Clinical insight among persons with schizophrenia spectrum disorders treated with amisulpride, aripiprazole or olanzapine: a semi-randomised trial

BACKGROUND

Antipsychotic treatment may improve clinical insight. However, previous studies have reported inconclusive findings on whether antipsychotics improve insight over and above the reduction in symptoms of psychosis. These studies assessed homogeneous samples in terms of stage of illness. Randomised studies investigating a mixed population of first- and multiepisode schizophrenia spectrum disorders might clarify this disagreement.

METHODS

Our data were derived from a pragmatic, rater-blinded, semi-randomised trial that compared the effectiveness of amisulpride, aripiprazole and olanzapine. A sample of 144 patients with first- or multiepisode schizophrenia spectrum disorders underwent eight assessments during a 1-year follow-up. Clinical insight was assessed by item General 12 from the Positive and Negative Syndrome Scale (PANSS). We analysed latent growth curve models to test if the medications had a direct effect on insight that was over and above the reduction in total psychosis symptoms. Furthermore, we investigated whether there were differences between the study drugs in terms of insight.

RESULTS

Based on allocation analysis, all three drugs were associated with a reduction in total psychosis symptoms in the initial phase (weeks 0-6). Amisulpride and olanzapine were associated with improved insight over and above what was related to the reduction in total psychosis symptoms in the long-term phase (weeks 6-52). However, these differential effects were lost when only including the participants that chose the first drug in the randomisation sequence. We found no differential effect on insight among those who were antipsychotic-naïve and those who were previously medicated with antipsychotics.

CONCLUSIONS

Our results suggest that antipsychotic treatment improves insight, but whether the effect on insight surpasses the effect of reduced total psychosis symptoms is more uncertain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01446328, 05.10.2011.

Outpatients with psychotic disorders still need physical health-promotion

Introduction

Premature death of people living with non-affective psychotic disorders are related to life-style somatic comorbidities. Current health-promoting treatment and care programs does not target people living with psychotic disorders and therefore prevention and treatment do not embrace the accompanying challenges.

Objectives

To identify and explore outpatients with non-affective psychotic disorders who are not offered existing municipal health-promoting treatment and care programs despite having a need.

Methods

Two hundred and six eligible outpatients from multiple sites of the Psychiatric Services in the Region of Southern Denmark were invited to participate. At last, 165 outpatients met the criteria and agreed to participate. A screening scheme was used to identify socio-economic characteristics, life-style related somatic comorbidities, medication status and consumption of cigarettes, drugs and alcohol. In outpatients’ medical records measured values and blood samples were obtained.

Results

Almost four-fifths of the outpatients were in need of health promotion out of whom more than half were not offered a municipal health-promoting treatment and care program. One or more of the investigated somatic comorbidities was found in more than one-third of the outpatients. 15% had type-2-diabetes mellitus and 10% had cardiovascular disease. Two-fifths of the outpatients were smokers. Mean number of cigarettes per day was 19 (SD=10) for smokers. Mean BMI for men was 29 kg/m2 (SD=7) and 34 kg/m2 (SD=8) for women.

Conclusions

In general, the outpatient’s state of health was poor. Many outpatients were not offered a municipal health-promoting treatment and care program despite having a need.

Disclosure

No significant relationships.

The Dietary Status of Adults With ADHD

Objective

The aim was to investigate the dietary status of adults with ADHD. Furthermore, we compared the group with a representative sample of a healthy adult Danish population.

Method

Data were collected from the ADHD database operated by the ADHD outpatient clinic at Aarhus university hospital. We used data from newly referred patients in a seven months period from April 2014 through October 2014. The collected data include weight, height, blood pressure, somatic or psychiatric co-morbidity, blood sample, physical activity scale. Concerning the diagnosis of ADHD: DIVA, ASRS, BRIEF-V. Inter99 was used to assess the dietary status. The representative sample was obtained as a part of a public health survey from 2010 called “how are you” conducted in the same region of Denmark as the location of the psychiatric hospital. Preliminary results, one hundred and forty-three patients were included in the study, 52% males. The mean age was 30.9 years. A larger proportion of ADHD patients fall in the category “unhealthy dietary pattern” compared to the representative sample population (26% vs. 12%), while the proportion in the “healthy dietary pattern” category is markedly lower (14% vs. 24%). The differences seem to be explained by lower than recommended intakes of fruits and vegetables.

Conclusion

Our findings suggest a general shift towards more unhealthy dietary patterns among patients with ADHD. This exposes them to higher risk of somatic diseases, notably diabetes mellitus and cardiovascular disease. Lifestyle interventions could be a necessary part of standard treatment for patients with ADHD.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The Widowhood Effect–mortality and Adverse Health Effects When Losing a Spouse in Old Age

Introduction

Losing one's spouse is a major life event which is associated to an increased risk of mental health problems as depression and sleep-disorders. There is also an increased risk of adverse effects on physical health, and even an increased risk of mortality. A phenomena called “the widowhood effect” Though this is well-known clinically, few studies have established the extent of the problem in old age.

