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This paper describes the sociodemographic characteristics of 196 psychotic patients admitted to acute psychiatric wards in the UK, Denmark, Germany and Italy, with the aim of comparing comorbid with non-comorbid patients.It is a prospective field study with repeated measures at 1, 6 and 12 months. Patients were recruited from acute psychiatric wards in four European centres. They were grouped as comorbid or not on the basis of urine analysis. The Schedules for Clinical Assessment in Neuropsychiatry was used to provide a psychiatric diagnosis, and the Positive and Negative Symptom Severity Scale for further information on specific symptoms with results from the Fragerstrom test for nicotine dependence also reported.Comorbid patients were younger than those who were not but did not differ significantly in the other sociodemographic measures. Differences in sociodemographic characteristics of patients between centres were apparent. Comorbid patients had higher levels of positive and lower levels of negative symptoms than those who were non-comorbid. Differences were found in the patterns of drug use between comorbid patients who were using cannabis compared with those who were not.Cross-cultural differences in the sociodemographic characteristics of the comorbid patient population give us a better insight into this heterogenous group.

Context Alcohol dependence is a serious and common public health problem. It is well established that genetic factors play a major role in the development of this disorder. Identification of genes that contribute to alcohol dependence will improve our understanding of the mechanisms that underlie this disorder. Objective To identify susceptibility genes for alcohol dependence through a genome-wide association study (GWAS) and a follow-up study in a population of German male inpatients with an early age at onset. Design The GWAS tested 524 396 single-nucleotide polymorphisms (SNPs). All SNPs with P −4 were subjected to the follow-up study. In addition, nominally significant SNPs from genes that had also shown expression changes in rat brains after long-term alcohol consumption were selected for the follow-up step. Setting Five university hospitals in southern and central Germany. Participants The GWAS included 487 male inpatients with alcohol dependence as defined by the DSM-IV and an age at onset younger than 28 years and 1358 population-based control individuals. The follow-up study included 1024 male inpatients and 996 age-matched male controls. All the participants were of German descent. Main Outcome Measures Significant association findings in the GWAS and follow-up study with the same alleles. Results The GWAS produced 121 SNPs with nominal P −4 . These, together with 19 additional SNPs from homologues of rat genes showing differential expression, were genotyped in the follow-up sample. Fifteen SNPs showed significant association with the same allele as in the GWAS. In the combined analysis, 2 closely linked intergenic SNPs met genome-wide significance (rs7590720, P = 9.72 × 10 −9 ; rs1344694, P = 1.69 × 10 −8 ). They are located on chromosome region 2q35, which has been implicated in linkage studies for alcohol phenotypes. Nine SNPs were located in genes, including the CDH13 and ADH1C genes, that have been reported to be associated with alcohol dependence. Conclusions This is the first GWAS and follow-up study to identify a genome-wide significant association in alcohol dependence. Further independent studies are required to confirm these findings.

The inherent sequence diversity of the hepatitis C virus (HCV) represents a major hurdle for the adaptive immune system to control viral replication. Mutational escape within targeted CD8 epitopes during acute HCV infection has been well documented and is one possible mechanism for T-cell failure. HLA-B*08 was recently identified as one HLA class I allele associated with spontaneous clearance of HCV replication. Selection of escape mutations in the immunodominant HLA-B*08-restricted epitope HSKKKCDEL 1395-1403 was observed during acute infection. However, little is known about the impact of escape mutations in this epitope on viral replication capacity. Their previously reported reversion back toward the consensus residue in patients who do not possess the B*08 allele suggests that the consensus sequence in this epitope is advantageous for viral replication in the absence of immune pressure. The aim of this study was to determine the impact of mutational escape from this immunodominant epitope on viral replication. We analyzed it with a patient cohort with chronic HCV genotype 1b infection and in a single-source outbreak (genotype 1b). Sequence changes in this highly conserved region are rare and selected almost exclusively in the presence of the HLA-B*08 allele. When tested in the subgenomic replicon (Con1), the observed mutations reduce viral replication compared with the prototype sequence. The results provide direct evidence that escape mutations in this epitope are associated with fitness costs and that the antiviral effect of HLA-B*08-restricted T cells is sufficiently strong to force the virus to adopt a relatively unfavorable sequence.

Propofol is a widely used general anaesthetic with multisite mechanisms and especially ultrashort activation of certain central GABA-A receptors. Since its introduction into the market in the mid 1980s this is the seventh report on propofol dependence in the literature. The present case shows for the first time that craving for propofol can be quite intense and able to induce addictive behaviour.

