The perceived quality of hospital care

For the functional psychoses of late life, epidemiological information comes from two sources: studies of persons who have reached psychiatric services; and surveys of elderly persons sampled from the general population. A conspectus of published data from both sources leads to the following conclusions: States phenomenologically similar to those found in clinics do occur in the community in non-trivial numbers. There is no notable divergence in the information obtained from clinical series and from population-based surveys. These states are more common in women, they become more common with increasing age and are sometimes associated with decline in cognitive performance or with degenerative changes in the brain revealed by neuroimaging. Genetic factors appear to be less important than in early-onset psychoses but remain ill-defined, and the roles of social isolation and disorders of personality have not yet been sufficiently elucidated. Both clinical and community-based studies have found an association with sensory impairment. The community-based data suggest that paranoid symptoms may be detectable at subclinical level, and an association between them and cognitive impairment is demonstrable in individuals who are not diagnosable cases either of psychosis or of dementia. Differences exist between late-onset paranoid psychoses and affective psychoses in symptomatology and response to treatment. These observations confirm the importance of the late-onset psychoses for research directed towards uncovering the origins of psychotic symptoms in any age group.     

Differing haemodynamic and catecholamine responses to exercise in three groups with peripheralautonomic dysfunction: insulin-dependent diabetes mellitus, familial amyloid polyneuropathy and pure autonomic failure

BACKGROUND: The nosological status of postpartum psychoses has remained controversial because of their often 'atypical' symptomatology. A polydiagnostic approach may further clarify this issue. METHODS: In a retrospective study, we applied the ICD-10 and Leonhard's classification to 39 patients with severe postpartum psychiatric disorders. The patients were personally reexamined on average 12.5 years (6-26 years) after the onset of the illness. RESULTS: An acute onset and a polymorphous psychotic symptomatology with rapid changes characterized the majority of our cases. Unipolar depressive disorders (28%) and acute polymorphous psychotic disorders (21%) represented the largest proportions within the ICD-10-classification. Applying Leonhard's classification, over half the patients (54%) suffered from a cycloid psychosis. Among cycloid psychoses, motility psychoses clearly predominated. Schizophrenias occurred rarely (10%) according to both classifications. LIMITATIONS: Due to the unknown prevalence of the various diagnoses among women of child-bearing age, it is impossible to statistically infer a specific association between childbirth and a distinct diagnosis from our data. CONCLUSIONS: Our findings suggest that cycloid psychoses, in particular motility psychoses, account for the majority of postpartum psychoses, and do not support the hypothesis of a nosological independence of postpartum psychoses.     

Arthralgias following dilation and curettage

The paper presents the results of examination of 110 alcoholic patients who have committed criminal actions and were recognized as irresponsible at forensic examination. It was established that wide spectrum of mental disorders were present in such cases--from superacute psychotic states (15 patients) and acute disorders (49) to chronic psychoses (33) and encephalopathy (13). According to clinical manifestations mental disorders correspond in such cases to reactions of exogenic type. In contrast to general medical departments where patients with alcoholic delirium prevail, the studied sample of patients had primarily psychoses with hallucinative-delirious and delirious disorders. Disorders of personality manifested as typical alcoholic, asthenoneurotic, psychopathic-like, residual-psychotic, psychoorganic changes and partial dementia (19 cases).     

1997 IPA/Bayer Research Awards in Psychogeriatrics. The wish to die in very old persons near the end of life: a psychiatric problem? Results from the Berlin Aging Study

The wish to die in elderly persons is currently under debate. Experts are questioning whether it is natural for these individuals to show a wish to die, whether the right to eventually kill oneself should be respected, or whether suicidal intentions in old age are expressions of mental disorders that need intensive, professional care. A representative community sample of 516 persons aged 70 to 105 was extensively investigated by psychiatrists using the structured interview Geriatric Mental State Examination-Version A (GMS-A) and several self-rating and observer-rating scales. Diagnoses were made according to DSM-III-R criteria and by clinical judgment. The goal of the study was to find examples of "pathology-free wishes to kill oneself." A total of 115 out of 516 very old (70 to 105 years) persons, which represents 21.1% of the community population, said at the time of investigation that they wanted to die or felt life was not worth living (Hamilton Depression Rating Scale [HAMD] score 1, 2, or 3). Forty-three very old persons (6% of the community population) had the wish to be dead according to the HAMD or the GMS-A, and 11 persons (2% of the community population) had suicidal intentions. Depending on the intensity of suicidality, 80% to 100% were clinically diagnosed as having psychiatric disorders and half to three quarters showed symptoms fulfilling the criteria of at least one specified psychiatric diagnosis. Acute suicidal intentions were in all cases associated with at least one specified diagnosis according to DSM-III-R. Thirteen persons out of 54 who actually wanted to die (GMS-A category 4, 5, 6 or HAMD category 2, 3) did not fulfill criteria for specified diagnoses. Seven individuals showed scores in self-rating and observer-rating scales that speak for mental disorders apart from pure suicidality. Six remaining persons are described in greater detail in short case vignettes. They showed either mild but chronic psychiatric disorders, fluctuating courses, or an atypical phenomenology of psychiatric disorders. The results of this study strongly suggest that the wish to be dead in the very old is most probable, and suicidal intentions are definitely associated with psychiatric disorders.     