Objectives

This study aims to examine the risk of mortality associated to widowhood in old age, and adverse health effects both regarding physical and mental health.

Methods

A nationwide register-based case control study. All Danish people aged 65 years and above who became widowed in the period of 2000–2010 are included. A background population sample of 4:1 is matched on age and gender. By using the personal identification number a linkage between registers containing information regarding health service use, pharmacologic use and demographic information is made. Mortality is analysed using Kaplan-Meier estimate and the statistical comparison between the groups is done by Cox-regression. Adverse health effects are assessed by the health care use and pharmacological use, and are compared between the two groups by t-test, linear and logistic regression depending on the variables.

Results

The study is under conduction, results will be presented.

Conclusions

Widowhood in old age has been associated to an increased risk of mortality and adverse health effects. This study assesses the outcome of this in a nationwide register-based sample.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Oxidative stress – A promising candidate in explaining the neurobiology of autism spectrum disorders

Introduction

The diagnoses of autism spectrum disorders (ASDs) are based on a phenotype, characterized by impaired social interaction and communication and by repetitive and restricted interests. However, this might not represent a single clinical entity, but a behavioral manifestation of different neurodevelopmental deficits with a multifactorial etiology. Small studies have shown elevated levels of oxidative stress and lower levels of anti-oxidants in patients with ASD, and correlations with the severity of ASD. Therapies targeting oxidative stress have shown improvements regarding behavior, social interaction and verbal communication in patients with ASD, supporting the oxidative stress theory.

Objectives

To evaluate the importance of oxidative stress in the neurobiology of adults with ASD.

Aims

There is a need to understand the neurobiology of ASD, therefore this study analyzes the level of oxidative stress in a larger cohort of patients with ASD and compares to controls.

Methods

The study includes 350 patients over 18 years of age diagnosed with ICD-10 diagnoses F84.0, F84.1, F84.5 or F84.8 and compared to gender and age matched neurotypical controls. The included probands will have their serum and plasma analyzed for levels of oxidative stress (superoxide dismutase 1 and 2, catalase, glutathioneperoxidase, malonialdehyde, thiobarbituric acid reactive substances and xanthinoxidase).

Results

The preliminary results will be presented at the EPA in March 2016 in Madrid.

Conclusion

With this study we aim to elucidate some of the neurobiology in ASD. This could lead to new potential targets for treatment and prevention of the disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Are assisted reproduction technologies associated with categorical or dimensional aspects of psychopathology in childhood, adolescence or early adulthood? Results from a Danish prospective nationwide cohort study

An increasing number of children are conceived using assisted reproduction technologies (ART), but little is known about the long-term risk in terms of mental health outcomes. All twin and singleton children conceived via ART and born in 1995 were sampled from the Danish in vitro fertilization registry and matched to four spontaneously conceived (SC) children. The children were followed-up at the age of 3, 7, 14 and 18 years in the Danish Psychiatric Central Research Registry, to estimate the prevalence of all possible psychiatric diagnoses; dimensional aspects of psychopathology were assessed at the age of 14 years, using the Child Behavior Checklist (CBCL). The study included 858 ART children and 3436 SC children. ART and SC children were not clinically distinguishable on either the categorical measures of psychopathology at the age of 3, 7, 14 and 18 years, or on CBCL scale scores at the age of 14 years. The findings remained nonsignificant after controlling for sample differences. This large, prospective, nationwide cohort study provides evidence to support that ART exposure does not increase the risk of adverse mental health outcomes considered as a whole, while power was limited to discard an effect of ART on specific mental health disorders.

QTc Interval in individuals with schizophrenia receiving antipsychotic as monotherapy or polypharmacy

Introduction

Antipsychotics are associated with the polymorphic ventricular tachycardia, Torsade's de pointes, which in worst case can lead to sudden cardiac death. The QTc interval is used as a clinical proxy for Torsade's de pointes. QTc interval is prolonged by monotherapy with antipsychotic, but it is unknown if the QTc interval is prolonged further with antipsychotic polypharmacy.

Objectives

To investigate the associations between QTc interval and antipsychotic mono- and polypharmaceutical treatment, respectively, in schizophrenic patients.

Aims

To learn more about the impact of antipsychotics on the QTc interval.

Methods

An observational cohort study of unselected patients with schizophrenia visiting outpatient facilities in the Region of Central Jutland, Denmark. Patients were enrolled from January 2013 through March 2015 with follow-up until June 2015. Data was collected from clinical interviews and clinical case records.

