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Hält die durch stationär-psychosomatische Behandlung erreichte klinische Besserung ein bzw. 2 Jahre nach der Entlassung an? Wie verändert sich die medizinische Inanspruchnahme nach der Entlassung verglichen mit dem Jahr vor der stationär-psychosomatischen Behandlung?Die einwilligende Stichprobe zum Entlasszeitpunkt (N=250) wird anhand von 6 klinischen, 2 ressourcenbezogenen und 11 versorgungsmedizinischen Variablen zu 6 Messzeitpunkten (Aufnahme, Entlassung und jeweils 6, 12, 18, 24 Monate nach Entlassung) untersucht. Die adhärente Teilstichprobe (n=86) und die nicht adhärente (n=164) Teilstichprobe werden anhand von 25 Variablen verglichen. Der Verlauf der Zielvariablen wird graphisch anhand von Box-Plots dargestellt. Bivariate Vergleiche werden mit Mann-Withney-, Wilcoxon- und t-Tests mit Bonferroni-Korrektur durchgeführt, Vergleiche aller Messzeitpunkte für die Zielvariablen unter statistischer Kontrolle mit ausgewählten Kovariaten anhand von multivariaten Random-Effects-Regressionsmodellen unter Einsatz von multipler Imputation für Zeitreihen (MICE).Die adhärente und die nichtadhärente Teilstichprobe unterscheiden sich kaum nach Korrektur der Alpha-Inflation. Zwei Jahre nach der Entlassung sind bei der adhärenten Teilstichprobe alle Zielvariablen im Vergleich zum Aufnahmezeitpunkt signifikant gebessert (p0,001; durchschnittliche Gesamteffektstärke 1,12). Psychische Symptombelastung und Depressivität haben nach der Entlassung weiter signifikant abgenommen, Selbstwirksamkeit und Lebenszufriedenheit haben signifikant zugenommen. In bivariaten Modellen sinken Krankenhaustage, Arbeitsunfähigkeitstage, Arztbesuche und Medikation ein und 2 Jahre nach der Entlassung verglichen mit dem Jahr vor der Aufnahme. Multivariate Modelle mit der Gesamtstichprobe zum Entlasszeitpunkt bestätigen den positiven Verlauf der klinischen Variablen, zeigen jedoch geringere Unterschiede für die versorgungsmedizinischen Variablen.Die Limitation durch progressive Dropouts zeigte sich unter dem Einsatz multipler Imputation verringert. Die anhaltende klinische Besserung und die Verringerung der medizinischen Inanspruchnahme 2 Jahre nach der Entlassung sprechen für eine mittelfristige Effektivität der stationären psychosomatischen Behandlung. Strukturniveau der Persönlichkeitsorganisation und Neurotizismus sind die besten Prädiktoren für Ausmaß der psychischen Belastung über alle Messzeitpunkte hinweg.Does the clinical improvement achieved by inpatient psychosomatic treatment last one or 2 years after discharge? How does the medical utilization change after discharge compared to the year before the investigated inpatient psychosomatic treatment?The consenting sample at discharge (N=250) is examined using 6 clinical, 2 resource-related and 11 medical care variables at 6 measurement points (admission, discharge, and 6, 12, 18, 24 months after discharge). The adherent subsample 2 years after discharge (n=86) and the nonadherent subsample (n=164) are compared using 25 variables. The course of the target variables is graphically represented by box plots. Bivariate comparisons are performed using Mann-Withney, Wilcoxon and t tests, considering Bonferroni corrections. Comparisons of all measurement points for the target variables under statistical control with selected covariates are performed using multivariate random effects regression models employing chained multiple imputation for time series (MICE).The adherent and non-adherent sub-sample not differed significantly at discharge after correction of alpha inflation. Two years after discharge, all target variables in the adherent sub-sample improved significantly compared to admission (p0.001; average total effect size 1.12). Mental symptom burden and depression continued to decrease significantly after discharge, self-efficacy and life satisfaction increased significantly. In bivariate models, hospital days, incapacity to work days, number of doctor visits and medication one and two years after discharge decreased compared to the year before admission. Multivariate models with the total sample confirm the positive course of the clinical variables, but show smaller differences for the medical utilisation DISCUSSION: The limitation by progressive dropouts was reduced thanks to the use of multiple imputation. The continuing clinical improvement and the reduction in medical utilisation two years after discharge indicate that inpatient psychosomatic treatment is effective in the medium term. Structural level of personality organization and neuroticism are the best predictors of mental burden across all measurement points.