First-contact rate for schizophrenia in community psychiatric care. Consideration of the oestrogen hypothesis

The study deals with the incidence of schizophrenia in Finland. All patients aged 15 years and over who during 1 year for the first time in their life contacted any psychiatric treatment unit in six health care districts (catchment areas), with a total population of 1.1 million people, and suffered from schizophrenia as defined by the DSM-III (schizophrenic and schizophreniform disorders) or ICD-8 classifications were studied and followed for 5 years. A total of 186 DSM-III and 158 ICD-8 schizophrenia patients were registered. The incidence rate of DSM-III schizophrenia was 17 per 100,000 total population and that for ICD-8 schizophrenia 14 per 100,000. The incidence rates for individuals aged 22-34 years, singles and those with low education were higher than average, but there were no gender differences. The comprehensiveness of the psychiatric services may explain why the age distributions were similar for both genders and why the mean age of patients at their first psychiatric contact was lower than in many other studies dealing with hospitalized patients. The patients' age at first psychiatric contact did not support the view that oestrogens specifically delay the onset of schizophrenia in women. There is some evidence, however, that oestrogens as antidopaminergic agents may protect women from psychotic disorders in general and that the reduction in oestrogen production may explain why at menopause and afterwards admissions for psychotic disorders for women increase more than for men.     

Occurrence and clinical correlates of psychiatric comorbidity in patients with psychotic disorders

BACKGROUND: The aim of this study was to explore patterns and clinical correlates of psychiatric comorbidity in patients with schizophrenia spectrum disorders and mood spectrum disorders with psychotic features. METHOD: Ninety-six consecutively hospitalized patients with current psychotic symptoms were recruited and included in this study. Index episode psychotic diagnosis and psychiatric comorbidity were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Psychopathology was assessed by the SCID-P, Brief Psychiatric Rating Scale, Scale for the Assessment of Negative Symptoms, and Hopkins Symptom Checklist. Awareness of illness was assessed with the Scale to Assess Unawareness of Mental Disorders. RESULTS: The total lifetime prevalence of psychiatric comorbidity in the entire cohort was 57.3% (58.1% in schizophrenia spectrum disorders and 56.9% in mood spectrum psychoses). Overall, panic disorder (24%), obsessive-compulsive disorder (24%), social phobia (17.7%), substance abuse (11.5%), alcohol abuse (10.4%), and simple phobia (7.3%) were the most frequent comorbidities. Within the group of mood spectrum disorders, negative symptoms were found to be more frequent among patients with psychiatric comorbidity than among those without comorbidity, while such a difference was not detected within the group of schizophrenia spectrum disorders. Social phobia, substance abuse disorder, and panic disorder comorbidity showed the greatest association with psychotic features. An association between earlier age at first hospitalization and comorbidity was found only in patients with unipolar psychotic depression. Patient self-reported psychopathology was more severe in schizophrenia spectrum patients with comorbidity than in those without, while such a difference was less pronounced in mood spectrum psychoses. CONCLUSION: These findings suggest that psychiatric comorbidity is a relevant phenomenon in psychoses and is likely to negatively affect the phenomenology of psychotic illness. Further studies in larger psychotic populations are needed to gain more insight into the clinical and therapeutic implications of psychiatric comorbidity in psychoses.     

The mental health needs of physically disabled persons: Their perspective.

