The 'European Alliance Against Depression (EAAD)': a multifaceted, community-based action programme against depression and suicidality

Action programmes fostering partnerships and bringing together regional and national authorities to promote the care of depressed patients are urgently needed. In 2001 the 'Nuremberg Alliance Against Depression' was initiated as a community-based model project within the large-scale 'German Research Network on Depression and Suicidality' (Kompetenznetz 'Depression, Suizidalität'). The 'Nuremberg Alliance Against Depression' was an action programme, conducted in the city of Nuremberg (500,000 inhabitants) in 2001/2002, addressing four intervention levels (Hegerl et al. Psychol Med 2006;36:1225). Based on the positive results of the Nuremberg project (a significant reduction of suicidal behaviour by more than 20%) 18 international partners representing 16 different European countries established the 'European Alliance Against Depression' (EAAD) in 2004. Based on the four-level approach of the Nuremberg project, all regional partners initiated respective regional intervention programmes addressing depression and suicidality. Evaluation of the activities takes place on regional and international levels. This paper gives a brief overview of the background for and experiences with the EAAD. It describes the components of the programme, provides the rationale for the intervention and outlines the current status of the project. The aim of the paper is to disseminate information about the programme's potential to reduce suicidal behaviour and to provide examples of how European community-based 'best practice' models for improving the care of depressed patients and suicidal persons can be implemented using a bottom-up approach. EAAD is mentioned by the European commission as a best practice example within the Green Paper 'Improving the mental health of the population: Towards a strategy on mental health for the European Union' (European Commission 2005).

Patterns of social distance towards people suffering from schizophrenia in Austria: a comparison between the general public, relatives and mental health staff

OBJECTIVE

The aims of this study were to identify the different aspects of the attitudes towards people suffering from schizophrenia and to find factors influencing these attitudes -- especially the willingness to contact people suffering from schizophrenia -- as well as to obtain information on how to reduce stigma and discrimination.

METHOD

We conducted a study to investigate these attitudes in Austria. A representative sample of the general public, different professional groups working in the field and relatives of mentally ill people were interviewed. The public, relatives and people working in the mental health field were asked a number of the same questions, to allow for comparisons between groups.

RESULTS

We found great differences in key dimensions of the attitude towards people suffering from schizophrenia between groups: these included different causal attributions to schizophrenia, different attitudes concerning the perceived success of the treatment of schizophrenia, different fears concerning perceived dangerousness and a different willingness to interact voluntarily with schizophrenia patients.

CONCLUSION

The factors influencing the distance towards people suffering from schizophrenia differ between groups. Our findings should help to optimize campaigns fighting against stigma and discrimination.

Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric treatment

Although telepsychiatry in the form of videoconferencing has been well received in terms of increasing access to care and user satisfaction, few data on treatment outcomes and efficacy from telepsychiatry applications are available at the present time. This paper evaluates the efficacy of telepsychiatry through videoconference in the treatment of mental disorders by comparing to face-to-face conventional (F2FC) treatment. We carried out a randomized clinical trial where 140 psychiatric outpatients were randomized to either F2FC treatment or videoconference telepsychiatry (VCTP) treatment. Patients were diagnosed according to International Classification of Diseases, 10th edition (ICD-10) criteria using the Composite International Diagnostic Interview. Treatment involves eight consultations lasting 30 minutes over the 24-week study period. Patients received pertinent psychotropic medication plus cognitive- behavioral therapy during sessions. The same psychiatrist diagnosed and treated all the patients that were recruited from the Community Mental Health Centre of San Sebastian de la Gomera, in the Canary Islands. Change in psychiatric test scores served as the primary efficacy criterion. Efficacy was determined by comparing baseline (visit 1) Clinical Global Impressions-Severity of Illness (CGI-S) and -Improvement (CGI-I) scales as well as Global Indexes (GSI, PSDI, and PST) from SCL-90R with scores obtained at the end of the study period (week 24). Response was defined as a CGI-I score of 1 or 2. Reliable Change Indexes were computed in SCL-90R Global Indexes scores. Of 140 patients randomized, 130 completed 24 weeks of treatment. Only 4 patients dropped out prematurely from the study in VCTP and 6 in F2FC. The study involves 534 teleconsultations, 522 F2FC consultations, and more than 500 hours of clinical practice. Significant improvements were found on the CGI and SCL-90- R Global Indexes scores of both treatment groups, showing clear clinical state improvement. No statistically significant differences were observed when the efficacy of VCTP treatment was compared to F2FC psychiatric treatment efficacy. This study demonstrated that telepsychiatry treatment through videoconference has equivalent efficacy to F2FC psychiatric treatment. Telepsychiatry showed to be an effective mean of delivering mental health services to psychiatric outpatients living in remote areas with limited resources.