Aims: To describe important non-biological factors wh ich infl uence the course of opiate addiction. Method: Studies were reviewed that present empirical results on the long-term course of opiate addiction, progress of opiate addicts during and after treatment, variables that predict remission and abstinence, comparisons of treated and untreated samples, and recovery from opiate addiction without formal help. Results: Opiate addiction is a chronic disorder with high mortality risk. The course of opiate addiction often consists of recurring sequences of addictive opiate use and abstinence. Treatment for opiate addiction, especially maintenance treatment, reduces opiate use; however, it is unclear how long after treatment the effects last. In treated samples, long-term opiate use can be moderately predicted from psychosocial factors, such as peer-group relationships, family problems, employment, and social support. Little is known about addicts who do not participate in treatment or who recover without treatment. Common factors that both treated and untreated addicts view as most important to their success are the social environment and their social life and daily activities. Conclusions: In view of the chronic course of opiate addiction and the phenomenon of spontaneous recovery without treatment, the role of drug-abuse treatment as an infl uencing factor would seem to require further clarifi cation. Current treatment programmes may leave unaddressed important factors that contribute to the recovery of drug addicts. Copyright © 2008 John Wiley & Sons, Ltd.

Background: In this report, we present the case of a patient with a relapse of schizophrenia following an episode of depression and increased anxiety after antiobesity treatment with rimonabant, a cannabinoid type 1 receptor antagonist. Case Report: After 4 weeks of treatment the patient developed psychiatric symptoms, i.e. depressed mood and elevated anxiety. Four months after the discontinuation of rimonabant, the patient presented with psychotic symptoms fulfilling ICD-10 criteria of paranoid schizophrenia. Antipsychotic treatment with quetiapine was initialized. A stable recovery took further 4 weeks in which combined treatment with quetiapine and ziprasidone was given. Conclusion: The course of the illness suggests that the continuous affective symptoms, which were most likely a side effect of rimonabant, may have triggered the psychosis analogous to the stress-diathesis model of schizophrenia. As a consequence, rimonabant may not be the first choice in obese patients with a history of schizophrenia due to a potentially increased risk of a relapse via an indirect mechanism.

Die heute weltweit akzeptierten Diagnosesysteme des DSM IV-TR der American Psychiatric Association (APA) und der ICD-10 der World Health Organization (WHO) verwenden mit den Begriffenschadlicher Gebrauch (ICD-10), Substanzmissbrauch (DSM IV) und Substanzabhangigkeit (ICD-10 und DSM IV) drei wesentliche Diagnosebegriffe, um die beiden hafigsten substanzinduzierten psychischen Storungen gruppenubergreifend beschreiben zu konnen.

Due to demographic trends and an aging cohort, which has higher rates of substance abuse than any previous generation, an increase in numbers of elderly alcohol abusers is predicted. The number of older alcohol dependent adults in Germany has been estimated to 400 000, the prevalence of risky use up to 2 million. Despite this reported high prevalence, patients over age 60 are seldom seen attending in- or outpatient treatment programs for alcohol dependence. In addition, little is known about this growing population of older adults with alcohol-related disease, e. g. regarding course of alcohol addiction, consumption patterns, somatic and mental comorbid disorders. This article shows the state of research in this area and reviews clinically-relevant concepts related to identifying, assessing and treating older adults with alcohol-related disability. Emphasis will be placed on the psychotherapy-methods of brief interventions and cognitive-behavioral therapy and on the pharmacological approaches for treating alcohol dependence with disulfiram, acamprosate and naltrexone.

Background In many countries, buprenorphine and methadone are licensed for the maintenance treatment (MT) of opioid dependence. Despite many short-term studies, little is known about the long-term (12-month) effects of these treatments in different settings, i.e. primary care-based (PMC) and specialized substitution centers (SSCs). Objectives To describe over a period of 12 months: (1) mortality, retention and abstinence rates; (2) changes in concomitant drug use, somatic and mental health; and (3) to explore differences between different types of provider settings. Methods 12-Month prospective-longitudinal naturalistic study with four waves of assessment in a prevalence sample of N = 2694 maintenance patients, recruited from a nationally representative sample of N = 223 substitution physicians. Results The 12-month retention rate was 75%; the mortality rate 1.1%. 4.1% of patients became “abstinent” during follow-up. 7% were referred to drug-free addiction treatment. Concomitant drug use decreased and somatic health status improved. No significant improvements were observed for mental health and quality of life. When controlling for initial severity, small PMC settings revealed better retention, abstinence and concomitant drug use rates. Conclusion The study underlines the overall 12-month effectiveness of various forms of agonist MT. Findings reveal relatively high retention rates, low mortality rates, and improvements in most 12-month outcome domains, except for mental health and quality of life. PMC settings appear to be a good additional option to improve access to MTs.