Results

ECGs were available in 58 patients receiving antipsychotic treatment. We observed no difference in average QTc interval for the whole sample of patients receiving monotherapy or polypharmacy (P = 0.29). However, women presented longer QTc-interval on polypharmacy than on monotherapy (P = 0.01).

Conclusion

We recommend an increased focus on monitoring the QTc interval in woman with schizophrenia receiving antipsychotics as polypharmacy.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Adult with autism – oxidative stress, co-morbidity and predisposition

Introduction

The etiology of autism spectrum disorder (ASD) is unclear. Studies involving children with ASD suggest that oxidative stress could explain some of the pathology. Few reports have investigated the role of oxidative stress into adulthood. Furthermore, the knowledge on psychiatric and somatic comorbidities, as well as socio-economic status in a trajectory across lifespan is sparse.

Objectives

Investigating oxidative stress related markers in ASD, along with trajectories in socio-economic functioning and comorbidities.

Aims

To evaluate the importance of oxidative stress in the neurobiology of adults with ASD and assess the socio-economic level of functioning and comorbidities.

Methods

Plasma levels of antioxidant super-oxide-dismutase isoenzymes (SOD1 and SOD2) and pro-oxidant xanthineoxidase (XO) were measured in 56 patients ≥18 years of age, diagnosed in childhood with ASD (F84.0, F84.1, F84.5 or F84.8), along with gender and age matched controls. Participants were interviewed regarding their health, familial predisposition and social status.

Results

Cases showed higher levels of SOD1 (268.2 ng/mL vs. 205.6 ng/mL). We found no differences regarding SOD2 and XO. Patients had a higher BMI (27 vs. 24), fewer drank alcohol (40% vs. 75%), more had a psychiatric co-morbidity (50% vs. 2%), more had family member with a psychiatric diagnosis (80% vs. 50%). None of the bio-psycho-social factors showed association with biomarker levels.

Conclusion

Oxidative stress seems to play a role in ASD. Furthermore, patients with ASD often have psychiatric comorbidities; more often have a family history of psychiatric diagnoses, and are less healthy physically.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Treatment profiles in a Danish psychiatric university hospital department

Introduction

Despite concerns about rising treatment of psychiatric patients with psychotropic medications and declining treatment with psychotherapy, actual treatment profiles of psychiatric patients is largely unknown.

Aims

To describe patterns in the treatment of patients in a large psychiatric university hospital department.

Methods

A descriptive mapping of treatment of in- and outpatients in a psychiatric department at Aarhus University Hospital Risskov, Denmark. Information was collected by health care staff using a 25-item survey form. The P-value was calculated with a Chi2 test and P < 0.05 was considered significant. The study was preceded by a pilot study on 41 patients.

Results

Over a 1 month period we assessed a total of 343 consecutive patients and hereof included 200 in the age range 18–90 years (mean 53.76); 86 men and 114 women. One hundred and eighty-eight patients (94%) used psychotropic medication, 37 (19%) as monotherapy and 148 (74%) in combination with non-pharmacological therapy. Ninety-seven (49%) had psychotherapy and 104 (52%) social support. Among inpatients, 21 (64%) had physical therapy, and 10 (30%) electroconvulsive therapy. In total, 163 (82%) had non-pharmacological therapy. Fifty-two (26%) patients had monotherapy and 148 (74%) polytherapy. Mean number of treatment modalities used pr. patient was 2.07 for all patients and 3.23 for inpatients.

Conclusions

In our department, polytherapy including non-pharmacological modalities is applied widely across all settings and patient categories. However, psychotropic medication clearly dominates as the most frequently applied treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Participation in medical decision-making across Europe: An international longitudinal multicenter study

BACKGROUND

The purpose of this paper was to examine national differences in the desire to participate in decision-making of people with severe mental illness in six European countries.

METHODS

The data was taken from a European longitudinal observational study (CEDAR; ISRCTN75841675). A sample of 514 patients with severe mental illness from the study centers in Ulm, Germany, London, England, Naples, Italy, Debrecen, Hungary, Aalborg, Denmark and Zurich, Switzerland were assessed as to desire to participate in medical decision-making. Associations between desire for participation in decision-making and center location were analyzed with generalized estimating equations.

RESULTS

We found large cross-national differences in patients' desire to participate in decision-making, with the center explaining 47.2% of total variance in the desire for participation (P<0.001). Averaged over time and independent of patient characteristics, London (mean=2.27), Ulm (mean=2.13) and Zurich (mean=2.14) showed significantly higher scores in desire for participation, followed by Aalborg (mean=1.97), where scores were in turn significantly higher than in Debrecen (mean=1.56). The lowest scores were reported in Naples (mean=1.14). Over time, the desire for participation in decision-making increased significantly in Zurich (b=0.23) and decreased in Naples (b=-0.14). In all other centers, values remained stable.

