The investigation of coping strategies leads to accentuating the patients' subjective individual views concerning their demands, goals, and coping activities in daily living and their schizophrenic illness. The concept of quality of life is increasingly receiving attention in various domains of professional care and it is very relevant to the issues discussed here. Consequences of this approach for therapy and research are outlined.

Psychopathology and the analysis of therapeutic effects

The different domains of psychopathological research are described. An example of taxonomies that may be relevant for therapy is given. For the apathy scale of the AMDP system it is demonstrated that there is an equivalent severity of this syndrome in acute paranoid hallucinatory schizophrenia and in unipolar depression. In schizophrenia the apathy syndrome may subsume some, if not all, of the negative symptoms, that cause major problems for therapy. A common pathophysiological factor for the syndrome in the two diseases is discussed. A systematic psychopathological approach to the identification of pathophysiological factors of drug effects and their involvement in psychiatric diseases, including experimental variables, is characterized.

[Possibilities for psychological intervention in persistent delusions and persistent acoustic hallucinations in schizophrenic patients]

In practice the therapy of treatment resistant psychotic symptomatology (delusions and hallucinations) is a difficult and up to now unsolved problem. This overview presents and discusses behaviour therapy oriented studies (in the main part single case studies). The majority of studies show that it is in principle possible to influence this symptomatology. Because of methodological limitations of many studies finally some proposals for future research are discussed.

Blood serotonin, serum melatonin and light therapy in healthy subjects and in patients with nonseasonal depression

The 24-h rhythms of blood serotonin and serum melatonin were determined in 39 unmediated inpatients with nonseasonal affective disorder and in 14 healthy men and women after 7 days of morning bright-light (2500 lx) or dim-light (50 lx) treatment. Bright-light treatment led to a more than 50% decrease in the Hamilton Rating Scale for Depression (HRSD) score in 4/19 patients and dim light in 1/17 patients. After light treatment the mesor (the daily mean estimated by cosinor analysis) of patients' and subjects' melatonin levels did not change significantly, nor was there a correlation between phase change and decrease in HRSD score. We observed after bright- and dim-light treatment a consistent increase in blood serotonin in patients and healthy subjects, which differed significantly between healthy subjects and patients. These findings suggest the involvement of serotonergic mechanisms following light therapy.

Phototherapy in nonseasonal depression

Previous reports have shown that bright light exposure may benefit patients with seasonal depression. In the present study, the possible therapeutic effect of bright light in nonseasonal major depressive disorder was examined. Forty-two depressed patients not receiving additional antidepressant medication were exposed to bright white light of 2500 lux or dim red light of 50 lux over one week for two hr daily in the morning. The change in depressive symptoms was assessed by rating scales (Hamilton Depression Rating Scale, CGI) and by self-rating scales (Depression Scale, Complaint List, Visual Analogue Scale). Consistent for all ratings, the decrease in depressive symptoms after bright white light was only slight and not different from dim red-light exposure. Contrary to the findings in seasonal affective disorder, phototherapy administered over one week for two hr daily is not effective in nonseasonal major depressive disorder.

Side-effects of phototherapy in nonseasonal depressive disorder

The data of the Berlin light therapy study were systematically reinvestigated for side-effects of light therapy as described in the literature. Forty-two patients with major depressive disorder (RDC), who also met the criteria of ICD-9 (296.1 and 296.3), were included. Patients were either given bright white-light treatment (2,500 lux) or dim red-light treatment (50 lux) from 7.20 a.m. to 9.20 a.m. every morning for a period of seven days. The study did not reveal any differences in side-effects between the two treatments. The results are discussed in relation to the two different treatment conditions.

Diurnal variations of mood and sleep disturbances during phototherapy in major depressive disorder

The influence of diurnal variations of mood (DVM) and sleep disturbances on treatment response was investigated in 42 patients with major depressive disorder (not SAD) under the treatment of either bright white light (2,500 lx) or dim red light (50 lx). We found only a slight influence in certain subscales of DVM and no influence of sleep disturbances. These results are discussed under a clinical point of view and with respect to phase shift theories of depressive disorders.

The symptom pattern variations of unipolar depression during life span: a cross-sectional study

The psychopathological syndromes are analyzed for 436 patients suffering from a unipolar affective psychosis, depressed type, without any further psychiatric or somatic diagnosis, separately for the second to eighth decade of life. The intensity of the depressive syndrome, as well as the apathy syndrome according to the Manual for the Assessment and Documentation of Psychopathology (AMDP) system, does not decrease. The autonomic syndrome increases for the group in the involutional age, and the psycho-organic syndrome for the group in the old age. The analysis of special symptom patterns, as for the agitated behavior or symptoms of the psycho-organic syndrome, is presented.