[Attempts to overcome the stigma of schizophrenia]

The results of research into attitudes show clearly that the knowledge, the attitudes and views of our society towards psychiatric topics strongly influence practical psychiatric services. Those affected report that they are confronted with a high degree of prejudice and exclusion which considerably inhibits their recovery, their integration and their quality of life even today. Especially people with schizophrenic illnesses are affected by stigmatisation and exclusion. These are not just caused by a lack of information. Prejudices and misconceptions are deeply rooted in our cultural tradition. The negative consequences for the treatment and way of life of those affected are such that Asmus Finzen spoke of a "second illness" which may be caused by stigmatisation.Set against the background of the vulnerability-stress-paradigm, the social consequences can result in stressors. Disadvantages in terms of societal participation, negative assessments and humiliating discrimination can undermine self-esteem, ability to cope and compliance and thereby hinder the recovery process and strengthen remaining marks of the illness. Since there is extensive informed understanding about these problems, the discussion focuses increasinlgy on questions about what psychiatry and those working in psychiatry can contribute to reverse this negative attitude. This is the aim, for example, of the World Psychiatric Association's international awareness campaign, which uses modern communication techniques to try to counter the myths and misunderstandings surrounding the schizophrenic illness and its name. The study being introduced here was carried out in conjunction with the Society for Mental Health Tyrol. It was attempted to discover how information should be conveyed in order to change the attitudes of school pupils. On the basis of these results, we have begun to offer information sessions in schools throughout the Tyrol.

[Status and development of psychiatric care in Italy. 22 years after Franco Basaglia's reform regulation no. 180]

Since reforms were introduced in 1978, the treatment of mental illness in Italy is less uniform than ever before. The essential and core aspects of these reforms were not implemented in many southern provinces, but there are flourishing private clinics in Rome and other metropolitan areas, and in the highly developed regions of northern and central Italy there are institutions meeting very high standards of complementary care. However, reforms in these areas had begun as early as in 1968 in accordance with Act 431 passed that year, and in these regions the newer reforms functioned only as a catalyst. The extremely high goals set by the "Italian experiment" were not realized, but the achievements of several Italian provinces in the areas of ambulant and supporting psychiatric care can certainly be viewed as exemplary. A general trend toward increased critical examination of ways of dealing with the mentally ill from the medicinal, humanitarian, and social points of view is emerging.

["...not dangerous, but nevertheless frightening". A program against stigmatization of schizophrenia in schools]

OBJECTIVE

Evaluation of a brief school programme providing information about schizophrenia to high school students. It was investigated whether the programme changed the students' attitude towards this target group and whether information given by a patient affects the results.

METHODS

114 high school students (6 school classes) took part in the programme: 57 students were informed by a psychiatrist and an afflicted person (group A), the other 57 were informed by a psychiatrist and a social worker (group B). The students' attitude towards schizophrenics was assessed using a vignette of a fictitious class-mate suffering from schizophrenia (according to DSM criteria) and by questionnaires assessing the students' emotional and cognitive reactions and their social distance towards the person described by the vignette.

RESULTS

Only in group A (psychiatrist and afflicted) there was a significant improvement regarding the emotional reaction (reduction of fear, increase in positive emotions) and a significant decrease in social distance. Moreover, students no longer associated psychiatric illness with being "crazy". In group B (psychiatrist and social worker) these changes could not be observed. There was even a significant increase in describing patients with schizophrenia as dangerous.