Rationale The endogenous alkaloid harmane is enriched in plasma of patients with neurodegenerative or addictive disorders. As harmane affects neuronal activity and viability and because both parameters are strongly influenced by intracellular pH (pHi), we tested whether effects of harmane are correlated with altered pHi regulation. Methods and results Pyramidal neurons in the CA3 field of hippocampal slices were investigated under bicarbonate-buffered conditions. Harmane (50 and 100 μM) reversibly decreased spontaneous firing of action potentials and caffeine-induced bursting of CA3 neurons. In parallel experiments, 50 and 100 μM harmane evoked a neuronal acidification of 0.12 ± 0.08 and 0.18 ± 0.07 pH units, respectively. Recovery from intracellular acidification subsequent to an ammonium prepulse was also impaired, suggesting an inhibition of transmembrane acid extrusion by harmane. Conclusion Harmane may modulate neuronal functions via altered pHi-regulation. Implications of these findings for neuronal survival are discussed.

In this investigation, the hypothesis was tested whether the selective dopamine D 2 /D 3 receptor antagonist tiapride is effective in maintaining abstinence after detoxification in alcohol-dependent patients. The rationale of the study was based on the relevance of the dopaminergic system for addictive behaviour as well as some preliminary studies. A multi-centre, randomized, double-blind, placebo-controlled, parallel-group study was conducted. A total of 299 detoxified alcohol-dependent patients (ICD-10: F10.2) received either tiapride (300 mg/d) or placebo over a 24-wk study period. Subjects with severe comorbid psychiatric disorder such as schizophrenia or Wernicke-Korsakoff syndrome were excluded. Primary outcome variable was the time to first relapse with relapse defined as any alcohol consumption after detoxification. Data analysis was done with Kaplan-Meier estimates with log-rank test (one-sided, p

Take-home dosages in maintenance treatment are of great therapeutic importance, but they include the risk of the substitute being distributed illegally. We reviewed the extent of consumption of illegally acquired medical opiates by 142 opiate- or poly-addicted patients consecutively admitted to a detoxification ward. 76 (53.5%) of them admitted to taking illegally acquired medical opiates, usually methadone, at least once. The cumulative duration was 30 days (median). Motivation was usually due to difficulties in acquiring heroin, however one third reported use in an attempt at self-detoxification or as transition before entering maintenance treatment. Maintenance patients were usually the source of the opiates. The results prove the necessity of stringent conditions for take-home dosages, and illustrate deficits in the health care system.

A controlled trial was conducted evaluating cognitive-behavioural group psychotherapy as a measure to reduce concomitant drug use in methadone maintenance treatment (MMT). 73 opiate addicts were randomly assigned to local routine MMT or to routine MMT plus group psychotherapy (20 sessions over 20 weeks). Psychotherapy was delivered by therapists according to a manual. Drug use (urine screen) was compared at onset of psychotherapy, end of intervention period (6 months after study onset), and 6 months later. Data analysis was done according to intention-to-treat principles. Results indicated that patients in the psychotherapy group (n = 41) showed less drug use than control subjects (n = 32). This group difference was statistically significant at 6-month follow-up (p = 0.02). These findings underscore the usefulness of group psychotherapy in MMT. The delayed effect is comparable to other studies evaluating cognitive-behavioural psychotherapy.