External attributions and outcome in depressive in-patients

Thirty-four voluntarily admitted depressive in-patients were asked by their clinicians in the first interview why they came into hospital and what they expected there. Some patients expressed external attributions referring to other persons who were viewed as being responsible for the admission or for improvement under treatment. External attributions of this kind were found to have some negative predictive value for the outcome of treatment.

ICD-10 field trial in German-speaking countries--summary, judgement and perspectives

On the basis of the results of the field trial, the most important classificatory innovations of ICD-10, together with their advantages and disadvantages are described. The initial good acceptance of the new system could be further improved by structural modifications, such as a uniform and systematic description of the individual diagnostic categories. Criticism of content was focused on affective and neurotic disorders and adult personality disorders. When it is introduced, the psychiatric chapter of ICD-10 will surpass most of the hitherto existing psychiatric classification systems in size, differentiation and international testing.

Neurotic, stress-related and somatoform disorders (section F4) and physiological dysfunction associated with mental or behavioural factors (section F5): results of the ICD-10 field trial

The results of the ICD-10 field trial in German-speaking countries relevant to sections F4 (neurotic, stress-related and somatoform disorders) and F5 (physiological dysfunction associated with mental or behavioural factors) show a comparatively low level of acceptance. Interrater-reliability in various diagnostic categories is not always adequate. In particular the allocation of some of the "old" diagnostic entities of ICD-9 to various sections of ICD-10, and in part unsatisfactory classificatory distinctions gave rise to certain problems.

Mood (affective) and schizoaffective disorders (section F3): results of the ICD-10 field trial

Section F3 (affective disorders) of ICD-10 has preserved a high degree of continuity with respect to ICD-9, and a strong convergence towards DSM-III-R affective disorders is evident. Despite this tendency, some categories, like F31, F33 and F36, need further specification. In general, section F3 was adequately accepted by clinicians, easy to use and proved to be user-friendly for a wide variety of psychiatrists with different orientation.

Schizophrenia, schizotypal and delusional disorders (section F2): results of the ICD-10 field trial

To determine whether the use of ICD-10 provides greater diagnostic reliability than ICD-9, a field trial of the ICD-10 draft (WHO, 1987) was carried out. A total of 1,778 diagnoses made on the basis of ICD-10, ICD-9 and, in part, DSM-III were established by 134 clinicians in 10 centres using case reports and interviews. The corrected reliability coefficients of schizophrenic disorders obtained with ICD-10, with kappa-coefficients of reliability of 0.69 for the 2-character category and 0.67 for the 3-character category are higher than those reported for the diagnosis of schizophrenia made without specified criteria, but lower than those reported for DSM-III. Despite the operationally defined diagnostic guidelines, diagnostic discrepancies still persist when organic disturbances, substance abuse or psychogenic features are additionally present. The diagnoses of each rater remain stable on change over from ICD-9 to ICD-10. Our data suggest that ICD-10 is suitable for worldwide use in diagnosing schizophrenia.

Feasibility, suitability, and interrater reliability of ICD-10 during different stages of the ICD-10 field trial

A total of 134 clinicians in 10 centres participated in the WHO-initiated field trial in German-speaking countries prior to the introduction of ICD-10 (chapter V; categories F00-F99. Mental, Behavioural, and Developmental Disorders), and provided 1,778 diagnostic assessments of 90 cases. Since these assessments were made in different phases of the field trial, the present study investigated how the "feasibility" and "suitability" of the so-called "Clinical Descriptions and Diagnostic Guidelines" was assessed within the individual phases. In addition, the interrater reliability of diagnostic assessments for the respective phases was investigated. The results show that ICD-10 was accepted both at the beginning of the study, and after several months of use. With respect to interrater reliability, improvements in some of the categories are necessary.

ICD-10 field trial in German-speaking countries--summary of the quantitative empirical results

The summary of the quantitative results of the ICD-10 field trial in German-speaking countries shows a adequate acceptance of ICD-10. The figures for interrater reliability for the diagnostic categories are adequate for most categories considering the comparatively low level of familiarity with the new system. The high degree of overlap between the diagnostic categories in ICD-9 and ICD-10 is an indication of the validity of ICD-10. The major source of disagreement is the relocation of several diagnostic categories to different sections.

Effect of bright white light on non-seasonal depressive disorder

In previous research, the therapeutic effect of bright white light for so so-called seasonal affective disorder was clearly confirmed. The aim of the present study was to evaluate possible beneficial effects of bright white light in non-seasonal depression. 30 patients fulfilling RDC-criteria for major depressive disorder were randomly assigned to a 7 day exposure from 7.20 to 9.20 a.m. The degree of illness was ascertained both objectively with observer rating scales (Hamilton Depression Scale, AMDP-system) and through self-rating scales (Complaint List and Depression Scale by von Zerssen). No difference was noted between bright light and dim light though a significant reduction of depressive symptomatology was observed for all patients during the treatment. These results were consistent for both observer rating and self-rating. In conclusion, bright white light has no superior effect as compared to dim light exposure in non-seasonal depression.