CONCLUSION

As high school students themselves consider their level of knowledge about psychiatric illness as low, information about this topic should be given more attention than is currently done (also from a preventive point of view). For such information to be effective and to affect students' attitudes positively, it appears necessary that students have the opportunity to get in contact with a person affected by psychiatric illness. For changing attitudes it is also essential how information is presented.

[Prevalence of psychiatric disorders in elderly inpatients of medical and surgical departments]

OBJECTIVE

The aim of the present survey was to study the psychiatric prevalence among elderly patients of medical and surgical wards in Austria.

METHODS

244 inpatients, 60 years and above, were investigated by research psychiatrists using the Clinical Interview Schedule.

RESULTS

The prevalence was found to be 38.7% in medical departments, and 33.0% in surgical departments. According to DSM-III-R criteria, dementia (20.9%) and minor depression (7.0%) were the most frequent psychiatric categories, followed by substance abuse disorders (4.5%). Among those suffering from psychiatric disorders, 68.5% received psychotropics. Only a quarter of these drugs were prescribed by consulting psychiatrists, while about three quarters were ordered by ward physicians.

CONCLUSIONS

These facts underline the importance of an intensive cooperation between specialists for somatic medicine and psychiatrists.

Recognition of psychiatric disorders in nonpsychiatric hospital wards

OBJECTIVE

Although many studies have reported that many psychiatric cases are missed by their nonpsychiatric physicians, their methods are often limited because ward physicians' recognition has been assessed from potentially unreliable sources such as medical notes. The aim of the present study was to assess recognition by using direct questions to ward physicians.

METHODS

Five hundred five (505) nonpsychiatric in-patients were interviewed using the Clinical Interview Schedule. Ward physicians' recognition of psychiatric disorders was assessed using a rating form for every patient.

RESULTS

The psychiatric prevalence of the total sample was 37.3%. Overall, ward physicians' diagnostic sensitivity was 54.5%, but their sensitivity varied for the different diagnoses (31.3-89.5%). In addition to psychiatric symptoms and abnormalities, intake of psychotropics before admission significantly predicted identification of psychiatric disorders.

CONCLUSIONS

In our study, physicians' sensitivity was higher than that reported from surveys based on medical notes. The fact that nearly half of all psychiatric disorders were missed by ward physicians suggests that better psychiatric training for nonpsychiatric doctors is necessary.

[Does psychiatric comorbidity increase length of stay in medical, surgical and gynecological departments?]

Several studies from Anglo-American countries indicate that in non-psychiatric hospital departments mentally ill patients have a longer length of hospital stay than mentally well, while in Austria and Germany, until now, no studies concerning this question exist. Therefore, we investigated the influence of psychiatric comorbidity on the length of stay in 608 patients of medical, surgical and gynecological departments in Vienna and Tyrol. Based on the Clinical Interview Schedule, 28.1% of the patients in this sample suffered from psychiatric disorders. The presence of psychiatric disorders, as well as type of hospital department (medical department), higher age, more previous non-psychiatric treatment periods, and more somatic diagnoses predicted a longer duration of inpatient treatment. To avoid the influence of cofounding variables, psychiatric cases were matched with psychiatric non-cases. The mentally ill group was treated for a markedly longer period as inpatients than the mentally well. Patients with a diagnosis of dementia or of substance abuse showed a significantly increased length of stay, while we could not confirm this for other psychiatric diagnoses.

Polypharmacy in psychiatric treatment. Patterns of psychotropic drug use in Austrian psychiatric clinics

There are great variations in the way psychotropic drugs are prescribed. Most experts are in favour of psychopharmacological monotherapy, but little is known about the extent to which it is actually practised. A survey of the psychopharmacological medication of all patients under treatment was carried out in three Austrian psychiatric clinics of various types on two separate days. A psychiatric university clinic, the psychiatric department of a general hospital and a regional mental hospital were selected for the survey. It was established that only 8% to 22% of the patients underwent psycho-pharmacological monotherapy and that the patients received 2.2 to 3.3 psychotropics on average. Five to 22% of the patients received five or more psychotropic agents. The results are presented in more detail in relation to the diagnoses of schizophrenia and depression. The rare occurence of monotherapy might be due to unsound treatment regimens in some instances, but much more to a general trend in psychiatry fostering polydrug use.