Background Recent epidemiological data show an increased trend of official estimates for syphilis infection in the general population. Many of the infected cases remain undetected leaving an underestimation of the true prevalence of syphilis in the general population, but also among subpopulations such as illicit drug users. There is limited epidemiological data published on the proportion and risk factors of syphilis infections associated with illicit drug abuse. Methods Illicit drug addicts (n = 1223) in inpatients units in Germany were screened (2000–01) for syphilis and interviewed regarding patterns of drug use and sexual behaviour. TPHA-test for initial screening and FTA-ABS-IgM test in TPHA-positive patients were used. Results In total, TPHA-tests were positive in 39 (3.3%) and 7 patients (0.6%) were IgM positive. The prevalence rate for syphilis in males was 1.9% and for women it was 8.5%. Female patients were 4.56 (CI 95% 2.37–8.78) times more likely to have a positive TPHA test than males. Sexual behaviours such as high number of sexual partners, sex for drugs/money, sex on the first day were associated with syphilis infection only in women. Females with frequent sex for drugs or money had 4.31 (CI 95% 2.32–8.52) times more likely a reactive TPHA test than remaining patients. Neither the sociodemographic factors nor sexual behaviour were statistically significant associated with syphilis infection among men at all. Conclusion Our data suggest the need for screening for syphilis among these illicit drug users in inpatient settings, in particular among sexual active women. This conclusion is corroborated by the finding of increasing numbers of syphilis infections in the general population. The identification of syphilis cases among drug addicts would give treatment options to these individuals and would help to reduce the spread of infection in this population, but also a spread into heterosexual populations related to prostitution.

Eine qualifizierte Behandlung von Patienten mit Abhängigkeitserkrankungen kann in einem spezialisierten tagesklinischen Setting als Teil der regulären psychiatrischen Krankenhausbehandlung durchgeführt werden. Es ist wenig über die psychiatrische und körperliche Komorbidität von Alkoholabhängigen in tagesklinischer Bedingung bekannt. Deshalb führten wir eine Querschnittstudie zur Erhebung der psychiatrischen und körperlichen Komorbidität von alkoholabhängigen Patienten (N = 184) in der Tagesklinik für Abhängigkeitserkrankungen des Zentrums für Psychiatrie und Psychotherapeutische Medizin, Bielefeld im Jahr 2002 durch. Es zeigte sich, dass mehr als die Hälfte aller Patienten eine weitere psychiatrische Erkrankung aufwiesen, während sie in der Suchttagesklinik behandelt wurden. Die häufigsten Zweitdiagnosen waren eine weitere Abhängigkeitserkrankung und affektive Störungen. Knapp die Hälfte der Patienten litt an einer somatischen Alkoholfolgekrankheit. Bei vier von fünf Patienten wurde eine weiterführende Suchttherapie im Anschluss an die tagesklinische Suchtbehandlung durchgeführt bzw. initiiert. Unsere Ergebnisse verdeutlichen die Notwendigkeit zur Diagnostik und Therapie komorbider psychiatrischer und körperlicher Erkrankungen bei Patienten in tagesklinischer Suchttherapie. Darüber hinaus kann geschlussfolgert werden, dass die tagesklinische Suchtkrankenbehandlung essentieller Bestandteil der Gesamtbehandlung von Suchtkranken auch mit komorbiden psychiatrischen und körperlichen Störungen darstellt.

Opiate addicts terminate inpatient detoxification prematurely in about 50% of treatment episodes. Premature termination of treatment is often considered to be motivated by intensive withdrawal symptoms. Therefore, the relation between discontinuing treatment and the intensity of withdrawal symptoms and heroin craving is investigated. 130 opiate addicts consecutively admitted to a detoxification ward daily assessed the intensity of withdrawal symptoms on the Short Opiate Withdrawal Scale (SOWS) as well as the intensity of heroin craving on a visual analogue scale. Withdrawal symptoms were treated by stepwise reduction of methadone and symptom-oriented medication. 66 patients (50.8%) terminated treatment prematurely. However, during the days preceding treatment termination, these patients did not differ from regularly detoxified patients assessed on corresponding days with respect to craving, and reported even less intensity of withdrawal symptoms. In conclusion, neither the intensity of withdrawal symptoms nor the intensity of heroin craving constitutes the primary reason for premature termination of detoxification.