Hintergrund Die allgemeine Frage nach dem „Sinn des Lebens“ wird empirisch in Form von allgemeinen und personalen Lebensbedeutungen formuliert. In der Medizin erhalten Lebensbedeutungen eine relevante Tragweite bei einem Verlust von Sinn, der als krankheitsfördernd angesehen wird, v. a. aus psychosomatischer Perspektive. Fragestellung Die vorliegende Studie untersucht die psychometrischen Eigenschaften der deutschsprachigen revidierten Version des Life Attitude Profile (LAP-R) von Reker für eine Stichprobe stationär-psychosomatischer Patienten sowie mögliche Assoziationen mit klinischen Outcome-Variablen. Material und Methoden Die Stichprobe (n = 138) von elektiv stationär-psychosomatisch behandelten Patienten wird zu den Zeitpunkten Aufnahme und Entlassung untersucht. Reliabilität im Sinne von interner Konsistenz wird mit Cronbachs α ausgewertet; Konstruktvalidität wird mit konfirmatorischer Faktorenanalyse und konvergente Validität anhand von Korrelationsmatrizen mit validierten klinischen Skalen erfasst. Ergebnisse Die interne Konsistenz des LAP‑R für die einzelnen Dimensionen zeigt Cronbachs-α-Werte zwischen 0,69 und 0,85, für den Gesamttest beträgt Cronbachs α 0,92. Die konfirmatorische Faktorenanalyse zeigt einen guten Daten-Fit („root mean square error of approximation“ [RMSEA], χ2/Freiheitsgrade [df]), aber einen zu geringen Modell-Fit („Tucker-Lewis index“ [TLI], „comparative fit index“ [CFI]). Die Korrelationen zwischen den Dimensionen des LAP‑R sind meist moderat. Die Korrelation zwischen dem Ausmaß der klinischen Besserung und der Zunahme der Lebensbedeutungen ist mäßig, aber mit der rückblickenden therapeutischen Beziehung hoch. Schlussfolgerung Die deutsche Version des LAP‑R zeigt für die Stichprobe stationär-psychosomatisch behandelter Patienten gute interne Konsistenz, gute konvergente Validität, jedoch uneinheitliche Konstruktvalidität. Die übergeordneten Indizes („personal meaning index“ [PMI], „existential transcendence“ [ET]) korrelieren signifikanter mit klinischen Variablen als die einzelnen Dimensionen., publishedVersion

Problem: Core-specific sensorimotor exercises (CSSE) combined with technically applied unexpected high-intensity perturbations (UHIP) are able to enhance neuromuscular activity of the trunk muscles (TM). SinceincludingUHIP into clinical practice is complicated, it is warranted to implement a feasible perturbation task. Aim of the study was to analyze the effects of an additional motoric-task perturbation on trunk neuromuscular activation pattern during CSSE exercise.Methods: Ten participants (5m/5f; 292years; 1777cm, 7412kg) were included and prepared with a surface EMG-setup for trunk muscles. EMG-data were collected during a side plank on stable surface (SP; 30sec) and randomly in 3 different conditions: adding a pad under the right elbow (SPP), adding a perturbation task (SP+P) and adding pad and perturbation task (SPP+P). Root mean square (RMS) was calculated for the whole exercise cycle (30sec) and normalized to MVIC (%MVIC). Muscles were grouped to ventral (VR; VL) and dorsal (DR; DL) right/left. In addition, the ratios of Ventral: Dorsal (V: D) and Side-Right: Side-Left (SR: SL) were calculated. Differences between conditions were assessed for muscle groups and ratios (repeated-measures ANOVA; =0.05).Results: SPP+P showed the highest EMG-RMS for all muscles except DL, showing significant differences between conditions SP and SP+P in VR and VL,respectively. No differences (p