Evaluated disabled persons' perceptions of the types of problems experienced by the disabled population and the extent of this population's need for psychological services. 145 severely physically disabled former clients of a state rehabilitation commission responded to a questionnaire. Data show that 55% of Ss were aged 16–29 yrs, while 88% were 55 yrs old or less. 61.3% of Ss were males; 41% of Ss were married, 13% were divorced, 8% were separated, and 36% were single. 75% reported substantial need; 8% felt there was minimal or no need. Perceived problem areas included personal/emotional, organic/biological, marital/family, and vocational/career planning. Results suggest that this group of consumers perceives that there is a significant need for mental health services among individuals who are physically disabled. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Biochemistry and biomechanics of healing tendon: Part I. Effects of rigid plaster casts and functional casts

OBJECTIVE: The state psychiatric hospital is experiencing an increase in medically sick and aging patients who die of natural causes while hospitalized. This study explored the "medicalization" of the state hospital by examining the prevalence of medical illness and its relationship with psychiatric illness and age among state hospital psychiatric inpatients who died of natural causes--deaths that were not accidents, homicides, or suicides. METHODS: A total of 179 inpatients who died of natural causes at Western State Hospital in Washington State between 1989 and 1994 were studied retrospectively through case file review. Their demographic and institutional characteristics and psychiatric diagnoses were compared with those of others treated at the hospital (N=9,258). The medical diagnoses of patients who died were analyzed by age and psychiatric condition. RESULTS: The patients who died were much older than the other patients treated during the study period. Two-thirds of those who died had organic mental disorders, mostly dementia, whereas only a fifth of the other patients had these disorders. The patients who died had a mean of eight physical illnesses, with a range from none to 21. Circulatory and respiratory conditions were most prevalent, affecting half to two-thirds of patients; these conditions had high rates of comorbidity with organic mental disorders. CONCLUSIONS: The characteristics of the state hospital population and the services provided are shifting in response to mental health reform and new policies on patient self-determination. Increased emphasis on medical care added to traditional psychiatric services will require increased financial and personnel resources.     

Lack of permanent nigrostriatal dopamine deficit following 6-hydroxydopamine injection into the rat striatum. Short communication

OBJECTIVE: Understanding the contributors to physical disability in older adults is an important component of the national health objective of expanding disability-free life by the year 2000. The purpose of this study was to determine the frequency with which older adults attribute their difficulty performing a number of common daily tasks to "old age" and to identify specific conditions and diseases associated with this attribution. Finally we sought to determine the characteristics that might differentiate persons able to attribute their disability to specific conditions from those who cite old age as the etiology of their disability. DESIGN: A cross-sectional, observational, study. SETTING: The Johns Hopkins Functional Status Laboratory. PARTICIPANTS: Two hundred thirty community-dwelling volunteers 60 years of age and older who could stand unassisted for > or = 1 minute and who were without cognitive impairment. MEASUREMENTS: A 1-day evaluation included physical performance evaluations, both performance-based and self-reported function for 27 tasks, and self-report of physician-diagnosed diseases. Those with difficulty in a task and those who denied difficulty but had changed the method of task performance (modification) because of an underlying health or physical condition were identified and asked to name the cause of their difficulty or task modification; options were specific diseases/medical conditions or "old age." The prevalence of "old age" citation as a cause of functional limitation, as well as its associated characteristics and medical conditions, was determined. MAIN RESULTS: Twenty percent of the 230 participants cited "old age" as the cause of their disability in two or more tasks. Tasks for which difficulty was most frequently attributed to "old age" were dressing oneself (31%), walking around the home (25%), walking 1/2 mile (5-6 blocks) (25%), cutting toenails (16%), getting in or out of a bed or chair or out a car (14% each), and ascending/descending stairs (13%). Significantly higher levels of arthritis, heart disease, and hearing loss were reported in persons attributing their disability to "old age" than in those not reporting "old age" as the cause of their disability. We found no differences in age, gender, race, education, or cognitive status for the two groups. However, individuals citing "old age" as the cause of functional decrements walked more slowly than those who cited a specific disease. CONCLUSIONS: These data suggest that a significant proportion of functional decline attributed to "aging" in older adults may be associated with specific conditions. Identifying and reducing the impact of these conditions may prove to be a useful approach to preventing or minimizing functional loss.     

Follow-up and family study of postpartum psychoses. Part I: Overview

A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2-35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.     

Individual differences in spatial organization of cortical electrical activity during formation of a set to visual stimuli

Vascular affections of the brain remain a formidable psychiatric challenge nowadays. According to WHO reports cerebrovascular disorders constitute one of the three chief causes of mortality in the population of the economically developed countries of the world. The most important cause of vascular psychoses is considered to be atherosclerosis and hypertensive disease. Today vascular psychoses have become a most common type of abnormal mental states in young adults (greater then 30-40 years old). The studies made have yielded evidence in support of the psychoses morbidity to be dependent upon particular season of year as well as on the climatic features of the locality. Natural factors have been found out to affect the prevalence of vascular psychoses in Chernivtsi Province. The findings obtained suggest to us a substantial prevalence of atherosclerotic and hypertensive psychoses in the plains-men living under conditions of a mild climate.     