[Subjective quality of life of schizophrenic patients. Effect of treatment setting, psychopathology and extrapyramidal motor drug effects]

OBJECTIVE

In a cross-sectional study in 79 schizophrenic patients the quality of life (QOL) of a group of community-based patients under supervision of an outpatient unit (n = 47) and a group of long-stay patients in an inpatient rehabilitation centre in the same area (n = 32) was compared.

METHODS

The patients' QOL was evaluated using the Lancashire Quality of Life Profile. Moreover psychopathology and extrapyramidal-motoric side-effects were assessed.

RESULTS

Long-stay patients had a more distinct psychopathological symptomatology and more severe side-effects than community-based patients. After adjustment for psychopathology and side-effects, the subjective QOL of long-stay patients was significantly reduced in two out of eight life domains: housing and leisure activities. While psychopathology was negatively correlated with QOL, a subgroup with very marked psychopathology showed unexpectedly high QOL ratings.

CONCLUSIONS

Results suggest that psychopathology is a stronger predictor of subjective QOL than side-effects and treatment setting. Patients with very distinct psychopathology probably use lower standards than others when evaluating their QOL which should be taken into consideration when analysing this type of data.

Use of psychotropic drugs in gynecological, surgical, and medical wards of general hospitals

OBJECTIVE

The purpose of the present study was to investigate the prevalence of psychotropic drug use and the predictors of use during hospitalization.

METHOD

We investigated 728 patients admitted to medical, gynecological, and surgical wards of two non-university general hospitals in Austria for psychotropic drug use, psychiatric morbidity, and sociodemographic characteristics.

RESULTS

The use of psychotropics was highest in medical wards (67.6%), followed by surgical (59.3%), and gynecological wards (37.8%). Older age, psychiatric caseness, consultation by psychiatrists and use of psychotropics before admission were predictors for psychotropic drug use. Psychotropics were given for a longer duration to psychiatric cases than to non-cases. Anxiolytics were prescribed most often (39.6%), followed by hypnotics (16.9%), neuroleptics (10.7%), and antidepressants (7.0%).

CONCLUSIONS

The fact that psychiatric illness is a significant predictor of psychotropic drug use suggests that these drugs were prescribed aptly. The longer duration of use among psychiatric cases supports the idea of appropriate prescriptions.

The impact of work-related rehabilitation on the quality of life of patients with schizophrenia

In a cross-sectional study of 60 outpatients with schizophrenia (mean age 36.3 +/- 11.1) the effect of a work-related rehabilitation programme on the patients quality of life was investigated. A group of patients with the same diagnosis, but without rehabilitation, served as controls. Patients of the rehabilitation group had been attending the programme for a mean duration of 15.0 months. The programme focuses on occupational and everyday skills and also involves social aspects. The patients' quality of life was assessed using two self-administered questionnaires: the Munich List of Life Dimensions (MLDL, Heinisch et al. 1991) and the Everyday Life Questionnaire (Bullinger et al. 1993). Life satisfaction as well as functional quality of life were higher in the rehabilitation group in the majority of domains assessed. Difference between groups was highest for satisfaction with work, followed by leisure-time activities, independence and friendships/acquaintances. Results indicate that the rehabilitation programme acts like a "lever" which, applied to one point (work, day structuring), subsequently affects most domains of daily living.