Waiting times for the admission into a so called psychosomatic hospital in Germany prevent the necessary immediate treatment. They lead to further incapacity for work and chronic manifestation of the disease. It is reported that most psychosomatic hospitals have waiting times, but there are no studies on data on that. Therefore, it was the aim of this study to access prospectively in a defined region, how long it takes for the patients to get an outpatient preliminary talk and thereafter, how long they have to wait for their admission.7 hospitals out of the region of South-Württemberg took part on this study, 2 of them had bigger day hospitals. Data were assessed prospectively in 2015 over 9 months, in total 916 admissions were assessed.The waiting time until a preliminary talk, in which the indication for inpatient treatment was secured, was in the mean 25 days (SD=31). The waiting time after this talk until admission was 56 days (SD=47). Patients who waited for a day treatment had to wait even longer. An urgency remark, given by the therapist of the preliminary talk, as well as a private illness insurance led to shorter waiting times. The diagnosis had no influence on the waiting time.The waiting times are substantial and imply a burden for the patient and also for the health care system. It is recommended to assess and publish these waiting times on a regularly basis. Politics, but also the actors in the health care system should discuss if and how this deficit can be changed.Wartezeiten auf die Aufnahme in eine psychosomatische Klinik verhindern die akut notwendige Behandlung und können zu verlängerter Arbeitsunfähigkeit und weiterer Chronifizierung führen. Von den meisten psychosomatischen Kliniken werden Wartezeiten berichtet, es existieren bisher jedoch keine Studien und verlässlichen Daten hierzu. Daher war es das Ziel dieser Studie, in einer definierten Region prospektiv zu untersuchen, wie lange es bis zu einem ambulanten Vorgespräch und bis zur Klinikaufnahme dauert. Weiter sollte geprüft werden, ob es externe Faktoren gibt, die diese Dauern beeinflussen.7 Kliniken aus der Region Süd-Württemberg nahmen an dieser Untersuchung teil, 2 davon betreiben größere Tagesklinken. Die Daten wurden 2015 über 9 Monate prospektiv erhoben, insgesamt wurden 916 Aufnahmen erfasst. Erfasst wurde die Wartezeit bis zu einem Vorgespräch, in dem die Indikation geprüft wurde, und die Zeit bis zur tatsächlichen Aufnahme in die Klinik.Die Wartezeit bis zum ambulanten Vorgespräch betrug im Mittel 25 Tage (SD=31), bis zur Aufnahme nach dem Vorgespräch 56 Tage (SD=47). Insgesamt dauerte es vom Erstkontakt bis zur Aufnahme im Mittel demnach mehr als 10 Wochen. Patienten, die auf einen Tagesklinikplatz warteten, mussten noch länger warten. Ein Dringlichkeitsvermerk durch den Therapeuten des Vorgesprächs sowie eine private Krankenversicherung führten zu etwas kürzeren Wartezeiten. Die Diagnosegruppe hatte keinen Einfluss auf die Wartezeit.Die Wartezeiten sind beträchtlich und belasten den Patienten, aber auch das Gesundheitssystem. Es wäre wünschenswert, wenn solche Wartezeiten systematisch erhoben und veröffentlicht würden. Die Politik, aber auch die Handelnden im Gesundheitswesen sollten in einem Gesprächsprozess klären, ob und wie dieser Missstand verändert werden kann.

The human gut microbiome plays a key role in human health 1 , but 16S characterization lacks quantitative functional annotation 2 . The fecal metabolome provides a functional readout of microbial activity and can be used as an intermediate phenotype mediating host–microbiome interactions 3 . In this comprehensive description of the fecal metabolome, examining 1,116 metabolites from 786 individuals from a population-based twin study (TwinsUK), the fecal metabolome was found to be only modestly influenced by host genetics (heritability (H2) = 17.9%). One replicated locus at the NAT2 gene was associated with fecal metabolic traits. The fecal metabolome largely reflects gut microbial composition, explaining on average 67.7% (±18.8%) of its variance. It is strongly associated with visceral-fat mass, thereby illustrating potential mechanisms underlying the well-established microbial influence on abdominal obesity. Fecal metabolic profiling thus is a novel tool to explore links among microbiome composition, host phenotypes, and heritable complex traits. Comprehensive fecal metabolic profiling in 786 individuals from TwinsUK provides insights into the influence of host genetics and gut microbial composition on metabolites that may mediate microbiome-associated phenotypes.

The existential concept of "limit situation" was proposed by Jaspers as the inevitable threshold of human beings at their ordinary mode of being, namely Dasein, which has to be crossed to reach Existence as the proper mode of being after having transcended an existential challenge. A failure at facing limit situations indicates that they are ineluctable and have to be assumed.The starting point is the analysis of Jaspers' concept of limit situations, both within the antinomic structure of the human condition as well as the duality of being-in-the-world. An attempt is made here to interpret the ontological determination of the limit situation as an ontic one, which could be relevant to psychiatric and psychotherapeutic practice.The distinction between Dasein and Existence as modes of being is at the basis of Jaspers' existential philosophy. Limit situations cannot be veiled; therefore, they require a transcendence movement of the self in order to overcome enclosures and to reach the mode of being of Existence as authentic selfhood. Jaspers creates an ontological typology of limit situations in which suffering plays a key role. An ontic correspondence for psychiatry and psychotherapy refers to the importance of critical life events, of suicidality, of rigid thought styles and behavior patterns as enclosures; illness is both a limit situation in itself and also its consequence. In anthropological terms, the concepts of existential vulnerability and competence in dealing with limit situations have proved to be rewarding.The ontic correspondence to Jaspers' ontological concept of limit situations suggested by the author makes a fruitful contribution to psychiatry and psychotherapy, because it draws attention to the person-environment fit as a possible predetermined breaking point that could lead to psychopathologically relevant failure. Critical life events understood as relational, as well as existential vulnerability and defense mechanisms biographically illuminated could contribute to an improvement of competence in dealing with limit situations within the psychotherapeutic practice.