Affective-cognitive structure and psychosis. New perspectives of the study of hallucination experience with psychodysleptics

This paper comparates classic experimental "model psychosis" psychodysleptic induced and psychotic adverse reactions to psychodysleptic habitude or episodic use as clinically observed. Biochemical, neurophisiological and psychopathological back-ground of psychodysleptic states and clinical data are discussed in the aiming to investigate and explain interaction between cognitif and affectif destructuration in spreading off a psychotic crises. A multidisciplinary approach provides new insight about destructuration processes in exogenous or endogenous psychoses and about mental developmental in child.     

Drug and alcohol problems among individuals with severe mental illness in south London

BACKGROUND: High rates of comorbid alcohol and drug disorders have previously been found among individuals with severe mental illnesses such as schizophrenia and bipolar affective disorders. Clinical and social outcomes have been reported to be worse in this group and service costs greater than in individuals with severe mental illness only. These 'dual diagnosis' patients have mainly been investigated in the USA, and there has been very little research in Europe, where patterns of substance abuse may be different. METHOD: All patients with psychotic illnesses who had any contact with the mental health services in a geographically defined sector in South London over a specified period were studied. Individuals with problems related to alcohol or drugs were identified using standardised interviews with subjects and their keyworkers. Data on psychiatric service use during the previous 2 years were also obtained. RESULTS: One hundred and seventy-one subjects with psychotic illnesses were interviewed (response rate: 78.4%). The one-year prevalence rate for any substance problem was 36.3% (95% CI = 29.1-43.5), for alcohol problems it was 31.6% (95% CI = 24.6-38.5), and for drug problems 15.8% (95% CI = 10.3-21.3). Young male subjects were at higher risk of having substance problems. Patients with substance problems had spent almost twice as many days in hospital as those without such problems over the previous two years (difference = 26.3 days, 95% CI = 3.8-48.7). CONCLUSIONS: The prevalence of substance problems among people suffering from severe mental disorders is high, and seems to be associated with greater use of in-patient services. This is a significant clinical problem, with cost implications. Further investigation is needed for adequate service provision.     

Factor analysis of dynamic series (FADS) in somatostatin receptor imaging

The serotonin transporter gene is a primary candidate for involvement in major psychoses. A functional polymorphism in the upstream regulatory region of the serotonin transporter gene (5-HTTLPR) has recently been reported to be associated with a variety of psychopathological conditions. In the present study, we investigated the potential influence of the 5-HTTLPR on the psychopathology of schizophrenia. One hundred and sixty-one inpatients affected by schizophrenia (DSMIII-R) were assessed by the Operational Criteria checklist for psychotic illness (OPCRIT) and were typed for their 5-HTTLPR variants by PCR techniques. Mania, Depression, Delusion and Disorganization were the four symptomatologic factors used to define phenotype. 5-HTTLPR variants were not associated with these symptomatologic factors, and consideration of possible stratification effects such as sex, and age of onset did not reveal any association either. The serotonin transporter gene is not a liability factor for the symptomatology of schizophrenia.     

Psychiatric morbidity among adults in The Netherlands: the NEMESIS-Study. II. Prevalence of psychiatric disorders. Netherlands Mental Health Survey and Incidence Study

OBJECTIVE: To determine the prevalence of psychiatric disorders in non-institutionalised Dutch adults. DESIGN: Cross-sectional. SETTING: Trimbos Institute, Utrecht, the Netherlands. METHODS: A representative sample of 7076 adults (18-64 years) in the Netherlands' population were interviewed in 1996 to determine the prevalence of mental disorders ever, in the previous 12 months and in the previous month. Objectives and study design are described in the previous article (1997: 2448-52). The 'Composite international diagnostic interview' (CIDI) was used to assess the following mental disorders according to Diagnostic and statistical manual of mental disorders, 3rd revised edition (DSM-III-R): affective disorders, anxiety disorders, eating disorders, schizophrenia and other non-affective psychoses, substance dependence and substance abuse. RESULTS: Mental disorders were common in the general population: the prevalence 'ever' of all disorders was 41.2%, the 12-month prevalence 23.5%, without sex differences. Depression, anxiety disorders and alcohol abuse and dependence showed high prevalence and comorbidity. The prevalence 'ever' of schizophrenia and other non-affective psychoses was low (0.4%).     