CONCLUSIONS

This study demonstrates that patients' desire for participation in decision-making varies by location. We suggest that more research attention be focused on identifying specific cultural and social factors in each country to further explain observed differences across Europe.

The impact of climate on risk of mania

Introduction

Bipolar disorder varies with season: admissions for depression peak in winter and mania peak in summer. Sunlight presumably increases the risk of mania through suppression of melatonin. If so, we expect admissions for mania to vary in accordance with climate variations.

Objectives

To investigate how climate and climate changes affects admissions for mania.

Aims

To identify which climate variables – sunshine, ultraviolet radiation, rain and snow cover – affect admissions for mania.

To examine whether year-to-year weather variation as well as long-term climate changes reflects the variation in number of admissions for mania.

Methods

This register-based nationwide cohort study covers all patients admitted for mania (ICD-10 code F31 or F30.0–F30.2) between 1995 and 2012 in Denmark. Climate data, obtained from the Danish Meteorological Institute, were merged with admission data and correlated using an Unobserved Component Model regression model.

Preliminary results

In total, 8893 patients were admitted 24,313 times between 1995 and 2012: 6573 first-admissions and 17,740 readmissions. Linear regression shows significant association between admissions per day and hours of sunshine (P < 0.01) and ultraviolet radiation (UV) dose (P < 0.01). Average days with snow cover and rain were not significantly correlated with admissions. Analyses on year-to-year variation and long-term change are not yet available.

Preliminary conclusions

Admissions for mania are correlated with sunshine and UV, but not rain and snow cover. If more patients are admitted during very sunny summers compared with less sunny summers this implies a relation with light itself and not just season.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Depression and the risk of autoimmune disease: a nationally representative, prospective longitudinal study

BACKGROUND

Autoimmune diseases are associated with substantial morbidity and mortality, yet the etiology remains unclear. Depression has been implicated as a risk factor for various immune-related disorders but little is known about the risk of autoimmune disease. This study examined the association between depression and the risk of autoimmune disease, and investigated the temporal and dose-response nature of these relationships.

METHOD

A prospective population-based study including approximately 1.1 million people was conducted using linked Danish registries. Depression and autoimmune diseases were diagnosed by physicians and documented in medical records. In total, 145 217 individuals with depression were identified between 1995 and 2012. Survival analyses were used to estimate the relative risk of autoimmune disease among those with, compared to without, depression. Analyses were adjusted for gender, age, and co-morbid mental disorders.

RESULTS

Depression was associated with a significantly increased risk of autoimmune disease [incidence rate ratio (IRR) 1.25, 95% CI 1.19-1.31], compared to those without a history of depression. Results suggest a general increased risk of autoimmune diseases following the onset of depression during first year (IRR 1.29, 95% CI 1.05-1.58), which remained elevated for the ensuing 11 years and beyond (IRR 1.53, 95% CI 1.34-1.76). Findings did not support a dose-response relationship.

CONCLUSIONS

Depression appears to be associated with an increased risk of a range of autoimmune diseases. Depression may play a role in the etiology of certain autoimmune conditions. If replicated, findings could highlight additional clinical implications in the treatment and management of depression. Future studies are needed to investigate the possible social, genetic, and neurobiological underpinnings of these relationships.

The gap between available knowledge and its use in clinical psychiatry

OBJECTIVE

The time span between knowledge becoming available and its integration into daily clinical routine is lengthy. This phenomenon is explored in this study.

METHOD

We used the outcomes of our activities for investigating and strengthening the research-based activities to improve physical health in the routines of clinical psychiatric wards as examples for our analyses.

RESULTS

The time span between new knowledge becoming available and its implementation into general clinical treatment is very long. However, a shortening of this time span is seen through active leadership backup and clinical research experience among psychiatrists and staff in the wards. In particular, the involvement of medical students interested in clinical research activities seems to have a positive impact.

CONCLUSION

Academia needs to be re-implemented into clinical psychiatry. Staff with research experience is needed in all professions to increase evidence-based practice. Leaders must take responsibility for implementing new knowledge into the routines of the department and must support staff in these activities on a daily basis.

Fifty years' development and future perspectives of psychiatric register research

OBJECTIVE

This article illustrates the development of psychiatric register research and discusses the strengths, limitations, and possible directions for future activities.

METHOD

Examples illustrating the development from the post-World War II introduction of psychiatric register research until today are selected.

RESULTS

The strengths of register research are seen especially within health service. Until recently, when starting linking registers to biobanks, register research had limited value in cause-seeking. Register research benefits from the possibilities for following identifiable persons over long time (lifelong) and the possibilities for linking to other registers and databases. Important limitations of register research are the heterogeneity and questionable validity of the clinical data collected.