Understanding of bitterness ranges from a negative general human emotion to a destructive complex affekt due to a non adequate processed affront or resentment.Relevant associations between kinds of bitterness and clinical as well as personality-related variables in hospitalized psychosomatic patients were examined.Prospective naturalistic study over 14 months of consecutive admitted psychosomatic patients without exclusion criteria (N=166). General bitterness and 4 subscales were investigated on the basis of the Berner Verbitterungs-Inventar (BVI), personality traits on the basis of BFI-10, and clinical variables mainly on the basis of validated instruments (HoNOS, BDI, HADS, GAF, CGI, IIP-D, BSCL, comorbidity, duration of illness and structure as well as conflict-load according to OPD-2). Differences among levels of bitterness were examined with ANOVA tests, relationships between bitterness and clinical as well as personality-related variables using multivariate linear and multinomial regression models.The general bitterness falls within the average range. ANOVA models show higher scores for neuroticism, IIP, BDI, HADS, and BSCL when bitterness is above-average. In multivariate regression analyses, BDI, BSCL and neuroticism are positively associated with bitterness, whereas GAF, illness duration, and conscientiousness are negatively associated with bitterness. Diagnoses, severity of disease and burden of conflicts as well as level of organization of personality are not associated with bitterness. Models explain 11-39% of variance of bitterness.Bitterness in psychosomatic patients is hardly associated with personality variables, diagnoses, and psychopathological burden with the exception of depressiveness and neuroticism. Burden of interpersonal concerns may better explain bitterness than psychopathology or personality.Bitterness could be interpreted as a theoretical construct widely independent from severity of disease, personality, and diagnosis, showing importance in clinical practice.

Lernende Städte - ein Begriff, der ungewöhnlich klingt. Bei genauerem Hinsehen zeigt sich, dass er es auch ist. Was es mit dem Konzept 'Lernende Stadt' auf sich hat, was lebenslanges Lernen damit zu tun hat und wie das Ganze in Deutschland aussieht, ist Gegenstand dieses Beitrags.

To assess possible differences in clinical, social, care, and satisfaction profile of patients treated by outpatient clinics or office based psychiatrists.The study sample consists of 100 patients of a psychiatric outpatient clinic and 100 patients treated by office based psychiatrists in the same catchment area. Patients were examined using standardized assessment instruments for severity of illness (HoNOS, CGI), general (GAF) and specific functional impairment (PSP), and satisfaction with psychiatric services (ZUF-8). Chi-square tests, univariate ANOVAs and stepwise multivariate logistic regression models were applied.Compared with patients treated by office based psychiatrists, patients treated by the outpatient clinic showed higher HoNOS and CGI scores, lower GAF and PSP scores, and had more often a disability pension, a legal guardianship, a schizophrenia diagnosis, suicide attempts, hospitalizations, and therapeutic contacts. However, there were no significant differences regarding care satisfaction.The assessed outpatient clinic met the German statutory criteria for its legitimation. However, care needs have to be specified in a better way, and the different care intensity as well as concrete interventions between both settings have to be specified more accurately.

Psychiatric outpatient clinics (PIAs) are an indispensable care service for crisis intervention and multidisciplinary treatment of people suffering from severe and persistent mental disorders. The decentralization of outpatient clinics can be understood as a further step in the deinstitutionalization process.This cross-sectional study (n=1,663) compared the central outpatient clinic with the decentralized teams for the year 2010 by means of analyses of variance, χ(2)-tests and robust multivariate regression models. The longitudinal assessment (descriptively and by means of Prais-Winsten regression models for time series) was based on all hospitalizations for the two decentralized teams (n = 6,693) according to partial catchment areas for the time period 2002-2010 in order to examine trends after their installation in the year 2007.Decentralized teams were found to be similar with respect to the care profile but cared for relatively more patients suffering from dementia, addictive and mood disorders but not for those suffering from schizophrenia and personality disorders. Decentralized teams showed less outpatient care costs as well as psychopharmacological expenses but a lower contact frequency than the central outpatient clinic. Total expenses for psychiatric care were not significantly different and assessed hospitalization variables (e.g. total number of annual admissions, cumulative length of inpatient-stay and annual hospitalizations per patient) changed slightly 3 years after installation of the decentralized teams. The number of admissions of people suffering from schizophrenia decreased whereas those for mood and stress disorders increased.Decentralized outpatient teams seemed to reach patients in rural regions who previously were not reached by the central outpatient clinic. Economic figures indicate advantages for the installation of such teams because care expenses are not higher than for patients treated in centralized outpatient clinics and because hospitalization figures for the whole catchment area did not increase.

