[Excited Delirium Syndrome (ExDS): emergence and emergency management]

The Excited Delirium Syndrome (ExDS) is a state of maximum psychophysiological excitation far beyond mental agitation. Patients themselves are at an acute risk and put others at a high risk. We present data from eleven patients and a short literature review. Results: 9 of 11 patients were acutely intoxicated (alcohol, magic mushrooms, THC, ecstacy, or "flakka"). Eight had a history of substance abuse and 4 of other mental illness. None of the patients responded to attempts at verbal de-escalation. Seven had significant injuries at the time of admission to the hospital. The aggressive "psychiatric" presentation of ExDS can lead to vital risks being overlooked (hyperexcitation, acidosis, rhabdomyolysis, hypoxemia, and cardiovascular decompensation), which may even be increased by severe methods of restraint (hogtie; positional asphyxia). Early recognition of ExDS and its risks, comprehensive management and the prevention of inappropriate treatment will help to reduce fatal outcomes.

Long-term follow-up after severe suicide attempt by multiple blunt trauma

Background

After parasuicide there is a high risk of reattempts. However, it seems that patients who survived severe suicidal trauma recover well. Therefore, the outcome of patients with severe multiple blunt trauma as a result of a suicide attempt was investigated with respect to psychiatric and somatic health, quality of life (QOL) and suicide reattempt rates.

Methods

Patients who underwent a suicide attempt were isolated from a prospectively collected sample of trauma patients from a level I University Trauma Centre. Follow-up examination was performed 6.1 ± 3 years after the trauma. A physical and psychiatric examination was performed, using established psychiatric scales.

Results

Twelve percent of severely injured patients were identified as suicide attempters (male/female: 37/28, mean age 38 ± 18 years, mean Injury Severity Score (ISS) 40 ± 15 points). A psychiatric diagnosis was present in 90% at the time of the suicide attempt. Twenty-one patients died during the hospital stay (32%) and six subjects died thereafter, none due to suicide. Thirty-five individuals were eligible for examination. None of them had reattempted suicide. Seventeen (48%) had good outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings and good psychosocial ability. An indeterminate outcome was determined in 24%. Predictive variables for an adverse outcome (10 patients, 28%) were found to be a diagnosis of schizophrenia, continued psychiatric treatment and being without employment.

Conclusions

Despite the seriousness of the suicide attempt, survivors recovered well in about half the cases with no further suicide attempt in any patient. An early psychiatric consultation already on the Intensive Care Unit (ICU) is recommended.

Do antipsychotics lead to cognitive impairment in dementia? A meta-analysis of randomised placebo-controlled trials

Behavioural and psychological symptoms in dementia (BPSD) are common and often treated with antipsychotics, which are known to have small efficacy and to cause many side effects. One potential side effect might be cognitive decline. We searched MEDLINE, Scopus, CENTRAL and www.ClincalStudyResult.org for randomized, double-blind, placebo-controlled trials using antipsychotics for treating BPSD and evaluated cognitive functioning. The studies identified were summarized in a meta-analysis with the standardized mean difference (SMD, Hedges's g) as the effect size. Meta-regression was additionally performed to identify associated factors. Ten studies provided data on the course of cognitive functioning. The random effects model of the pooled analysis showed a not significant effect (SMD = -0.065, 95 % CI -0.186 to 0.057, I ² = 41 %). Meta-regression revealed a significant correlation between cognitive impairment and treatment duration (R ² = 0.78, p < 0.02) as well as baseline MMSE (R ² = 0.92, p < 0.005). These correlations depend on only two out of ten studies and should interpret cautiously.

[Psychiatric Emergencies in Psychiatric Hospitals in Germany]

Objective: Psychiatric hospitals are confronted with high rates of psychiatric emergencies. There are, however, only few investigations that focus on psychiatric emergency care in German psychiatric hospitals, their supply structures and diagnostic and treatment standards. The aim of the survey was a systematic acquisition of the diagnostic and therapeutic approach in treating psychiatric emergencies in German psychiatric hospitals. Methods: We conducted a survey in psychiatric hospitals throughout Germany. The questionnaire consisted of questions concerning the structures of supply and diagnostic and therapeutic standards treating psychiatric emergencies. Results: 42 % of all admissions to German psychiatric hospitals were emergency admissions. More than 60 % of the patients in psychiatric emergency ambulances had to receive inpatient treatment. As standard procedures for medical clearing in psychiatric emergencies physical examination, measurement of heart rate and blood pressure and conducting certain laboratory tests and breath alcohol were named. The most common psychopharmacological agents for emergency situations were diazepam, lorazepam, haloperidol and zuclopenthixol. Conclusion: Diagnosing and treating psychiatric emergencies need more standardisation. More specific data is required to generate diagnostic and therapeutic standards.

The effect of aerobic exercise on cortical architecture in patients with chronic schizophrenia: a randomized controlled MRI study

Via influencing brain plasticity, aerobic exercise could contribute to the treatment of schizophrenia patients. As previously shown, physical exercise increases hippocampus volume and improves short-term memory. We now investigated gray matter density and brain surface expansion in this sample using MRI-based cortical pattern matching methods. Comparing schizophrenia patients to healthy controls before and after 3 months of aerobic exercise training (cycling) plus patients playing table football yielded gray matter density increases in the right frontal and occipital cortex merely in healthy controls. However, respective exercise effects might be attenuated in chronic schizophrenia, which should be verified in a larger sample.