CONCLUSION

Future register research can go in the direction of big is beautiful collecting data from all possible sources creating giga-registers. In that case, low data quality will still be an unsolved problem. Or it can take the direction of smaller local clinical databases which has many advantages, for example, integrating clinical knowledge and experience into register research. However, in that case, registers will not be able to deal with rare conditions and diseases.

Decreasing rates of incident schizophrenia cases in psychiatric service: A review of the literature

A review of the literature shows that the admission rates of new cases of schizophrenia vary with a factor of two to five in North American studies as well as in European studies. Furthermore, the tendency has been decreasing for the last 40-50 years in Europe. Eighteen studies specifically analyzing the development over the last 20 years are reviewed. The studies preponderantly show significant decreases most probably due to the reduction of the number of available psychiatric beds alongside the decentralization of psychiatry, and to decreasing virulence of schizophrenia. Alternatively, a diagnostic delay of schizophrenia can hardly explain the decrease.

Psychiatric morbidity preceding psychotic and non-psychotic depression

Introduction

Psychotic depression differs significantly from non-psychotic depression in many aspects. These differences comprise etiology, severity, treatment response and prognosis.

Objectives/aims

The aim of the study was to assess the diversity of the psychiatric morbidity preceding psychotic and non-psychotic depression.

Methods

Danish, register-based, nationwide cohort study. Subjects were all Danish residents assigned with an ICD-10 diagnosis of severe depression with- (F32.3 and F33.3) or without (F32.2 and F33.2) psychotic symptoms between January 1st 1994 and December 31st 2007. Psychiatric diagnoses preceding the severe depression were assessed through the Danish Psychiatric Central Research Register. It was investigated whether patients with psychotic depression had a history of more diverse/severe psychiatric morbidity and a different use of psychopharmacological drugs prior to index, compared to their non-psychotic counterparts.

Results

The study included 29,254 subjects with severe depression. Of these, 9,768 patients (33%) were of the psychotic subtype while 19,576 (67%) were non-psychotic.

Patients with the psychotic depressive subtype had a psychiatric history involving more and longer admission, more diverse diagnoses and a different pattern of psychopharmacological treatment compared to their non-psychotic counterparts. The results indicate, that psychotic depression may be more related to the bipolar/schizophrenia/psychosis spectrum than to the depression/anxiety spectrum.

Conclusions

The results add to a growing body of literature proving fundamental differences between psychotic- and non-psychotic severe depression. This should be considered in the upcoming revisions of the current diagnostic classifications.

Mortality among individuals with cannabis, cocaine, amphetamine, MDMA, and opioid use disorders: a nationwide follow-up study of danish substance users in treatment

Introduction

Little is known about the excess mortality associated with use of some illicit substances. In particular, this concerns the risks associated with injection drug use and psychiatric disorders.

Aims

This study estimated mortality following substance abuse treatment among primary users of cannabis, cocaine, amphetamine, MDMA, and opioids. The risks associated with injection drug use and psychiatric comorbidity were assessed.

Methods

A register of individuals in treatment for illicit substance disorders was linked with registers on psychiatric treatment and mortality. The study population consisted of 20581 individuals who received treatment in Denmark between 1996 and 2006. There were 1441 deaths recorded over 111445 person-years of follow-up.

Results

Standardized Mortality Ratios (SMRs) for primary users of specific substances were: Cannabis: 4.9, cocaine: 6.4, amphetamine: 6.0, heroin: 9.1, and other opioids 7.7. For MDMA the crude mortality rate was 1.75/1000 person-years, and the SMR was not significantly elevated. Sharing of syringes was associated with increased mortality in both primary users of opioids (hazard ratio (HR): 1.58 [95% CI 1.22–1.99], p < .001) and cocaine/amphetamine (HR: 9.52 (95% CI 3.94–23.02, p < .001). Overall, psychiatric comorbidity was associated with modestly increased mortality (HR: 1.15 [95% CI 1.03–1.29], p = .012) and in particular for primary users of cocaine/amphetamine (HR: 2.74 [95% CI 1.56–4.80], p < .001).

Conclusions

High SMRs were found among individuals who had received treatment for cannabis, cocaine, amphetamine, and opioid use disorders. Injection drug use was clearly associated with excess mortality, while the impact of psychiatric comorbidity was generally modest.

Outpatient treatment in mental health care

Introduction

There is a lack of knowledge on outpatient treatment in mental health and its outcome. The major reason for this is that research on clinical decision making in health care has primarily focused on well-defined situations in physical conditions, while there has not been any research in clinical decision making in people with schizophrenia with its high demands on patient's treatment adherence and establishing stable therapeutic relationships.

Objective

This study is about clinical decision making in outpatient mental health care with specific focus on patients diagnosed with schizophrenia.

Aims of the study

To identify the types of decision making between the patient and the therapist (paternalistic, shared and informed). Moreover, to investigate the patient's understanding of the decision making, involvement and analyse type of decision making as a possible predictor of adherence to treatment.