To compare long-term trends in legal guardianship policy and involuntary psychiatric admissions in urban and rural areas for people suffering from mental illness.New and current legal guardianships as well as involuntary admissions according to Guardianship Law and also to Commitment Law were examined from 1998 to 2010.All investigated variables (new and current legal guardianships as well as involuntary admissions) increased significantly along assessed period of time. Current guardianship rates are lower in urban area. On the other hand, rates of involuntary admissions according to Guardianship Law are in urban area 3fold higher and those according to Commitment Law doubled. New and current guardianships' ratio as well as ratio between involuntary admissions according Commitment Law and Guardianship Law remained quite stable.The large differences in legal guardianship policy and involuntary treatment between urban and rural regions cannot be explained on the basis of available data. The role of community-based care networks in the process of reducing involuntary admissions should be further examined.

Given the steady rise of psychiatric coercive measures in Germany, the question arises whether this development is significantly influenced by the corresponding legal basis or through epidemiological, socio-economic or socio-structural factors.Based on full surveys of the Federal Ministry of Justice we examined the development and associations of 10 indicators of coercive psychiatric measures over a period of 18 years. Time trends of all indicators have been descriptively analysed. Statistical associations between time trends and between involuntary and admissions economic indicators were analysed by regression models.All annual involuntary commitment rates have increased, judicial ordered physical restraint measures particularly strongly (848%). The rate of judicial rejections of applied involuntary measures showed the lowest increase. On the other hand, quotas of involuntary admissions remained stable. In former East Germany, the involuntary admission rates are only a third of those in the former West Germany. Results of regression analyses indicate an excess increase of physical coercive measures in psychiatric hospitals in relation to the increase of psychiatric admissions. In former East Germany the rate of involuntary admissions at the federal state level is negatively correlated with the average gross income.The continuous increase of coercive psychiatric measures in consequence to the change in the Guardianship law suggests that this change has influenced the practice. The differences at federal and state levels, and the sharper rise in the former East Germany by lower rates in comparison to the former West Germany need an explanation, as well as the fact that the rate of involuntary admissions is associated at least in the former East Germany with economic conditions.

In this observational study indicators for the quality of psychiatric care in a psychiatric hostel will be examined for all residents over a period of 7 years.Data has been collected at an annual basis. Relationships among variables have been analysed by means of random effects regression analyses for longitudinal data.GAF score increases slightly. Number of psychopharmacological drugs and neuroleptics as well as inpatient costs remains stable. Psychiatric treatment costs are negatively related to the functional level, residents' age and the duration of stay in the residential facility. Even under control of several variables, variance of total costs was found to be mainly explained by the costs of inpatient and psychopharmacological treatment.Increase of the general functional level indicates a positive development of autonomy. Changes and the influence factors of psychopharmacological treatment may indicate a need-oriented drug therapy. Some findings may indicate an institutionalisation process and an increasing of medical conditions in chronically mentally ill people.

The Guardianship Law became effective in the year 1992 with the intention of replacing the paternalistic-restrictive model by a model based on the principles of participation and empowerment.Data from the Federal Ministry of Justice were used to examine the development of 12 legal guardianship parameters over a period of 17 years (1992-2009) at the level of federal states. Due to the completely different practise in both parts of Germany before reunification, the development will be analysed separately for the old and the new federal states.All examined parameters indicate an increase of legal guardianship. The highest increases were found for enlargement of the task scope (+606%) and for approval of contention measures (+868%). With the exception of involuntary commitment rates, in the new federal states the mean values of all variables score higher than in the old federal states. Legal guardianship installation only increased for the old federal states significantly (T(9)=6.64; p=0.007); however, the guardianship expenses were higher, but not significantly, for the new federal states.In spite of the legal changes in the direction of a dynamic instrument in mental health care, the practise of the Legal Guardianship Law indicates a continuous increase of guardianship orders since 1992. It is necessary to recognise that a slowdown of the upward trend is not in sight. Therefore it is pertinent to call those persons in charge of regulating legal guardianship to consider their daily practise carefully. On the other hand it is a task of mental health services research to analyse the driving factors of the presented developments.