In opioid addicted patients, respiratory regulation adapts allowing intake of otherwise lethal dosages of opioids. In contrast, little is known about cardiovascular regulation during chronic opioid receptor stimulation. We previously demonstrated that chronic mu-opioid receptor stimulation by methadone decreases resting muscle sympathetic activity (MSA). However, for short-term control of arterial blood pressure autonomic responses to arterial hypotension may be of greater importance. Accordingly, we tested the hypothesis that chronic opioid receptor stimulation attenuates muscle sympathetic and heart rate responses to arterial hypotension. Ten young patients (mean +/- SD, 30 years +/- 6) with a long history of mono-opioid addiction and under oral methadone substitution therapy (54 mg d(-1) +/- 31) for 12 months (+/-20) were studied. Peroneal MSA (microneurography) and heart rate responses to hypotensive challenges (sodium nitroprusside) were assessed in the awake state and compared with those of 10 matched healthy subjects. Effects of mu-opioid receptor blockade by naloxone (12.4 mg i.v.) were determined during propofol anesthesia. Chronic mu-opioid receptor stimulation markedly decreased the MSA response to hypotension (-0.5 units mm Hg(-1) +/- 0.2 vs. -2.0 +/- 1.8; p = 0.01) compared with healthy subjects despite similar arterial blood pressure and heart rate at rest. In contrast, the heart rate response to hypotension did not differ between addicted patients (6 ms mm Hg(-1) +/- 2) and healthy subjects (7 ms mm Hg(-1) +/-4). Opioid receptor blockade during propofol anesthesia markedly increased the MSA response to hypotension even beyond awake values (-1.2 units mm Hg(-1) +/- 1.1; p = 0.02 vs. awake) while the heart rate response remained unchanged. Thus, chronic mu-opioid receptor stimulation 1) results in uncompensated depression of cardiovascular sympathetic neural regulation, and 2) exerts differential effects on efferent sympathetic nerve activity to muscle and on heart rate control in response to arterial hypotension.

Various hypotheses try to explain the anticonvulsive and mood stabilizing effects of valproate. Among them, amplification of GABAergic inhibition and reduction of membrane excitability is favored. Here we show that superfusion with 0.1-1 mM valproate induced a moderate intracellular acidification of BCECF-AM-loaded CA3-neurons (hippocampal slices, guinea pig) which was measured as the difference between intracellular pH before (baseline pH(i)) and during valproate treatment (deltapH(i)). In two groups of neurons treated with 1 mM and 0.1-0.5 mM, deltapH(i) values amounted to 0.20 +/- 0.10 and 0.10 +/- 0.04 (deltapH(i) +/- S.D.), respectively, suggesting a dependence on the used valproate-concentration. DeltapH(i) did not correlate with the baseline pH(i). Furthermore, the acidification seems to be independent from an activation of postsynaptic GABA-A receptors, as it was not influenced by 0.1 mM picrotoxin. Since our previous studies clearly demonstrated a reduction of membrane excitability during moderate intracellular acidification, we suggest that the valproate-mediated intracellular acidification may substantially contribute to its anticonvulsive and mood stabilizing properties.

Background Mu-opioid receptor blockade by naloxone administered for acute detoxification in patients addicted to opioids markedly increases catecholamine plasma concentrations, muscle sympathetic activity (MSA), and is associated with cardiovascular stimulation despite general anesthesia. The current authors tested the hypothesis that the alpha2-adrenoceptor agonist clonidine (1) attenuates increased MSA during mu-opioid receptor blockade for detoxification, and (2) prevents cardiovascular activation when given before detoxification. Methods Fourteen mono-opioid addicted patients received naloxone during propofol anesthesia. Clonidine (10 microg x kg(-1) administered over 5 min + 5 microg x kg(-1) x h(-1) intravenous) was infused either before (n = 6) or after (n = 6) naloxone administration. Two patients without immediate clonidine administration occurring after naloxone administration served as time controls. Muscle sympathetic activity (n = 8) in the peroneal nerve, catecholamine plasma concentrations (n = 14), arterial blood pressure, and heart rate were assessed in awake patients, during propofol anesthesia before and after mu-opioid receptor blockade, and after clonidine administration. Results Mu-receptor blockade markedly increased MSA from a low activity (burst frequency: from 2 burst/min +/- 1 to 24 +/- 8, means +/- SD). Similarly, norepinephrine (41 pg/ml +/- 37 to 321 +/- 134) and epinephrine plasma concentration (13 pg/ml +/- 6 to 627 +/- 146) significantly increased, and were associated with, increased arterial blood pressure and heart rate. Clonidine immediately abolished both increased MSA (P < 0.001) and catecholamine plasma concentrations (P < 0.001). When clonidine was given before mu-opioid receptor blockade, catecholamine plasma concentrations and hemodynamic variables did not change. Conclusions Administration of the alpha2-adrenoceptor agonist clonidine decreases both increased MSA and catecholamine plasma concentrations observed after mu-opioid receptor blockade for detoxification. Furthermore, clonidine pretreatment prevents the increase in catecholamine plasma concentration that otherwise occurs during mu-opioid receptor blockade.