Methods

The study is an open, explorative study using a combination of both qualitative and quantitative methods. The study population consists of severe mentally ill outpatients diagnosed with schizophrenia. Data collection consists of both questionnaires, field observation and patient interviews.

Expected results

Specifications of primary areas for further improvement in CDM is an expected result of the study. Recommendations will be extracted and formulated from the study data to implement elements of best practice in CDM in the routine care for people with schizophrenia in particular and severe mental illness in general. The explicit focus will contribute to the strengthening of patient perspective.

Comparison of psychiatric ICD-10 diagnoses in Denmark and Germany

A dataset of psychiatric ICD-10 diagnoses from the Danish case register concerning psychiatric hospitals was compared with a sample of psychiatric diagnoses from 27 psychiatric hospitals in Germany. The comparison shows a higher proportion of F1 diagnoses in the German dataset and a difference in the coding of alcohol dependence and harmful use. Some further differences in the groups F0-F6 are demonstrated and some of them are discussed. The most frequent diagnoses found in both datasets but in different sequence are alcohol dependence syndrome and paranoid schizophrenia and, in third place, adjustment disorder. Various aspects of the problem of rarely used diagnoses are discussed.

Psychological distress as a predictor of frequent attendance in family practice: a cohort study

In cross-sectional studies, psychological distress has been associated with frequent health care utilization. However, there is a need for prospective studies to confirm these findings. This cohort study evaluated whether psychological distress predicted frequent attendance in family practice. In 1990, 185 consecutive adults who consulted their primary care physician (PCP) about an illness were rated on two psychometric scales (Hopkins Symptom Check List [SCL-8] and Whiteley-7), and their annual number of face-to-face contacts with a family practice was followed until 1996. Frequent attenders (FAs) were defined as the top 10%. A logistic regression analysis showed a significantly increased risk of becoming an FA with an increase of 1 point (odds ratio [OR] 1.17 [1.03-1.33]) on SCL and 1.28 (1.06-1.53) on Whiteley). An association was found between score and number of years as an FA (OR 1.16 [0.99-1.36] for SCL and OR 1.31 [1.05-1.65] for Whiteley). Psychological distress involved an increased risk of future frequent attendance among adult patients consulting family practice in the daytime about an illness.

Assessment of dementia in nursing home residents by nurses and assistants: criteria validity and determinants

OBJECTIVES

To describe the criterion validity of nursing home staff's assessment of organic disorder compared with ICD-10 criteria, and to identify determinants of staff assessment of organic disorder.

METHOD

Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. Nursing staff members were interviewed about the residents' activities of Daily Living, behavioural problems, orientation in surroundings and communication skills, and asked if the resident had an organic disorder. Multiple logistic regression was used to select the items that most strongly determined staff assessment of organic disorder.

RESULTS

Sixty-two per cent of the residents were diagnosed by GMS-AGECAT as having organic disorder, 78% of these were correctly identified by the staff. Whether analysed among residents with or without organic disorder, or in the total group of residents, the staff assessment of the presence of organic disorder depended on a limited set of behavioural characteristics of the resident, namely 'going to the toilet in inappropriate places', 'saying things that do not make sense' and impairment in orientation.

CONCLUSIONS

Staff comprehension of organic disorder resulted in over- as well as under-labelling of residents, a tendency that will affect communication with medical personnel and may lead to inadequate or wrong medical treatment and to negative performance as well as negative role expectations in everyday life in nursing homes.

Determinants for the use of psychotropics among nursing home residents

PURPOSE

To characterise the prescription pattern of psychotropics in Danish nursing homes and to identify diagnostic, behavioural, cognitive and performance characteristics associated with prevalent psychotropic drug use.

METHODS

Prescribed daily medication was recorded from nurses' files. Based on the Anatomical Therapeutical Chemical (ATC) classification index, psychotropics were categorised into neuroleptics, benzodiazepines and antidepressants. Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. One hundred and eighteen staff members were interviewed about the residents's Activities of Daily Living (ADL), behavioural problems (Nursing Home Behavior Problem Scale), orientation, communication skills and if the resident had any psychiatric disorder. Multiple logistic regression was used to select the items that determined the use of psychotropics.

RESULTS

Fifty-six percent of the residents received a psychotropic, 21% received neuroleptics, 38% received benzodiazepines and 24% received antidepressants. In the multivariate analysis, staff assessment of the resident's mental health was a determinant for the use of all types of specific psychotropics, whereas a GMS-AGECAT diagnosis only determined the use of neuroleptics. Behavioural problems were a determinant for the use of neuroleptics and the use of benzodiazepines irrespective of the psychiatric diagnosis of the resident. Use of antidepressants was associated with male gender and increasing age.