In this study trends in legal guardianship and involuntary treatment in a Bavarian catchment area in comparison to trends at federal state and federal level between 1999 and 2009 will be examined.Data from the federal department of justice, from the federal health monitoring system and data from a district court were used to compute rates, quotas and quotients. Regression analyses were conducted to analyse associations between time series.In comparison to the federal state and the federal level the target region shows a significantly higher rate of new guardianships but a lower rate of judicial ordered mobility restrictions and at least in comparison to the federal state level a significantly lower rate of involuntary admissions according to guardianship law.The obtained differences indicate significant differences in the legal guardianship and involuntary admission practise which cannot be explained by epidemiological developments. Therefore it is necessary to investigate potential socio-cultural and socioeconomic sources for these varieties.

In the light of increasing resistance to antibiotics used for the treatment of acute urinary tract infections, nitrofurantoin currently experiences a renaissance. Nitrofurantoin shows good efficacy against most bacteria expected in urinary tract infection, and the development of resistance is low. A study on the antimicrobial and clinical efficacy of nitrofurantoin in the treatment of acute lower urinary tract infections was conducted in Mexico City, an area where resistance rates of uropathogens to trimethoprim/sulfamethoxazole (cotrimoxazole) are high.In this open-label, single-arm study 20 adult patients (18 females, 2 males) with positive urine culture were treated orally with nitrofurantoin sustained release 100 mg twice daily for 7 days. Urinary nitrofurantoin concentrations were determined at baseline and day 4 of the study. Primary endpoint was the antimicrobial efficacy of nitrofurantoin at 12 to 16 days after baseline, assessed by changes in urine culture results.In the patient population treated per protocol, primary endpoint analysis revealed a microbial eradication rate of 92.3%. At 35 to 42 days, the eradication rate was 83.3%. At these times, all patients in the per protocol population were free of symptoms. In patients with complicating factors, e.g. diabetic polyneuropathy, both antimicrobial and clinical efficacy appeared to be reduced. Urinary nitrofurantoin concentrations were mostly above minimum inhibitory concentrations of the isolated uropathogens. The study drug was generally well tolerated. Most frequent drug-related adverse event was mild headache, occurring in 10.8% of patients. Two patients discontinued the study due to rash.The results of the present study indicate good antimicrobial and clinical efficacy of nitrofurantoin in the treatment of acute uncomplicated urinary tract infections as well as acceptable tolerability in adults.

This paper outlines an approach to assessing chronicity in psychiatric disorders, which represents a challenge for clinical practice. We began by accepting conclusions from well accepted anthropological and clinical studies of patients with chronic psychiatric disorders. Based on such key conclusions, we formulated several assumptions centred round anthropological concepts as a comprehension tool. Such an anthropological framework might improve orientation in the clinical evaluation of chronic psychiatric disorders. Ethical implications resulting from the above approach are discussed, specifically those revolving around the concept of "problematic people". Based on these considerations, ten practical concepts concerning the recovery from chronic psychiatric illness are discussed.

Se presenta una síntesis de la historiografía del Bronce Final y la Edad del Hierro en las provincias de Gipuzkoa y Bizkaia (Euskal Herria), incluyendo los actuales programas de investigación. Proponemos también una periodización a la luz de las últimas investigaciones.

Evaluation of a three-year pilot project which aims to improve the quality of care of gerontopsychiatric patients. The project goal was to expand regionally organized outpatient services.We examined the profile (n=1004) and course (n=790) of patients treated at the Kaufbeuren regional Gerontopsychiatric Centre on the basis of sociodemographic, clinical, and care-requirement variables.There was a diagnostic predominance of dementia and depression. During the running time of the pilot project, only 13 % of the patients had to be admitted to inpatient care.The results suggest that the quality of gerontopsychiatric care improves through consistent efforts that are outpatient-oriented, mobile and multiprofessionally organized.

We investigate the sociomedical effect of the development of Kaufbeuren's Psychogeriatric Center through the last six years by means of administrative and medical care variables. Whereas the number of admissions remained relatively stable, the medium duration of stay continuously decreased from 181 to 31 days--above all in favour of dementia--and the number of days hospital stay by 692%. The diagnosis with the greatest variation in number was the increase of depressive disorders to 31% of all admissions in 1998. Whereas the hospitalisation of patients initiated by general practitioners decreased by 12%, in the same period of time the number of admissions from our psychogeriatric outpatients' department increased by 16%. The number of admissions suggested by homes of the aged decreased, whereas the admission by patients' own initiative increased continuously. While the number of patients living in residential care decreased by 11%, the rate of patients living with their partners at home increased by 7%. These results point to the efficiency of community and visiting psychogeriatric care from both a patients' and an economically point of view.