There are high interindividual differences regarding the intensity of withdrawal symptoms. in opiate addicts. This study was carried out in order to test whether the intensity of withdrawal is influenced by the 393T>C polymorphism of the GNASI gene. Only patients addicted exclusively to opiates were included. Thirty-three out of 39 patients undergoing inpatient detoxification treatment achieved a drug-free state. During the most intense period of withdrawal (stop of methadone and following days) TT homozygotes (n=4) had a significantly higher pulse rate (primary outcome criterion) than C-allele carriers (n=29). This study and a previous study about GNB3 825C> T underline the possible role of G-protein polymorphisms in the interindividual variability of opiate withdrawal.

Background —Opioid-addicted patients undergoing detoxification provide a unique opportunity to assess the effects of chronic opioid receptor stimulation on the sympathetic nervous system. We tested the hypothesis that chronic oral methadone intake decreases resting efferent sympathetic nerve activity to muscle (MSA). Furthermore, we assessed whether this effect is reversed by μ-opioid receptor blockade during antagonist-supported detoxification under general anesthesia. Methods and Results —Fifteen young patients (30±1 years old, mean±SEM) with a long history of mono-opioid addiction and under oral methadone substitution therapy (65±10 mg/d for 21±6 months) were selected. Peroneal MSA (microneurography) and catecholamine plasma concentrations (high-performance liquid chromatography) were assessed in the awake state and compared with those of age-matched healthy control subjects. The effects of μ-opioid receptor blockade by naloxone (12.4 mg IV) were determined during propofol anesthesia. Compared with healthy volunteers, resting MSA (4±2 versus 22±2 bursts/min, P P =0.01) were markedly decreased in addicted patients despite similar arterial blood pressure and heart rate. Opioid receptor blockade markedly increased MSA (5±2 to 24±3 bursts/min) and norepinephrine (49±12 to 305±48 pg/mL) and epinephrine (13±2 to 482±67 pg/mL) arterial plasma concentrations as well as mean arterial pressure (82±4 to 108±3 mm Hg) and heart rate (70±3 to 86±4 beats/min). Conclusions —Chronic μ-opioid receptor stimulation by methadone decreases resting MSA in humans.

This paper deals with the methodology of psychiatric case histories. Three types of case histories are differentiated. The didactic case history teaches about the typical aspects of a psychiatric disorder or treatment by using an individual patient as an example. In the heuristic case history the individual case gives rise to challenging established concepts or to generate new hypotheses. Such hypotheses drawn from inductive reasoning have then to be tested using representative samples. The focus of hermeneutic case histories is the significance of pathological behaviour and experience in the context of the biography of an individual patient. So-called psychopathographies of important historical figures can also be differentiated according to these types. Based on these methodological considerations, quality standards for the named types of case histories are stated.

MDMA (ecstasy) is a popular recreational drug. Similar to other EU countries,1, 2 recorded lifetime prevalence of MDMA intake in Germany in the 15–24 age range group is about 4–6%.1, 3 Although per...

The question of psychophysiological reactivity of borderline hypertensives is still controversial.Young males with borderline blood pressure levels and normotensive controls were recruited during a routine examination. Samples of study I comprised 19 subjects, samples of study II 18 subjects. Two stressors were presented (distressing movie, mental arithmetic), each followed by a recovery phase. Systolic and diastolic blood pressure, heart rate, and electrodermal parameters were assessed repeatedly.Borderline hypertensives showed greater reactions to stressors in systolic blood pressure only. Changes in percentage of baseline levels were essentially the same. Recovery after stress did not differ between groups.Only moderate support is given to the hypothesis that borderline hypertensives show increased and slowly recovering psychophysiological responses.

Given the contradictory reports concerning psychophysiological reactivity of hypertensives this issue was reexamined. In contrast to the large majority of studies, the hypertensive sample should not be made up of patients in medical care and the control group should be comparable in all relevant aspects other than blood pressure. Twelve male subjects with blood pressure values in the borderline range and 12 normotensive controls were recruited from a blood donation program. Experiments consisted of two parts with baseline, stress and follow-up. Stressors were a short distressing movie and mental arithmetic. Systolic and diastolic blood pressure (SBP and DBP), heart rate (HR), skin conductance level (SCL) and number of spontaneous electrodermal fluctuations (SF) were assessed in 2-min intervals, plasma adrenaline and noradrenaline once during baselines, stress 2 and follow-up 2. Hypertensives exhibited significantly higher SPB levels, and partially elevated values for DBP, HR and SCL. Response reactions to stressors, however, did not differ between groups. There was no evidence that psychophysiological adaptation during stress and recovery thereafter was impaired in hypertensives. Our results do not support the reactivity hypothesis of hypertension. Possible reasons for our failure to replicate findings from other studies are discussed.