The cross-sectional GRAS sample: a comprehensive phenotypical data collection of schizophrenic patients

BACKGROUND

Schizophrenia is the collective term for an exclusively clinically diagnosed, heterogeneous group of mental disorders with still obscure biological roots. Based on the assumption that valuable information about relevant genetic and environmental disease mechanisms can be obtained by association studies on patient cohorts of ≥ 1000 patients, if performed on detailed clinical datasets and quantifiable biological readouts, we generated a new schizophrenia data base, the GRAS (Göttingen Research Association for Schizophrenia) data collection. GRAS is the necessary ground to study genetic causes of the schizophrenic phenotype in a 'phenotype-based genetic association study' (PGAS). This approach is different from and complementary to the genome-wide association studies (GWAS) on schizophrenia.

METHODS

For this purpose, 1085 patients were recruited between 2005 and 2010 by an invariable team of traveling investigators in a cross-sectional field study that comprised 23 German psychiatric hospitals. Additionally, chart records and discharge letters of all patients were collected.

RESULTS

The corresponding dataset extracted and presented in form of an overview here, comprises biographic information, disease history, medication including side effects, and results of comprehensive cross-sectional psychopathological, neuropsychological, and neurological examinations. With >3000 data points per schizophrenic subject, this data base of living patients, who are also accessible for follow-up studies, provides a wide-ranging and standardized phenotype characterization of as yet unprecedented detail.

CONCLUSIONS

The GRAS data base will serve as prerequisite for PGAS, a novel approach to better understanding 'the schizophrenias' through exploring the contribution of genetic variation to the schizophrenic phenotypes.

Patient participation in antipsychotic drug choice decisions

Patient inclusion in antipsychotic drug decisions is recommended by international treatment guidelines. For N=300 in patients with schizophrenia, we analysed patients' preferences for inclusion in decisions and physicians' estimates which patients actually participated in drug choice. Path analysis was used to examine the relationships between patients' preferences/actual participation and clinical variables measured. Forty percent of the patients expressed a wish to participate in clinical decisions. Those patients wishing to participate in medical decisions had less insight into the necessity of treatment. Psychiatrists gave better ratings of the doctor-patient relationship to those patients whom they rated as having participated in their drug choice. These patients had more positive attitudes towards antipsychotic medication. There was no relationship between the desire to participate and actual participation in the drug choice. When working with patients exhibiting poor insight and negative drug attitudes, psychiatrists use authoritative decision-making styles despite the patient's desire to participate.

Personality traits of emergency physicians and paramedics

OBJECTIVE

Personality influences behaviour and decision-making. This may play a particular role in emergency medical personnel (EMP) dealing with critical situations. So far very little is known about personality traits that distinguish paramedics (PM) and emergency physicians (EP) from other medical staff.

METHODS

A questionnaire including the ultra-short version of the Hamburg Personality Inventory (HPA) was distributed to EP, PM, medical doctors not practicing emergency medicine (MD) and medical students (MS).

RESULTS

274 EPs, 245 PMs, 48 MDs and 60 MSs returned the questionnaire. Four personality clusters in EPs and PMs were identified and to be found largely independent from demographic and job-related variables. For both groups one cluster revealed personality characteristics that seem particularly suitable for EMP ('resilient crisis manager'). 'Anxious' and 'insecure' personality traits were found in two clusters in PMs and in one cluster in EPs. Mental health problems in the participants or their relatives or the experience of loss increased scores in the dimensions neuroticism and openness.

CONCLUSIONS

The personality characteristics of EPs and PMs are not homogenous and do not differ substantially from those of MDs and MSs. 50-70% of EMP can be characterised as 'resilient and stable', up to 30-40% as 'anxious and insecure'. The presence of mental health problems in participants or their relatives or the experience of loss may lead to openness for new experiences and alternative behaviour or--on the other hand--may trigger feelings of insecurity and/or anxiety in emergency situations.

Hippocampal plasticity in response to exercise in schizophrenia

CONTEXT

Hippocampal volume is lower than expected in patients with schizophrenia; however, whether this represents a fixed deficit is uncertain. Exercise is a stimulus to hippocampal plasticity.

OBJECTIVE

To determine whether hippocampal volume would increase with exercise in humans and whether this effect would be related to improved aerobic fitness.

DESIGN

Randomized controlled study.

SETTING

Patients attending a day hospital program or an outpatient clinic.

PATIENTS OR OTHER PARTICIPANTS

Male patients with chronic schizophrenia and matched healthy subjects.

INTERVENTIONS

Aerobic exercise training (cycling) and playing table football (control group) for a period of 3 months.

MAIN OUTCOME MEASURES

Magnetic resonance imaging of the hippocampus. Secondary outcome measures were magnetic resonance spectroscopy, neuropsychological (Rey Auditory Verbal Learning Test, Corsi block-tapping test), and clinical (Positive and Negative Syndrome Scale) features.

RESULTS

Following exercise training, relative hippocampal volume increased significantly in patients (12%) and healthy subjects (16%), with no change in the nonexercise group of patients (-1%). Changes in hippocampal volume in the exercise group were correlated with improvements in aerobic fitness measured by change in maximum oxygen consumption (r = 0.71; P = .003). In the schizophrenia exercise group (but not the controls), change in hippocampal volume was associated with a 35% increase in the N-acetylaspartate to creatine ratio in the hippocampus. Finally, improvement in test scores for short-term memory in the combined exercise and nonexercise schizophrenia group was correlated with change in hippocampal volume (r = 0.51; P < .05).

CONCLUSION

These results indicate that in both healthy subjects and patients with schizophrenia hippocampal volume is plastic in response to aerobic exercise.