Discussing drug abuse and the concept of "low-threshold" in the treatment of drug addicts, we investigated development of detoxification strategies in the Department of Psychiatry at Kaufbeuren during the last 10 years. In the following we describe 4 different phases of this development: In 1988 we admitted 34 opiate-dependent patients treated in general psychiatric units. In 1998 almost, 1,000 drug addicts were treated in specialised drug detoxification units. In the beginning we realised opiate detoxification treatment without medication. In the second phase we treated the subjects symptomatically. During the last four years we have been offering homologue opiate withdrawal with L-polamidone. Last year we extended the opiate detoxification treatment to the day hospital and outpatient setting. The comparative examination of patient moods during the so called qualified and the homologue splitted opiate withdrawal treatment shows amazing similarities regarding the oscillations, leaving out of account that the remarkable worsening after one week of drug assisted detoxification was seen one week later in the homologue splitted detoxification group.

Ziel der vorliegenden Arbeit ist die Untersuchung a) ob sich Patienten mit einem festgestellten Konsilbedarf von Patienten ohne identifizierten Konsilbedarf unterscheiden, b) wie gut die Einschätzungen von Arzt, Pflege und Patient selbst hinsichtlich Symptombelastung und Versorgungsbedarf übereinstimmen, und c) ob Variablen auszumachen sind, die mit einem höheren Konsilbedarf assoziiert sind. Methode: Die Untersuchung wurde als naturalistische, monozentrische, prospektive Querschnittsstudie in einer internistischen Abteilung im Allgemeinkrankenhaus durchgeführt. Sie basierte bei einer Einwilligungsquote von 42% auf einer Stichprobe von N = 130 Patienten. Davon wurden n = 49 Patienten elektiv dem psychiatrischen Konsilarzt überwiesen und in der Vergleichsgruppe n = 81 Patienten aufgenommen, bei welchen kein Konsilbedarf seitens der behandelnden Internisten festgestellt wurde. Die psychische Belastung wurde mit validierten Selbstbeurteilungsskalen erhoben: Angst und Depressivität mit der „Hospital Anxiety and Depression Scale“ (HADS), die allgemeine psychopathologische Belastung mit der 9-Item-Version der „Symptom-Checklist“ (SCL-K-9), die Persönlichkeitsfaktoren mit dem „Big Five Inventory“ (BFI) und die Selbstwirksamkeitserwartung mit der „Generalisierten Selbstwirksamkeits-erwartung“ (GSW-6). Die Einschätzungen der somatischen und psychischen Belastung sowie des Konsilbedarfs wurden jeweils mit einer selbstentwickelten Skala erfasst. Unterschiede zwischen den Gruppen (Patienten mit und ohne Konsilbedarf) wurden mit t-Tests für unabhängige Stichproben und mit Chi-Quadrat-Tests ermittelt. Der Zusammenhang zwischen der Einschätzung des Konsilbedarfs aus allen drei Perspektiven und möglichen Prädiktoren wurde mit bivariaten Korrelationsanalysen untersucht, Unterschiede in Korrelationen wurden mit einer Fisher-z-Transformation überprüft. Im letzten Schritt wurde eine multivariate lineare Regressionsanalyse mit Rückwärtsselektion durchgeführt, um in unterschiedlichen Modellierungen mögliche Prädiktoren für die Einschätzung des Konsilbedarfs zu identifizieren. Ergebnisse : Die elektiv dem Konsilarzt überwiesenen Patienten waren vorwiegend weiblich und lebten häufiger alleine. Außerdem wiesen sie eine längere Liegedauer und mehr Krankenhausaufnahmen in den vorangegangenen 6 Monaten auf, nahmen mehr Psychopharmaka ein und zeigten insgesamt eine deutlich höhere psychische Symptombelastung - insbesondere mehr Angst- und depressive Symptome. Zudem gaben sie eine niedrigere Selbstwirksamkeitsüberzeugung an. Hinsichtlich der somatischen Belastung wurden die beiden Patientengruppen durch Konsilarzt, Pflege und Patient nicht unterschiedlich eingeschätzt. Dahingegen wurden die psychische Belastung und der Konsilbedarf der Konsilpatienten höher eingeschätzt als die der nicht konsiliarisch überwiesenen Patienten. Die Einschätzungen der somatischen und psychischen Belastungen und des Konsilbedarfs korrelierten jeweils signifikant in der paarweisen Betrachtung. Als wichtigster unabhängiger Prädiktor für die Einschätzung des Konsilbedarfs kristallisierte sich das Ausmaß der depressiven Symptomatik heraus.