Understanding the topography of the early psychosis pathways. An opportunity to reduce delays in treatment

BACKGROUND: This study aims to gain an understanding of treatment delays and their nature in initial psychotic episodes. We investigated to whom people turn for help, how long that approach takes and subsequent delays in commencing treatment. METHOD: Qualitative and quantitative methods were combined with interviews of 62 people suffering from first-episode psychoses, aged 16-30 years, who had recently accessed a specialist mental health service in Melbourne, Australia. A modified version of the World Health Organization Encounter Form was analysed in conjunction with other data. RESULTS: Pathways to care and the ways in which they were experienced were highly variable, with 50% of people experiencing psychotic symptoms before approaching any service. The general practitioner played a key role with 50% of people having had GP contact at some point prior to commencing effective treatment. Where an individual's own efforts to seek early help failed, the role of relatives and others was subsequently vital. CONCLUSIONS: Opportunities exist for shortening delays through targeted health promotion activities and professional training. The need is indicated for a multi-layered or topographical strategy to identify and minimise critical barriers on the route to early intervention. Refinement of interview techniques and instruments of measurement are needed to enhance the explanatory power of data collected.     

Folic acid deficiency in chronically hospitalized mental patients

Studies over the past 30 years have shown a relationship between folic acid deficiency and psychopathology. FA deficiency was observed more often in depressed and in psychotic patients, in alcoholics, in those suffering from organic mental disorders and in the psycho-geriatric population. In a chronic inpatient population of 120 patients, of the 106 in whom FA serum levels were examined, only 1 had a definitely subnormal level. An additional 16 had close to the lower limit of normal (2 ng/ml) and were considered borderline cases. FA-deficient and borderline patients were then compared to matched patients with normal FA levels on the MMSE and PANSS scales by blinded raters. Small differences were found between the 2 groups. The FA-deficient and borderline patients had more organic and psychotic symptoms, but the differences were not statistically significant.     

Psychiatric hospitalization of senile and arteriosclerotic dementia patients by commitment order under the 1991 Israeli Mental Health Act

Data regarding commitment orders issued by district psychiatrists for elderly patients aged 65 years or older were obtained from the national psychiatric case register. Out of a total of 2,284 commitment orders issued in Israel in the period 1 January 1992 to 30 June 1993 under the 1991 Mental Health Act, 191 (8.3%) involved patients aged 65 and over; these orders were issued for the commitment of 169 patients who suffered from the following ICD-9-CM diagnoses on discharge: senile and arteriosclerotic dementia; transient organic psychotic conditions; schizophrenic disorders; affective psychoses; paranoid states; or other psychiatric disorders. Demographic and clinical characteristics of the senile and arteriosclerotic dementia patients were compared with the same variables in the other diagnostic categories. Results showed that (a) involuntary commitment of senile and arteriosclerotic dementia patients involved a small minority of dementia sufferers; (b) it was usually the patients' first psychiatric admission; (c) most of the patients were discharged within a one-month period; and (d) most of the patients were referred for continuation of treatment in non-psychiatric institutions. Findings (c) and (d) characterized other diagnostic categories as well. The relevance of these findings to the Mental Health Act is discussed.     

Left ventricular, peripheral vascular, and neurohumoral responses to mental stress in normal middle-aged men and women. Reference Group for the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study

BACKGROUND: The normal cardiovascular response to mental stress in middle-aged and older people has not been well characterized. METHODS AND RESULTS: We studied 29 individuals 45 to 73 years old (15 women, 14 men) who had no coronary risk factors, no history of coronary artery disease, and a negative exercise test. Left ventricular (LV) volumes and global and regional function were assessed by radionuclide ventriculography at rest and during two 5-minute standardized mental stress tasks (simulated public speaking and the Stroop Color-Word Test), administered in random order. A substantial sympathetic response occurred with both mental stress tests, characterized by increases in blood pressure, heart rate, rate-pressure product, cardiac index, and stroke work index and rises in plasma levels of epinephrine and norepinephrine but not beta-endorphin or cortisol. Despite this sympathetic response, LV volume increased and ejection fraction (EF) decreased secondary to an increase in afterload. The change in EF during mental stress-varied among individuals but was associated positively with changes in LV contractility and negatively with baseline EF and changes in afterload. EF decreased > 5% during mental stress in 12 individuals and > 8% in 5; 3 developed regional wall motion abnormalities. CONCLUSIONS: Mental stress in the laboratory results in a substantial sympathetic response in normal middle-aged and older men and women, but EF commonly falls because of a concomitant rise in afterload. These results provide essential age- and sex-matched reference data for studies of mental stress-induced ischemia in patients with coronary artery disease.