Identifying the profile of optimal candidates for antipsychotic depot therapy A cluster analysis

OBJECTIVE

The prescription rate of antipsychotic depots for patients suffering from schizophrenia is currently low. Among these patients the assumable acceptance rate of depot as treatment of choice is markedly higher, but psychiatrists do report that patients frequently reject the offer of depot treatment. In a first step to highlight this contradiction we aimed at identifying attributes of patients that indicate their qualification for depot treatment in the eyes of the psychiatrists.

METHOD

We surveyed 201 psychiatrists about their evaluation of patients' attributes potentially influencing their qualification for depot treatment. Multidimensional and cluster analyses were applied to detect associated attributes. A second sample of further 248 psychiatrists was asked about their proposal of depot treatment to patients depending on the number of relapses in the past.

RESULTS

Two clusters of attributes were identified characterizing patients' qualification for depot treatment. In cluster I episodes of non-compliance and relapses in the past were considered as favoring the qualification. cluster II included a high level of insight, openness to drug treatment and profound knowledge about the disease representing attributes that increase patients' qualification. Patients were significantly more likely to be offered depot treatment after their fourth reexacerbation compared to their first relapse.

CONCLUSIONS

Attributes comprised in cluster I highly qualify a patient for depot treatment which is in line with the current prescription stereotype. This conservative notion of depot use is supplemented by an alternative cluster II patient profile. Patients fitting this cluster also potentially qualify for depot treatment according to the surveyed psychiatrists and should be offered depot in clinical routine considering the advantages of this form of administration.

Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings

BACKGROUND

Psychiatric emergency situations (PES) are of high importance to the German prehospital physician-based emergency medical system. So far, however, no prospective studies regarding the incidence of PES have been performed, neither have effects of training programs on diagnostic and therapeutic accuracy been studied.

METHOD

The protocols of two emergency medical services (EMS) were collected and analyzed prospectively. Emergency physicians (EPs) in Kaiserslautern (KL) attended a standardized educational program and underwent daily supervision. EPs in Homburg (HOM) had not been informed about the study. In KL, sociodemographic variables were collected. An investigator who was not involved in the individual EMS mission assessed the correct classification of PES.

RESULTS

Among all calls for an EP, 11.8% were classified as PES. There was no difference between the two centers. Correct classification of PES in KL was significantly higher than that in HOM (94.3% vs. 80.6%). Documentation of suicidal behavior was deficient in both centers. EPs in KL gave verbal crisis intervention significantly more often, administered less medication overall, and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders. Patients were more often treated at the scene and were less often transported to a hospital. Some sociodemographic variables were associated with psychiatric morbidity of treatment.

CONCLUSION

Accounting for 12% of all missions, psychiatric emergencies are a frequent reason for calls for EPs, equaling trauma-related and neurological emergencies. The most frequent reasons for calls were alcohol intoxication, states of agitation and suicidal behavior. The diagnostic and therapeutic accuracy of EPs may be improved with a concise standardized teaching program.

Intake of copper has no effect on cognition in patients with mild Alzheimer's disease: a pilot phase 2 clinical trial

Disturbed copper (Cu) homeostasis may be associated with the pathological processes in Alzheimer's disease (AD). In the present report, we evaluated the efficacy of oral Cu supplementation in the treatment of AD in a prospective, randomized, double-blind, placebo-controlled phase 2 clinical trial in patients with mild AD for 12 months. Sixty-eight subjects were randomized. The treatment was well-tolerated. There were however no significant differences in primary outcome measures (Alzheimer's Disease Assessment Scale, Cognitive subscale, Mini Mental Status Examination) between the verum [Cu-(II)-orotate-dihydrate; 8 mg Cu daily] and the placebo group. Despite a number of findings supporting the hypothesis of environmental Cu modulating AD, our results demonstrate that oral Cu intake has neither a detrimental nor a promoting effect on the progression of AD.

The attitude of patients towards antipsychotic depot treatment

In spite of their well known advantages, depot antipsychotics are seldom prescribed in the treatment of schizophrenia. A frequently stated reason is the patient's objection to depot treatment. We questioned 300 patients in nine psychiatric hospitals shortly before their discharge about their preferences in the mode of administration of antipsychotic treatment, taking earlier depot experience into account. 145 patients were naive to depot treatment, 95 had experienced a depot earlier and 60 were currently on a depot medication. Acceptance of depot treatment in relapse prevention was 73% in patients currently being treated with a depot and 45% in depot-experienced patients, compared with 23% in depot-naive participants. Participants, depending on their experience with the formulation, acknowledged suggested potential advantages of depot treatment. Preference of depots as favorable antipsychotic treatment depends on the patient's experience with the formulation. A considerable number of patients would accept a depot drug as a long-term treatment option. The gap between patients' acceptance and the low prescription rates can be narrowed by offering antipsychotic depots to more patients.

Copper and clioquinol treatment in young APP transgenic and wild-type mice: effects on life expectancy, body weight, and metal-ion levels

There is mounting evidence that the amyloid precursor protein (APP), the key protein in Alzheimer's disease (AD) is involved in the copper (Cu) homeostasis in the brain. Conflicting results about the potential use of dietary Cu and clioquinol (CQ), a known Cu chelator, have been reported using APP transgenic mice. Previously, in vitro studies have demonstrated that CQ can act as a Cu transporter. To analyze the potential function of CQ as a Cu transporter in vivo, the nutritional effect of Cu and CQ was analyzed in young APP transgenic mice and nontransgenics with food pellets containing either Cu, CQ, Cu plus CQ (Cu + CQ), or without addition of supplements (control). The offspring were fed with corresponding food pellets until the age of 14 weeks. We observed an increased lethality of APP transgenics upon CQ treatment, which could be rescued by a co-treatment with Cu. The exposure of Cu + CQ led to a modest but significant increase in cerebral Cu levels, most likely due to an enhanced transport of CQ-Cu complexes. In CQ or Cu + CQ treatment groups, the plasma levels of Cu, zinc, and iron were reduced in all animals; moreover, Cu treatment alone reduced only plasma iron levels. We conclude not only that CQ has certain toxicity but also that the chelating effect, perhaps, plays a secondary role with respect to its properties as an intracellular Cu transporter, thus, counteracting the supposed therapeutic effects of CQ as an agent for chelating therapy in AD.