CONCLUSIONS

Staff perceptions of psychiatric morbidity and norms have a greater impact on the prescription of psychotropics than standardised clinical criteria.

Mental disorders among internal medical inpatients: prevalence, detection, and treatment status

OBJECTIVE

To determine the prevalence of ICD-10 mental disorders among internal medical inpatients, the relation between mental disorder, age, and gender, and the recognition and referral of the disordered patients.

METHOD

294 consecutive medical inpatients were examined with a two-phase design using the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) for ICD-10 psychiatric diagnoses. Information from questionnaires and interviews with patients, doctors, nurses, and from medical records.

RESULTS

The prevalence of current mental disorders was 38.7%, being heavily increased in young patients. Main diagnoses were somatoform disorders (17.6%), phobias (12.9%), substance use disorders (10.9%), and depression (8.3%). Psychiatric consultations were very few. About 38-56% of the cases were recognized by medical doctors and nurses, and only about 20% were in mental health treatment.

CONCLUSION

The prevalence of mental disorders among internal medical inpatients is high and increased in young patients and women. Detection and referral are low, and few are treated.

Epidemiology in neurobiological research: exemplified by the influenza-schizophrenia theory

BACKGROUND

During recent years the strategy for aetiological research in schizophrenia has been to concentrate on two closely connected directions: the search for the genetic element and the search for environmental factors. Damage to the immature brain during pregnancy and delivery has given us the most interesting results from recent environmental research.

AIMS

To examine the validity of the influenza-schizophrenia hypothesis.

METHOD

A review of register-based epidemiological studies in Denmark conducted over a 10-year period.

RESULTS

The studies reviewed provided strong inferential evidence in favour of the hypothesis, but some methodological problems are unresolved and not all replication studies have been positive.

CONCLUSIONS

The brain-damage hypothesis points to possibilities for identifying high-risk individuals at an early stage of life and perhaps establishing specific preventive programmes. There is, however, a great need for closer international collaboration in future research.

Anorexia nervosa and cancer risk

OBJECTIVE

Energy restriction reduces the incidence of malignant tumors in experimental animals, but evidence for a similar effect in humans is lacking. To test the hypothesis in humans, we investigated cancer incidence among patients with anorexia nervosa, who have had an extremely low intake of calories for prolonged periods of their lives.

METHODS

Patients with anorexia nervosa (2151 women and 186 men) during 1970-1993 were identified in the population-based Danish Psychiatric Case Register and the National Registry of Patients. The cohort was linked to the Danish Cancer Registry, and cancer incidence among cohort members was compared with that of the general population.

RESULTS

The overall cancer incidence among women with anorexia nervosa was reduced by a factor of 0.80 (95% confidence interval 0.52-1.18) below that of the general population on the basis of 25 observed and 31.4 expected cases. Among men, two cases of cancer were observed, both confined to the brain, whereas 0.2 cases were expected.

CONCLUSIONS

The finding of a slight reduction in cancer risk among women with anorexia nervosa may support the theory that a low-energy diet may decrease tumor development in humans. However, longer follow-up and control for confounding factors are needed to obtain more convincing evidence.

Determinants for the use of psychotropics among nursing home residents

PURPOSE

To characterise the prescription pattern of psychotropics in Danish nursing homes and to identify diagnostic, behavioural, cognitive and performance characteristics associated with prevalent psychotropic drug use.

METHODS

Prescribed daily medication was recorded from nurses' files. Based on the Anatomical Therapeutical Chemical (ATC) classification index, psychotropics were categorised into neuroleptics, benzodiazepines and antidepressants. Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. One hundred and eighteen staff members were interviewed about the residents's Activities of Daily Living (ADL), behavioural problems (Nursing Home Behavior Problem Scale), orientation, communication skills and if the resident had any psychiatric disorder. Multiple logistic regression was used to select the items that determined the use of psychotropics.

RESULTS

Fifty-six percent of the residents received a psychotropic, 21% received neuroleptics, 38% received benzodiazepines and 24% received antidepressants. In the multivariate analysis, staff assessment of the resident's mental health was a determinant for the use of all types of specific psychotropics, whereas a GMS-AGECAT diagnosis only determined the use of neuroleptics. Behavioural problems were a determinant for the use of neuroleptics and the use of benzodiazepines irrespective of the psychiatric diagnosis of the resident. Use of antidepressants was associated with male gender and increasing age.

CONCLUSIONS

Staff perceptions of psychiatric morbidity and norms have a greater impact on the prescription of psychotropics than standardised clinical criteria.