Psychotropic drug intake in residents newly admitted to nursing homes

While several surveys have shown that psychotropic drugs are frequently used by nursing home residents, no studies have been performed to investigate whether the rates of drug use increase during the stay in nursing homes or whether residents have taken these drugs already before admission. Therefore, we investigated 262 residents admitted to rural and urban nursing homes in Austria for prevalence of psychotropic drug intake before admission, shortly after admission, and 6 months later. Two weeks after admission, 72.1% of the residents were being treated with psychotropics, while 6 months later 79.0% were receiving these drugs. The significantly higher rates of psychotropic drug use among the psychiatrically ill and in those suffering from sleeping problems suggest that these drugs were prescribed aptly, but residents without appropriate criteria for drug intake were often also treated with psychotropics. During 3 months before admission to nursing homes, 45.5% of the sample reported having taken psychotropics. In more than half of residents without drug intake before admission, psychotropic treatment was initiated within the first 2 weeks after admission, while during the first 6 months after admission the rate of drug use increased only slightly. This suggests that a large percentage of psychotropic intake is due to nursing home orders.

General life satisfaction and domain-specific quality of life in chronic schizophrenic patients

Subjective quality of life (QOL) has often been assessed through questionnaires or structured interviews focusing on the person's satisfaction with various life domains. In particular, most QOL instruments for psychiatric patients are based on this concept. We report on a study casting some doubts on the rationale of this approach. We investigated the QOL of 48 chronic schizophrenic outpatients with a long-term disease history (at least 20 years) using a German version of the Lancashire QOL Profile. The interrelations between general life satisfaction, satisfaction with specific life domains, psychological well-being and psychopathology were studied using correlation analysis and multiple linear regression. Of the life domains assessed, only two, namely social relations and health, contributed significantly to the patients' general life satisfaction, while the others (including work, leisure, family relations and housing) did not. The subscales on psychological well-being (self-esteem, affective state) as well as psychopathology were found to be more closely associated with general life satisfaction than almost all life domains considered. The findings are discussed with regard to the specific situation of the group of patients investigated. They give indications that the life domain approach to measuring QOL has its limitations, in particular when applied to patients having adapted to a very restricted everyday life.

[Quality of the location as a principle in psychiatric health care planning]

The goal of reasonable accessibility of specialised care to all those who need it must be kept in mind when planning to establish mental health service in the community. For methodological purposes, an attempt is made to quantify and thus render measurable the accessibility factor, also to be called "quality of location", based on "spatial" as well as "non-spatial" indicators. In many areas of community life involving planning and political decision making, the importance of such an approach cannot be underestimated. On the basis of the 1989 case register in the Austrian State of Tyrol, we investigated the relationship between administrative prevalence and the distance between the patient's home and the nearest hospital providing in-patient care, this distance being measured in terms of the time it takes to get to the hospital by public transportation. Our investigation confirmed the phenomenon described for the first time in 1852 by E. Jarvis, that there is an inverse relationship between the frequency of hospital admission and the geographical distance patients had to travel. This observation was validated, first of all, by excluding the possibility of selective migration influencing the inverse relationship between utilisation of available facilities by patients and the distance from their homes, and, secondly, by making suitable adjustments for the influence of "non-spatial" indicators such as rural/urban differences, socio-demographic variables and economic factors as indicated by the census figures. In the health service region we investigated, comprising of small town/rural areas, it was found that the Jarvis effect was slightly weakened; this observation, however, could not be explained solely in terms of the "non-spatial" indicators. What is new in the present investigation is the use of time as a dimension in the description of quality of location, as well as the approach combining the two sets of indicators, the "spatial" and the "non-spatial", which have hitherto been considered isolated from each other. Using the temporal dimension, it was possible to determine the time limit, i.e. the "sensitivity to distance" which can be looked upon as defining reasonable accessibility to in-patient care. This turned out to be about 30 to 45 minutes of travel by public transportation, this being shorter than the figure given by the German Mental Health Service survey. In summary, our investigation shows that the temporal dimension-the distance between home and hospital measured in terms of the time it takes to get to the hospital-is the most significant determinant of the quality of location; socio-demographic and economic factors play merely a secondary role.