Incidence of posttraumatic stress disorder after prolonged surgical intensive care unit treatment

The purpose of the study was to investigate the prevalence of posttraumatic stress disorder (PTSD) after prolonged intensive care unit (ICU) treatment and to study the differences between trauma patients and patients who were admitted with other diagnoses. Survivors of surgical intensive care of at least 30 days' duration underwent follow-up examination at about 35 months after discharge from the ICU. Thirty-seven patients were investigated. Seven patients met full DSM-IV criteria for diagnosis of PTSD. All of them had sustained severe multiple injuries. Patients with trauma were at significantly higher risk for developing PTSD than were non-trauma patients. After prolonged ICU treatment, PTSD seems more likely to occur when the reason for admission to the ICU was severe physical injury. The prevalence of PTSD does not seem to be related to injury severity or duration of ICU treatment.

Cognitive decline correlates with low plasma concentrations of copper in patients with mild to moderate Alzheimer's disease

Alzheimer's disease (AD) is a devastating brain disorder clinically characterised by progressive loss of characteristic cognitive abilities. Increasing evidence suggests a disturbed copper (Cu) homeostasis to be associated with the pathological processes. In the present study we analysed the plasma Cu levels and cognitive abilities using the Alzheimer's disease Assessment Scale-cognitive subscale (ADAS-cog) in 32 patients with mild to moderate AD. Statistical analysis revealed a negative correlation between plasma Cu levels and cognitive decline (r=-0.49; P<0.01). Patients with low plasma Cu (mean 82 +/- SD 9) had significant higher ADAS-cog values (mean 23 +/- SD 7), than patients with medium plasma Cu (mean 110 +/- SD 7), who exhibited lower ADAS-cog scores (mean 16 +/- SD 4; ANOVA, P<0.0001). Despite the fact that all patients had plasma Cu levels within the physiological range between 65 microg and 165 microg/dL, 87.5% of the patients revealed a significant negative correlation between plasma Cu and ADAS-cog. This finding supports the hypothesis of a mild Cu deficiency in most AD patients.

Clinical trial design in schizophrenia: implications for clinical decisions

PURPOSE OF REVIEW

Results from clinical trials do not necessarily provide information for decisions in clinical practice. This review aims to present strengths and limitations of different methodological types of clinical trials and to offer an overview of how knowledge from clinical trails can be distilled for clinical practice. Selected key questions in the treatment of schizophrenia are presented, with a focus on the possibilities and restrictions of translating trial results into real-world practice.

RECENT FINDINGS

Randomized controlled trials are the gold standard for proving efficacy of a diagnostic or therapeutic procedure. They have a high degree of internal validity and a clear-cut message when conducted to good-quality standards but suffer from a lack of generalizability (external validity). Effectiveness studies evaluate effects of treatments under conditions approximating usual care. They may include patient-centred outcomes or health economic evaluations. According to the type of trial, specific problems arise in the interpretation of results. Typical examples are given for the treatment of acute exacerbations of schizophrenia, for relapse prevention and for the treatment of cognitive impairment.

SUMMARY

Clinical decisions have to be made upon the best knowledge. Therefore, well conducted studies addressing all major issues from all relevant perspectives are needed. The assessment of a treatment regimen for clinical utility requires both efficacy and effectiveness studies. An understanding of the design, analysis and conventions of both study types is essential for the interpretation of results and their translation to the clinical decision-making process.

Risperidone: an open-label, observational study of the efficacy, tolerability, and prescribing behavior in acutely exacerbated patients with schizophrenia

OBJECTIVE

Efficacy of atypical antipsychotic in acute schizophrenic episodes is still in debate. This study evaluated treatment practices over 7 years of initial treatment with oral risperidone in acutely exacerbated patients with schizophrenia and in a subgroup of highly agitated, tense, and aggressive patients. Additionally, the study investigated the efficacy and tolerability of risperidone in routine clinical practice.

METHODS

In a prospective, multicenter, observational trial from 1996 to 2002, patients with schizophrenia experiencing acute symptom exacerbations were treated with risperidone within 24 hours of inpatient admission. Patients with a total score of > or =15 points on the agitation subscale of the Positive and Negative Syndrome Scale (PANSS) were defined as highly agitated. Efficacy measures were carried out with a modified PANSS, the Clinical Global Impression (CGI) and the Brief Psychiatric Rating Scale (BPRS).

RESULTS

A total of 1625 patients were evaluated. Despite prescription of decreasing risperidone dosages over 7 years, efficacy was maintained and tolerability improved significantly. Significant symptom relief occurred in all patients and was more pronounced in the subgroup of highly agitated patients (n = 256; P < 0.001 for PANSS, BPRS, and CGI). At Week 6, the mean daily dosage of risperidone was 4.8 mg in the highly agitated patients and 4.7 mg in the remaining patients, and more than 55% of all patients were receiving risperidone as monotherapy.