Die vorliegende Arbeit geht der Frage nach, inwiefern die Wirksamkeit der stationär-psychosomatischen Behandlung zwei Jahre nach der Entlassung nachhaltig ist. Die vorliegende Multimomentstudie ist prospektiv und naturalistisch angelegt. Die primären Zielvariablen sind klinische und ressourcenbezogene, die sekundären beziehen sich auf die medizinische Inanspruchnahme. Die ursprüngliche Stich-probe von 250 studienadhärenten Patienten zum Entlasszeitpunkt reduziert sich auf 86 studienadhärente Patienten zwei Jahre nach der Entlassung und eine Analyse der Drop-outs (n=164) mit den studienadhärenten Patienten (n=86) zeigt, dass die verbliebene Stichprobe als repräsentativ für die gesamte Stichprobe gilt. Die Patienten werden hinsichtlich klinischer Variablen anhand standardisierter Erhebungsinstrumente untersucht (z. B. 10 Item Big Five Inventory und andere), die versorgungsmedizinischen Informationen (Arbeitsunfähigkeits-Tage, Krankenhaustage, Arztbesuche, Medikamente) werden global erinnert jeweils für das Jahr vor der Indexaufnahme und zwei Jahre nach der Entlassung. Zum Einsatz kommen unterschiedliche statistische Tests wie Shapiro-Wilk-Tests, Wilcoxon-Tests, Varianzanalyse, Chi-Quadrat-Tests, bivariate Regressionsmodelle, lineare multivariate Regressionsmodelle und logistische multivariate Modelle. Bei allen Tests werden Effektstärken ermittelt (Cramers V, Cohens d und Hedgesʼ g). Bei Varianzanalysen kommen Post-hoc-Scheffe-Tests zum Einsatz. Für die studienadhärente Stichprobe lässt sich feststellen, dass zwei Jahre nach der Entlassung alle Zielvariablen (Funktionalität, Depressivität, psychische Symptombelastung, somatische Symptombelastung, Verbitterung, Lebensqualität und Selbstwirksamkeit) sich statistisch signifikant und mit Effektstärken je nach Zielvariable zwischen 0,53 und 1,51 gebessert haben, insbesondere für Funktionalität, Depressivität, psychische Symptombelastung, Lebensqualität und Selbstwirksamkeit. Der Vergleich für die studienadhärente Stichprobe zwischen dem Entlasszeitpunkt und zwei Jahre nach der Entlassung zeigt, dass es keine statistisch signifikanten Unterschiede gibt, dass Depressivität, psychische Symptombelastung und emotionale Verbitterung weiter abnehmen und dass Lebensqualität und Selbstwirksamkeit zunehmen, allerdings fallen die Effektstärken zwischen 0,14 und 0,32 gering aus. Was die medizinische Inanspruchnahme angeht, reduzieren sich zwei Jahre nach der Entlassung, verglichen mit dem Jahr vor der Indexaufnahme, die Arbeitsunfähigkeitstage, die somatischen und psychiatrischen Krankenhaustage, die Arztbesuche und die Anzahl an Internistika und Psychopharmaka bei moderaten Effektstärken, die am höchsten sind für die Reduktion der Arbeitsunfähigkeitstage (0,55), Anzahl stationärer Tage in somatischen Abteilungen (0,56) und Abnahme von Arztbesuchen (0,74). Insgesamt ist der Anteil der Patienten, die zwei Jahre nach der Entlassung eine Besserung der klinischen und ressourcenbezogenen Zielvariablen aufweisen, höher als der Anteil der Patienten mit einer Verschlechterung, insbesondere für Depressivität und Selbstwirksamkeit, allerdings bewegt sich der Anteil der Patienten mit einer Verschlechterung zwischen 35 und 48 %. Die Ergebnisse der Untersuchung zeigen, dass zwei Jahre nach einer stationären psychosomatischen Behandlung die Patienten im Durchschnitt eine nachhaltige Besserung aufweisen und dass der Anteil der Patienten mit einer Besserung größer ist als derjenige mit einer Verschlechterung. Multivariate Regressionsmodelle zeigen etwas unerwartet, dass praktisch keine prognostischen Faktoren für die Besserung oder Verschlechterung zwei Jahre nach der Entlassung oder für das Ausmaß der Besserung auszumachen sind als Ausdruck einerseits von sehr individuellen Verläufen (interpersonell), aber auch dass die klassischen Zielvariablen nicht geeignet sind für akkurate Prognosen und es weitere sensible Variable zu untersuchen gilt.