Tardive dyskinesia prevalence rates during a ten-year follow-up

We followed up patients in the State Psychiatric Hospital Mauer-Ohling, Mauer-Ohling, Austria, who had been examined in 1982 to determine the prevalence of tardive dyskinesia (TD). Of the 861 patients examined in 1982, 270 were still in hospital 10 years later. Only these patients were included in our study. The SKAUB (Skala für abnorme unwillkürliche Bewegungen, i.e., The German version of the Abnormal Involuntary Movement Scale) was used to quantify the occurrence of TD. The prevalence rate of TD was 3.7% in 1982 and 12.7% in 1992. The 1992 prevalence rate in patients who had not shown TD symptoms in 1982 was 11.4%. The major risk factor for TD was advanced age.

Late-onset schizophrenia and late paraphrenia

The term "late-onset schizophrenia" was first coined by Manfred Bleuler (1943) to describe a form of schizophrenia with an onset between the ages of 40 and 60. This concept has been adopted by German psychiatry. Until recently, British and American psychiatrists had little interest in this patient group. However, they often used the term "late-onset schizophrenia" interchangeably with late paraphrenia or as a generic term for both these diseases, even though the concept of late paraphrenia is quite different from that of late-onset schizophrenia. Late paraphrenia is a British concept that includes all delusional disorders starting after age 60. This confusion of terms and concepts is even more important now, because recent neuroimaging and neuropsychological studies suggest that an organic substrate probably exists in most cases of late paraphrenia, while only minor organic abnormalities can be found in late-onset schizophrenia. We believe it is of utmost importance to establish a clear boundary between late-onset schizophrenia and other delusional disorders in middle and old age, because the confusion in terminology and concepts is a serious impediment to comparative international research.

Serum concentrations of circulating endogenous granulocyte-macrophage colony-stimulating factor in HIV-1-seropositive injecting drug users

OBJECTIVES

We compared serum concentrations cytokines in seronegative and seropositive HIV-I intravenous drug abusers.

METHODS

The cytokines granulocyte-macrophage colony-stimulating factor (GM-CSF), tumor necrosis factor alpha (TNF-alpha), interleukin-1 beta (IL-1 beta) and the immune activation markers soluble interleukin-2 receptor (sIL-2R) and neopterin were determined in sera of HIV-1-seropositive and HIV-1-seronegative injecting drug users (IDUs).

RESULTS

HIV-1-seropositive IDUs showed significantly lower serum concentrations of GM-CSF (p = 0.0064) and significantly higher concentrations of neopterin (p = 0.0005) than HIV-1-seronegative IDUs. All HIV-1-seropositive IDUs had neopterin levels above the normal range. Levels of TNF-alpha in HIV-1-seronegative IDUs did not differ from HIV-1-seropositive IDUs. Increased levels of IL-1 beta were found in 83.3% HIV-1-seronegative and in 94.4% HIV-1-seropositive IDUs with no significant difference between the two groups. An increase of serum levels of sIL-2R was found in 60% HIV-1-seronegative and in 63.6% HIV-1-seropositive IDUs. Again, no difference was found between the two groups. Neopterin concentrations correlated with TNF-alpha in HIV-1-seropositive as well as in HIV-1-seronegative IDUs, neopterin concentrations correlated with sIL-2R only in the HIV-1-seropositive IDUs. No correlations were found for GM-CSF.

CONCLUSIONS

An impaired production of GM-CSF may contribute to the loss of the myelopoetic progenitor cells and to the functional abnormalities of leukocytes associated with HIV-1 infection. Injecting drug use contributes to the levels of immune activation markers, therefore their use in HIV-1 infection may be limited in IDUs. However, neopterin remains a useful marker for HIV-1 infected IDUs.