CONCLUSIONS

Prescribing patterns with risperidone in patients with acutely exacerbated schizophrenia, including highly agitated patients, changed with the experience gained with this compound. In routine clinical practice in this indication, risperidone was found to be effective and well tolerated.

Psychometric and psychopathological characterization of young male prison inmates with and without attention deficit/hyperactivity disorder

There is considerable evidence that attention deficit/hyperactivity disorder (ADHD) is associated with conduct problems, social maladaptation and delinquent behavior. The "Ottweiler Study" was performed to elaborate the prevalence of ADHD and comorbid disorders in 129 young adult detainees of the juvenile prison of Ottweiler (Germany) according to DSM-IV and ICD-10 criteria. Here we report psychopathological characteristics of 28 inmates, who fulfilled the diagnostic criteria for persisting ADHD, and 37 individuals with neither a history nor current ADHD symptoms. Childhood ADHD symptoms but no current ADHD were present in 64 individuals. The Wender-Reimherr Interview (WRI) based on the Utah criteria for adult ADHD, the NEO-five factor personality inventory (NEO-FFI) and the youth self report/young adult self report (YSR/YASR) according to Achenbach were used for the assessment of psychopathology and the description of behavioral problems. Regarding WRI and YSR/YASR we found a significant increase of emotional and internalizing problems in the ADHD group compared to delinquents without ADHD or ADHD history. ADHD delinquents scored higher on the personality dimension neuroticism, and showed lower scores on the dimensions agreeableness and consciousness. Using discriminant analysis, high scores on the WRI subscales disorganization and attention difficulties and NEO-FFI neuroticism were the best predictors of ADHD diagnosis. The results support prior findings of high ADHD prevalence in prison inmates and suggest that emotional and internalizing abnormalities are prominent problems in this population. Further studies are needed to elucidate the role of ADHD as an independent factor for life-persistent criminality, since specific treatment may help to ameliorate the legal prognosis.

Risperidone in acute and long-term therapy of schizophrenia--a clinical profile

Data from a range of well-controlled clinical trials, observational studies, and clinical use support the efficacy of risperidone for both acute and long-term therapy of schizophrenic psychoses. With regard to positive symptoms, the efficacy of risperidone was shown to be at least comparable with that of haloperidol. However, risperidone differs from conventional antipsychotics because it is more effective against the negative symptoms, has beneficial effects on affective and cognitive symptoms, and carries less risk of extrapyramidal side effects (EPS). To date, risperidone is the only atypical antipsychotic to have shown a significantly lower relapse rate compared with haloperidol in a long-term double-blind trial. This review describes comprehensive trial data and therapeutic observations gained with risperidone in the treatment of schizophrenia since its approval.

Patients on atypical antipsychotic drugs: another high-risk group for type 2 diabetes

Patients with schizophrenia are more likely than the general population to develop diabetes, which contributes to a high risk of cardiovascular complications; individuals with schizophrenia are two to three times more likely to die from cardiovascular disease than the general population. The risk of diabetes, and hence cardiovascular disease, is particularly increased by some of the new atypical antipsychotic drugs. Individuals taking an atypical antipsychotic drug, particularly younger patients under 40 years of age (odds ratio 1.63, 95% CI 1.23-2.16), represent an underrecognized group at high risk of type 2 diabetes. The mechanisms responsible for antipsychotic-induced diabetes remain unclear. Hypotheses include these drugs' potential to cause weight gain, possibly through antagonism at the H(1), 5-HT(2A), or 5-HT(2C) receptors. Other mechanisms independent of weight gain lead to elevation of serum leptin and insulin resistance. Patients with psychoses have difficulties with diet and lifestyle interventions for diabetes and weight management. If hyperglycemia develops, withdrawal from antipsychotic medication will often be inappropriate, and a change to an atypical antipsychotic drug with lower diabetogenic potential should be considered, especially in younger patients. Management of psychoses should routinely include body weight and blood glucose monitoring and steps to promote exercise and minimize weight gain. Careful collaboration between the psychiatric and diabetology teams is essential to minimize the risk of diabetes in patients taking atypical antipsychotic medication and for effective management when it develops. This collaboration will also help minimize the already high risk of cardiovascular disease in individuals with schizophrenia.

Suicides and suicide attempts in emergency medicine

OBJECTIVE

In emergency medicine, suicides and attempted suicides represent a major challenge for emergency physicians (EPs) and paramedics, both in terms of psychiatric and somatic treatment. To date no investigations have been performed to determine prevalence rates, method of suicide or attempted suicide, and the problems faced by EPs when treating these patients. This investigation presents a first evaluation of the complete emergency protocols from a major German city focusing on suicide and parasuicide.

METHODS

A retrospective analysis of all EP protocols from 1995 in the city of Hamburg was performed. All protocols were evaluated with respect to suicide parasuicide and suicidal ideation. Demographic data and information on method of suicide or attempted suicide, severity of illness, and underlying psychiatric disorder were extracted from the protocols.

RESULTS

A total of 26,347 emergency protocols were evaluated. Suicide and attempted suicide were considered either certain, probable, or possible in 743 cases (2.8%). Suicide was committed in 171 cases and attempted were made by 572 individuals. More men committed suicide in all age groups. By far the highest number of suicide attempts were by young men between 18 and 39 years of age. Hanging was the most commonly used method of completed suicide (41%), followed by jumping from a height (21%). The methods of intoxication with medication (54%) and illegal drugs (17%) clearly prevailed in suicide attempts. Documentation of suicides and attempted suicides was revealed to be unsatisfactory. Underlying psychiatric disorders were scarcely recorded.