Empirical weighting of the Standardized Mini Mental State Examination items among nursing home residents

Missing items in the Mini Mental State examination are dealt with in different ways. The main aims of this study were to calculate a weighted item score for organic disorder on the basis of the item score of the Standardized Mini Mental State Examination (SMMSE) test regardless of the completeness of the test and to compare the criterion validity of the weighted scores with the ordinal scores for the SMMSE test. With a participation of 91%, the study included 100 nursing residents. All residents were tested with the SMMSE test and concurrently diagnosed in accordance with the ICD-10 by a consultant psychiatrist. The two assessments were mutually blinded. Multiple conditional forward logistic regression was used to select the items that most strongly predicted organic disorder as assessed by the psychiatrist. The weighted score had significantly better validity parameters, performed better on a receiver operating curve (ROC), and was better at dichotomizing the population into organic disorder than the commonly used ordinal score. We propose that missing items in the SMMSE should be scored as missing and included in empirical weighting on SMMSE items, which will then be substantially more valid than the SMMSE score itself.

Psychoactive substance use diagnoses among psychiatric in-patients

OBJECTIVE

To estimate the prevalence and possible under-diagnosing of substance use disorders and to consider factors that might influence diagnosing of substance use disorders.

METHOD

Data collected from case records and PSE interviews of psychiatric in-patients from 12 psychiatric departments in Denmark admitted during October 1996 were compared with data from the Danish Psychiatric Register.

RESULTS

A substantially lower prevalence of substance use diagnoses were found in the register (26.1%) than in the research data (50.0%). A high prevalence of co-occurrence between substance use disorders and mental disorders other than substance use disorders was found (37.3%). In the majority of cases knowledge of the substance use disorders was present in the case records, although they had not resulted in a diagnosis.

CONCLUSION

The under-diagnosis of substance use disorders is due not only to concealed diagnostic signs and symptoms but also to an under-diagnosis by the psychiatrists, in spite of the fact that information on the substance use was accessible.

From psychiatric hospital to rehabilitation: the Nordic experience

Deinstitutionalization and decentralization in psychiatry have by now been the first items of the agenda for more than 30 years. A theory of social psychiatry with social rehabilitation and reintegration was the underlying basis for the activities which should make the change from mainly inpatients to community-based outpatients treatment possible. By means of the National Danish Psychiatric Case Register this paper shows how the process mostly has concentrated on the deinstitutionalization (or reinstitutionalization?) of the old long-stay psychiatric patients. A new but smaller group of long-stay patients has appeared in the statistics. The average age of this group is 40 years compared to the old long-stay patients' average age of 60 years. It is also shown that the readmission rate during the first year after the discharge following the hospitalization during which the schizophrenia diagnosis was given for the first time ever is almost unchanged (with a small increase) for both males and females. So, in Denmark it is on average between 45% and 50% for females and males respectively. A break down on these data on counties shows that the situation varies broadly from a little over 30% for the best (mainly rural counties) to a maximum of 54%. It seems as if social psychiatry in the Nordic countries mainly concentrate on social care and only to a less degree on network, employment and other basic rehabilitation and reintegrative social work. A basis for a successful social integrative work must be a treatment initiated as early as possible with an antipsychotic treatment and maximum of compliance.

[Prevalence of depressive disorders among frail elderly, assessed by psychogeriatricians, general practitioners and geriatricians]

The prevalence of depressive disorders (D) in 70 years of age or older frail elderly was studied. Two hundred and eleven (81%) recipients of Municipal Home Help Service (frail elderly) in a rural area of Jutland were included and screened by the Geriatric Depression Scale-15 (GDS). If participants had: a) a GDS-score > or = 5 points or/and b) a history of depression, further evaluation was given by: 1) general practitioners (GPs) (implicit criteria), 2) a psycho-geriatrician (ICD-10 criteria), and 3) a geriatrician with the Hamilton Test for Depression. Prevalence rates for D among the evaluators: 15-18%. The diagnostic agreement was only fair.

IN CONCLUSION

18% of the studied population fulfilled the ICD-10 research criteria for depression. The GDS may help GPs in diagnosing depression among frail elderly. False GDS negatives, found among GDS negatives with a history of depression, should be evaluated thoroughly when identifying depression in the target group.

Regional differences in schizophrenia incidence in Denmark

OBJECTIVE

To examine the regional distribution of schizophrenia incidence in Denmark.

METHOD

A cohort consisting of 2441 Danish psychiatric patients, with first-time admissions between January 1, 1978 and December 31, 1982, and diagnosed as having schizophrenia (ICD-8) at least once in a 10-year period of observation was divided into three regional groups by degree of urbanization.

RESULTS

Incidence increased for both sexes with increasing urbanization. A diagnostic delay was most pronounced in the least urbanized areas and was most pronounced for women.

CONCLUSION

Our study confirms the existence of regional differences in schizophrenia incidence on a national basis. Marked regional differences in diagnostic delay were also demonstrated. A possible explanation could be regional differences in diagnostic procedures, underlining the importance of uniform diagnostic patterns as a means for reliable mapping of psychiatric morbidity and, hopefully, adequate treatment.