Es ist der politische Wille, die Vergutungsform der Krankenhausbehandlung in Deutschland zu andern. Das bisherige Entgeltsystem ist ein Mischsystem aus tagesgleichen Pflegesatzen, Fallpauschalen und Sonderentgelten. In diesem System unterliegt die einzelne medizinische Leistung einer nicht transparenten Preisvielfalt im Vergleich verschiedener Krankenhauser. Hierbei ist insbesondere nicht bekannt, ob die aktuellen Preise sich durch Unterschiede in der Ergebnisqualitat begrunden lassen. Nach dem Gesundheitsreform-Gesetz 2000 soll ein pauschalierendes Entgeltsystem, wie es in anderen Landern bereits eingesetzt wird, auch in Deutschland eingefuhrt werden. Der Erlos (Preis) fur die Behandlung eines Patienten ergibt sich dabei wesentlich aus der zur Krankenhausbehandlung fuhrenden Hauptdiagnose, komplizierenden Begleiterkrankungen und der medizinischen Bezugsleistung. In Deutschland wird zu diesem Zweck das australische DRG-(Diagnosis Related Groups-)System adaptiert. Bislang sind stationare psychiatrische und psychosomatische Einrichtungen vom deutschen DRGSystem ausgenommen (§ 17b KHG), soweit aber Patienten mit psychiatrischer Hauptdiagnose in somatischen Einrichtungen behandelt werden, sind hierfur psychiatrische DRGs vorgesehen (siehe Definitionshandbucher unter www.g-drg.de). Dies ist insofern plausibel, als einige psychische Krankheiten (z. B. Delirien) gerade somatischer Behandlung bedurfen. Bei der Mehrzahl der Diagnosen ist es aber nur plausibel insofern, als ein erheblicher Anteil psychisch Kranker (insbesondere mit Depressionen und Angstkrankheiten) traditionell fehlalloziert in somatischen Einrichtungen behandelt zu werden pflegt. Hintergrund fur die Ausnahme psychiatrischer und psychosomatischer Einrichtungen ist die Schwierigkeit, anhand von medizinischen Merkmalen, insbesondere der Diagnose, die fur eine bestimmte Fallgruppe (Diagnosegruppe) entstehenden Behandlungskosten vorherzusagen. Anhand der erhobenen Merkmale sollten mindestens 50% der Kosten einer Fallgruppe vorhergesagt werden. Bei psychiatrischen Erkrankungen wird jedoch nur circa 10% der Varianz der Kosten aufgrund einfacher Patientenmerkmale erklart (Richter, 1999). Ein Grund hierfur sind regional unterschiedliche Versorgungsstrukturen, die wesentlich uber Dauer und Intensitat einer psychiatrischen Krankenhausbehandlung mitentscheiden (Fritze, 2002). In den USA hatte die Veterans Administration ein DRG orientiertes Finanzierungssystem fur psychiatrische Storungen 1984 eingefuhrt, aber schon 1988 wieder aufgegeben (Kunze, 2002). Grundsatzlich ist in Deutschland durch die Kategorien der PsychPV bereits ein gestuftes Finanzierungsmodell verfugbar. Es ist zum jetzigen Zeitpunkt nicht vorhersehbar, ob oder wie lange psychiatrische und psychosomatische Einrichtungen vom DRG-System weiterhin generell ausgenommen sind. Es konnte jedoch diskutiert werden, ob in Hinblick auf bestimmte psychiatrische Fallgruppen eine Vergutung im DRG-System moglich ist. Dies gilt insbesondere fur diejenigen Bereiche, in denen in einem uberschaubaren Zeitraum von einigen Wochen eine in Form eines Behandlungsprogramms strukturierte Therapie angeboten wird. Zu diesen Bereichen gehort die qualifizierte Entzugsbehandlung/Akutbehandlung bei Alkoholund Drogenabhangigkeit. Die Ziele, die Behandlungselemente und weitgehend auch die Behandlungsdauer sind (zumindest auf Landerebene) Editorial