CONCLUSION

In emergency medicine, the incidence of suicide or the attempt to commit suicide is small, yet disturbing. The frequency assessed may be too low as result of methodology. There is a need to improve the education of emergency physicians and paramedics in this area, and there is a need for data to be collected in a prospective design.

Suicides and suicide attempts in emergency medicine

OBJECTIVE

In emergency medicine, suicides and attempted suicides represent a major challenge for emergency physicians (EPs) and paramedics, both in terms of psychiatric and somatic treatment. To date no investigations have been performed to determine prevalence rates, method of suicide or attempted suicide, and the problems faced by EPs when treating these patients. This investigation presents a first evaluation of the complete emergency protocols from a major German city focusing on suicide and parasuicide.

METHODS

A retrospective analysis of all EP protocols from 1995 in the city of Hamburg was performed. All protocols were evaluated with respect to suicide parasuicide and suicidal ideation. Demographic data and information on method of suicide or attempted suicide, severity of illness, and underlying psychiatric disorder were extracted from the protocols.

RESULTS

A total of 26,347 emergency protocols were evaluated. Suicide and attempted suicide were considered either certain, probable, or possible in 743 cases (2.8%). Suicide was committed in 171 cases and attempted were made by 572 individuals. More men committed suicide in all age groups. By far the highest number of suicide attempts were by young men between 18 and 39 years of age. Hanging was the most commonly used method of completed suicide (41%), followed by jumping from a height (21%). The methods of intoxication with medication (54%) and illegal drugs (17%) clearly prevailed in suicide attempts. Documentation of suicides and attempted suicides was revealed to be unsatisfactory. Underlying psychiatric disorders were scarcely recorded.

CONCLUSION

In emergency medicine, the incidence of suicide or the attempt to commit suicide is small, yet disturbing. The frequency assessed may be too low as result of methodology. There is a need to improve the education of emergency physicians and paramedics in this area, and there is a need for data to be collected in a prospective design.

Comparing the efficacy of atypical antipsychotics in open uncontrolled versus double-blind controlled trials in schizophrenia

OBJECTIVE

Due to methodological reservations, open clinical trials investigating efficacy and tolerability of antipsychotic agents are often regarded with doubt. However, there are nearly no studies comparing findings of controlled double-blind with those of open trials. The aim of this study was to investigate whether results of open and double-blind approaches differ and thereby gain information about the validity of open trials.

METHODS

After literature research, three atypical antipsychotic agents were identified for which at least three open and double-blind trials existed that met the inclusion criteria and from which either the reduction of the Brief Psychiatric Rating Scale (BPRS)- or Positive and Negative Symptom Scale (PANSS) scores or the response rate could be determined.

RESULTS

There were no differences in the reduction of the BPRS- or PANSS scores or in the response rates for all three antipsychotic agents between open and double-blind trials.

CONCLUSIONS

Although double-blind controlled studies are essential in the investigation of new compounds, results of methodologically well-performed open studies are valid and deserve more attention. Preceding open trials may help in the design of double-blind studies.

[Outcome of long-term intensive therapy of surgery patients]

OBJECTIVE

The treatment of severely ill patients remains a medical and human challenge. The aim of the study was to determine the survival rate of patients with prolonged intensive care unit (ICU) treatment. Additionally, the somatic, psychological, and social sequelae of the survivors should be determined.

METHODS

Data of all patients who stayed for at least 30 consecutive days on a surgical ICU were evaluated with respect to age, sex, diagnosis on admission, APACHE II-Score, ISS, pre-existing diseases, therapeutic procedures, complications, organ dysfunctions, and mortality. The survivors passed a follow-up examination after 35 +/- 14 months. This included somatic, psychological, and social parameters.

RESULTS

Data of 101 patients were analysed (m/f: 78/23, mean age: 49.9 +/- 18.2 years, mean stay on ICU: 57 +/- 37 days, trauma patients: 46%). 31 subjects died on the ICU. Until the follow-up, another 24 patients deceased. Thus, the total mortality rose to 55%. Age, diagnosis on admission and severity of organ failure influenced the ICU mortality. Concerning the mortality after discharge, age, pre-existing morbidity and diagnosis on admission affected the outcome. 41 of the remaining 46 patients (89%) underwent the follow-up. Nearly half of them showed no or minor signs of impairment in any of the investigated areas. One third had severe handicaps. Trauma patients had the lowest mortality rates but showed worse results in rehabilitation.

CONCLUSIONS

The mortality after prolonged ICU-treatment is substantially higher compared to average ICU patients. However, having survived the acute phase of the illness, successful rehabilitation in somatic, psychic as well as social terms could be performed to a considerable extent. This outcome is comparable to the one of other ICU populations. The results encourage to a consequent use of all medical options.

[Psychiatric emergencies in preclinical emergency service; incidence, treatment and evaluation by emergency physicians and staff]

Preclinical psychiatric emergency situations (PES) rank third in frequency of calls in the German emergency medical system (EMS). However, few data exist concerning relevance and treatment of PES. The aim of this study was to investigate this relevance in preclinical EMS and its appraisal by emergency physicians and paramedics. The protocols filled in by EMS physicians on emergency duty in a German district were evaluated concerning PES. In addition, the emergency physicians and paramedics of the district were asked to complete a validated questionnaire concerning the importance, their own understanding of PES, and interest in training programs. With 9.2%, preclinical PES ranked third in frequency of all EMS calls. The most frequent case was substance abuse disorder (70%), followed by suicide attempts or ideation (33%). Specific therapy for psychiatric disorders is hardly ever performed. Emergency physicians and paramedics estimated the importance of knowledge about PES as high but rated their own knowledge as poor. Assessing five typical PES, emergency physicians gave the correct diagnoses in 71% of cases (paramedics 39%) and the correct therapy in 32% (paramedics 14%). The interest in training programs was significantly higher in experienced EMS physicians. Preclinical PES is a relevant diagnosis within EMS and correct treatment is hampered by limited knowledge. Sufficient training is not yet available, although programs are necessary and the willingness to participate in them is high.