Wilhelm Griesinger and the concept of community care in 19th-century Germany

Wilhelm Griesinger, a 19th-century German physician, can be considered one of the founders of the concept of community-based care for mentally ill patients. In an era when such patients typically spent most of their lives in asylums in remote rural areas, be recommended their integration into society and proposed that short-term treatment of acutely ill patients could be carried out in asylums that were located in cities and linked to general hospitals. He believed that short-term hospitalization could be effective only if professional and natural support systems cooperated closely. Although he did not assume that all mental illnesses could be cured, he thought that most patients should be discharged from long-term treatment in remote asylums. For those unable to live without support in the community, be suggested setting up sheltered living conditions. Although his ideas about community-based care were rejected by his contemporaries in favor of a system of rural asylums, many of Dr. Griesinger's suggestions are now being put into practice.

Antipsychotic maintenance treatment of schizophrenia patients: is there a consensus?

We obtained pharmaco-epidemiologic data regarding the antipsychotic maintenance treatment (AMT) of schizophrenia patients through a postal survey sent to all Austrian psychiatrists and neurologists. Drug therapy was considered the most important therapeutic approach in the long-term management of schizophrenia. However, the majority of the respondents clearly were not satisfied with the current status of scientific knowledge about dosage and duration of AMT. Single-drug treatment with antipsychotics was preferred by the respondents; oral and depot neuroleptics were used with equal frequency. Haloperidol was the oral drug most frequently mentioned as first choice (44% of the respondents), followed by clozapine (14.1%) and thioridazine (9.2%). The proposed mean daily doses showed striking variations among respondents. The proposed mean length of maintenance treatment in first-episode patients was 7.3 months; in multi-episode patients, it was 20.1 months. The results show considerable variation in physicians' attitudes toward AMT.

Stable pattern of stress coping in patients with rheumatoid arthritis

The stress coping mechanisms of patients with rheumatoid arthritis (74 women and 27 men) were compared to those of healthy controls (17 women and 16 men) using the Stress Coping Questionnaire of Janke et al. (1). Based on the duration of illness, male and female patients were divided into three groups, those with a duration of illness of less than 5 years, those with 5-15 years and a third group with 15 or more years of illness. From a comparison of these groups with healthy controls, the following conclusions can be drawn: (1) RA patients can be characterized by a coping pattern which is determined by significantly more cognitive mechanisms, e.g. trivialization, more attempts at controlling their reactions and less self-accusation. (2) The patient groups with different disease durations do not differ in their coping patterns. The stress coping behaviour of RA patients seems to be stable and does not appear to be influenced by the duration of illness.

[Clozapine in long-term treatment of schizophrenic patients]

Clozapine has advantages over standard antipsychotics in refractory schizophrenia. Studies on the efficacy of clozapine in the maintenance treatment are sparse and suffer from methodological limitations. Despite this fact clozapine ranked second in a survey dealing with the preference of this antipsychotic in the long-term treatment of schizophrenia. Doctors report on using a mean of 130 mg/d in this indication which is considerably less than the doses used in most of the published long-term trials. The discrepancy between the popularity of clozapine and the lack of sound empirical data on its long-term efficacy is discussed.

Smoking cessation--gradual or sudden stopping?

One hundred ten patients addicted to nicotine were subjected to either sudden or gradual withdrawal in the course of a smoking cessation programme. Eighty-two patients emerged from the treatment as non-smokers. In a follow-up after 1 year 70% of these successful clients replied to an anonymous questionnaire. Concerning the relapse rate, no significant difference could be found between the two treatment groups, but patients who underwent slow withdrawal smoked significantly less when comparing their current consumption with that before the start of the therapy. Patients who underwent sudden stopping reached their original level of nicotine use again.

[Cognitive training in psycho-organic syndromes]

Seven of fourteen elderly female patients (mean age 82.3 [75-89] years) with abnormalities of cognition, memory and affect of organic causation were randomly assigned to be given cognitive training, especially relating to memory, as part of rehabilitation measures for medical or orthopaedic diseases. The other seven served as controls. Training extended over 15 days, cognitive training given on 9 days for 45 min each. The control group had sessions of nonspecific attention. All patients were given psychological tests of memory and attention before and after cognitive training (or nonspecific attention). Behavioural changes were also assessed. The patients with cognitive training scored significantly higher than the controls, both in the individual exercises of the training programme and in the various tests of performance. The cognitive training also favourably influenced social behaviour, mood and level of volition. Maintaining and improving still present mental capacity in this type of patient is an essential task within a hospital setting, which otherwise provides little stimulus. Cognitive training is simple and effective, yet of great social importance.