Improvement of schizophrenic patients' subjective well-being under atypical antipsychotic drugs

Recent research indicates that subjective well-being is a major determinant of medication compliance in schizophrenia. However, it is yet unresolved whether atypical neuroleptics differ regarding subjective side-effects. A self-report instrument has been constructed to evaluate 'subjective well-being under neuroleptics' (SWN). The primary aims of the present study were to develop a short form of the SWN and to investigate the extent to which the atypical antipsychotic improves the patient's subjective well-being. The short form of the SWN was constructed following an item analysis based on data from 212 schizophrenic patients medicated with either typical or atypical antipsychotics. The short form of the SWN showed sufficient internal consistency and good construct validity. The SWN was only moderately correlated with positive and negative syndrome scale (PANSS) scores or changes in psychopathology (r=-0.20 to -0.37). SWN-ratings in patients receiving olanzapine were superior compared to those of patients medicated with either clozapine or risperidone on three of five domains of well-being. Clozapine reduced global psychiatric symptoms significantly more than risperidone. It is concluded that the assessment of subjective well-being under antipsychotic treatment provides an independent outcome measure which is relevant to compliance.

[Psychiatric emergencies in the physician-based system of a German city]

OBJECTIVE

Pre-clinical Psychiatric Emergency Situations (PES) gain more scientific interest. First investigations revealed them to be the third major cause for emergency physician (EP) calls. However, there is still very little data concerning prevalence, diagnosis and therapy.

METHODS

A retrospective analysis of all anonymised EP protocols of the year 1995 in the city of Hamburg was performed. Data of each multiple-choice category was evaluated as well as handwritten and personal notes to determine prevalence, diagnoses and therapy of PES.

RESULTS

2550 out of 26,347 protocols (9.7%) revealed to have a psychiatric disturbance as a major cause for the call. The most frequent diagnoses in the overall young (average age: 43.1 +/- 17.6 years) and male (60.3%) population were found to be alcoholic intoxication (34%), state of agitation (23%) and suicide attempts (22%). In 55% the emergencies could be considered as purely psychiatric; in 35% as a combined somatic-psychiatric emergency. A specific psychopharmacological treatment was not performed.

CONCLUSIONS

Psychiatric patients are a considerable group in pre-clinical emergency medicine, however, disturbances are much too rarely documented, diagnosed and treated. Training programs are necessary. Psychiatry has to play a more active role in planning and performing these programs.

[Evaluation of a training program "Psychiatry for EmergencyPhysicians"]

OBJECTIVE

Psychiatric education was neglected in emergency medicine until lately. Although measures for assuring the quality of care are established, there are up to now no investigations about the effectiveness of the psychiatric programs which are used in the German Emergency Physicians' Basic Training Program (EPTP-B, "Fachkundenachweis Rettungsdienst"). Herewith a first evaluation of a training program for psychiatric emergencies is presented.

METHODS

Participants of the EPTP-B in Hamburg were imparted defined contents to achieve the educational objective. Before and afterwards two semi-structured questionnaires had to be answered asking for previous knowledge, attitudes, educational success and necessity for further training.

RESULTS

At the beginning of the course 42 medical doctors (m/f: 22/20, mean age: 32.2 +/- 4.6 years) estimated their knowledge as poor and the necessity for training as high. At the end, the majority rated the program as educative, informative (69%) and practical (81%). However, the training was judged to be too short (81%) and the participants still felt too distant from the educational objective.

CONCLUSIONS

There are necessity, demand and interest for an intensified psychiatric education of emergency physicians who are confronted with a high number and variety of psychic disturbances. On-the-job training of the theoretical matters is essential.

[Quality of life after long-term surgical intensive care treatment]

INTRODUCTION

Long-term treatment in surgical intensive care units (SICU) subjects the patient to a high degree of somatic, psychological, and social stress. The aim of this study was to determine their outcome in terms of quality of life and health status.

METHODS

All patients from a 4-year period in a SICU with a length of stay (LOS) of 30 days or more were included. All survivors were interviewed and examined after 35 +/- 14 months; they also completed several questionnaires (Munich Inventory for Quality of Life and Health Status, POMS, and Spitzer Quality of Life Index).

RESULTS

One hundred one patients fulfilled the inclusion criteria, and 46 survived until follow-up. Forty-one (89%) could be traced and examined. Male:female ratio was 31:10, age 42 +/- 17 years, and LOS 51 +/- 19 days, Diagnoses on admittance were multiple trauma (n = 32) and other (n = 9). When classifying patients according to physical impairment, one third each showed no, mediocre, or severe limitations. Subjective appraisal of quality of life and well-being was sufficient for about half the patients in every test. Trauma victims experienced more severe impairment of quality of life. There were no differences between sex, age, or time until follow-up.

CONCLUSION

After prolonged SICU treatment, about half of the patients report limitations in their quality of life as a result of their illness and the subsequent treatment. Some patients, in particular after trauma, exhibit striking psychosocial problems despite satisfactory somatic treatment results. These problems can be positively addressed in rehabilitative efforts.