[Compliance--a complex problem]

During the past 15 years medical and psychological literature has increasingly focused on compliance or noncompliance as a relevant aspect of patient care. The following paper is an attempt at categorizing the large variety of factors with impact on compliance, aiming at a more differentiated view at this problem. The paper is complemented by a short questionnaire which should allow the therapist (physician/psychologist) to assess the compliance of his patients/clients.

Is schizophrenia linked to alteration in cellular immunity?

To reinvestigate the viral hypothesis of schizophrenia as well as possible immunological dysfunction, neopterin, which is an indicator of the activity in the cellular immune system, was determined in acute and chronic schizophrenics. Both diagnostic groups showed neopterin levels within the normal range. Patients with chronic schizophrenia of the residual type presented a significant dependency between neopterin concentrations and Brief Psychiatric Rating Scale (BPRS) total scores. In a long-term observation of 14 acute schizophrenic (paranoid type) inpatients, neopterin levels were found to be lowest at day 0. During the first week of treatment neopterin concentrations increased significantly whereas a concomitant decrease of the psychopathological symptoms could be observed. In comparison to healthy controls patients showed significantly lower neopterin levels at baseline. These findings will be discussed referring to the viral hypothesis of schizophrenia as well as to possible immunological alterations caused by stress or by changes in neurotransmitter synthesis.

Dose-related plasma levels of clozapine: influence of smoking behaviour, sex and age

Drug monitoring in psychiatry is of increasing interest due to compliance problems, side effects of psychoactive drugs and the search for adequate dosage. In the present study, plasma levels of clozapine, as determined by high performance liquid chromatography, were investigated in 148 patients receiving a daily dose between 12.5 and 700 mg clozapine. Regression analysis revealed a linear relationship between dose and plasma concentrations. Plasma concentrations at a given dose (level divided by dose and body weight) in male patients reached only 69.3% of the concentrations in female patients (Mann-Whitney U Test P less than 0.001). When the patients were divided into smokers and non-smokers, the corresponding plasma levels were also found to be linearly dose dependent in each of the two groups. However, the average plasma concentration at a given dose was only 81.8% in smokers, compared to non-smokers. This difference was statistically significant (variance analysis P = 0.022). Dividing female patients into smokers and non-smokers, the smokers reached nearly the same plasma levels as the non-smokers. Male smoking patients reached average plasma concentrations which were only 67.9% of those of non-smokers. This difference was statistically significant (Mann-Whitney U Test P = 0.0083). The plasma levels of the different age groups at a given dose per kg body weight were compared using the Mann-Whitney U Test. Significant differences were found between group 1 (18-26) and group 4 (45-54) (P less than 0.01) and group 2 (27-35) and group 4 (P less than 0.01) showing higher plasma levels in the older age group.(ABSTRACT TRUNCATED AT 250 WORDS)

Mood-altering effects of biperiden in healthy volunteers

There has been considerable evidence that, aside from various other effects, synthetic anticholinergics also possess a significant euphoriant property. A double-blind placebo-controlled study was conducted in an attempt to answer the following questions: Can euphoria be induced by experimental intravenous administration of biperiden in therapeutic dosages? Is the individual's psychic response to anticholinergics associated with particular personality traits? In a study with a double-blind placebo cross-over design 28 healthy volunteers were given biperiden intravenously. The evaluation of their reaction to the drug using the Bech-Rafaelsen Mania Scale (MRS) revealed two groups of about the same numerical size demonstrating a considerable difference in their reaction to the drug.

Preliminary results of guanfacine treatment of acute opiate withdrawal

Ten patients experiencing sudden opiate withdrawal received low doses of guanfacine. Improvement was noticeable within the first 4 days and was most evident in moderate to severe cases. The major effect was on autonomic symptoms. Tolerance to guanfacine was excellent.