[Open studies in comparison to controlled studies in testing of neuroleptics]

OBJECTIVE

Due to methodological reservations, results concerning the efficacy of neuroleptics in open trials are often regarded with doubt. Until now, there are nearly no studies comparing findings of controlled double-blind with those of open trials. Aim of this study was to investigate if results of an open or double-blind approach differ and hereby to gain information about the validity of open trials.

METHODS

After a literature research, five neuroleptics were identified for which at least 3 open and 3 double-blind trials exist which met the inclusion criteria and from which either the reduction of the BPRS (Brief Psychiatric Rating Scale)-score or the response rate could be determined.

RESULTS

There were no differences in the reduction of the BPRS-score or response rate for all 5 neuroleptics between open and double-blind trials. Furthermore, the efficacy of all 5 neuroleptics was comparable.

CONCLUSIONS

Double-blind controlled studies are essential in the investigation of new compounds. But results of methodologically well performed open studies are valid and deserve more attention. Preceding open trials may help in the design of double-blind studies.

Long-term results and quality of life after parasuicidal multiple blunt trauma

OBJECTIVE

This study evaluates the somatic, socioeconomic, and psychiatric long-term results, as well as the factors for adverse outcome, in a significant subset of patients with severe multiple injuries resulting from attempted suicide.

DESIGN

The follow-up study 6.1 +/- 3 (SD) yrs after trauma was based on prospectively documented data of patients with multiple injuries.

SETTING

Level I university trauma center in a major German city.

MEASUREMENTS AND MAIN RESULTS

Data derived from thorough physical and psychiatric evaluations. The Brief Psychiatric Rating Scale and the Global Assessment of Functioning Scale served to describe psychiatric outcome.

PATIENTS

In a series of 539 severely injured patients (Abbreviated Injury Score in two regions > or = 3), 65 (12%) attempted suicides were reported (Injury Severity Score, 40 +/- 15; age, 38 +/- 18 yrs). Twenty-one patients of the study cohort died during the hospital stay, and six subjects died thereafter, none because of suicide. Three patients were lost to follow-up, resulting in 35 individuals eligible for examination. None of the latter had reattempted suicide. Seventeen (48%) had good or satisfactory outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings (Brief Psychiatric Rating Scale), and good psychosocial ability (Global Assessment of Functioning Scale). For eight patients (24%), the result was indeterminate. The adverse outcomes in ten patients (28%) were mainly influenced by the presence of chronic schizophrenia (n = 4), affective disorder (n = 2), or severe traumatic brain injury (n = 3).

CONCLUSIONS

Despite the parasuicidal origin, the long-term results after severe trauma were good or satisfactory in approximately half the cases and without further suicide attempts in any of the patients. Good recovery of the parasuicidal patients in our study is approximately 20% lower than in an unselected group of patients with multiple injuries and may be attributed mainly to the underlying chronic psychiatric disease.

Suicide attempts with mirtazapine overdose without complications

BACKGROUND

One important aim of pharmacotherapy in depressed patients is the prevention of suicide attempts. Therefore, the medication given should be efficient and safe in overdose.

RESULTS

We saw two patients after they had overdosed with mirtazapine because of suicidal intention. Both patients had taken 30 and 50 times a normal daily dose and achieved a full recovery without any complications or harm.

CONCLUSIONS

Mirtazapine seems to be a safe compound in overdose. Therefore, it is an important therapeutic agent in depressed and suicidal patients.

[Psychiatric emergencies from the viewpoint of the emergency physician]

OBJECTIVE

In the German physician-based emergency medical system (EMS) psychiatric emergency situations (PES) rank on third place contradictory to it's importance during emergency physician training program. The aim of our study was to examine the relevance of PES and the stress which PES imposes upon EMS physicians. Further, the interest of training programs on that issue was determined. Knowledge about PES was investigated by a short test.

METHODS

952 emergency physicians were sent a questionnaire about following: demographic data, frequency of PES, strain by PES, own knowledge, interest about training programs. Further five typical PES were presented for diagnostic and therapeutic judgement.

RESULTS

222 responded (183 men/37 women/2 without gender data, average age: 40.1 +/- 6.7, qualification as emergency physician: 9.6 +/- 5.1 years, most frequent subspeciality in-hospital physicians: anaesthesiology 67.5%, in-practice physicians: general medicine 72.1%). PES frequence was estimated at 9.4%, personal knowledge judged only by 13% as sufficient, 14.2 felt incapable by PES. 73% saw importance of training, especially expressed by the more experienced (P < 0.05). Test presented 65% correct diagnoses, 33% correct therapy, 26% incorrect decision of hospital admission.

CONCLUSION

PES are a frequent problem of pre-hospital patient care for emergency physicians. As personal knowledge was estimated to be insufficient, the interest for courses concerning PES issues is high.

Human immunodeficiency virus antibody test and seroprevalence in psychiatric patients

Psychiatric inpatients are at risk for human immunodeficiency virus (HIV) infection. Investigations in the United States revealed seroprevalence rates of 5.5-8.9%. Therefore, inclusion of HIV antibody testing in routine laboratory screening is sometimes suggested. To investigate this issue for inpatients in the Department of Psychiatry, University of Munich, the incidence, reason for HIV testing and results were analyzed. Of 12,603 patients, hospitalized from 1985 to 1993, 4.9% (623 patients, 265 in risk groups) underwent the HIV test after informed consent. Thirty patients (4.8% of those tested) were found to be positive, but only in 5 cases (all of risk groups) was infection newly detected. Data indicate that, in psychiatry, HIV testing is reasonable only in patients in risk groups or if clinical variables suggest HIV infection.