Consultation-liaison Psychiatry In Germany, Austria And Switzerland (Advances in Psychosomatic Medicine)

Consultation-Liaison Psychiatry in Germany, Austria and Switzerland

Advances in Psychosomatic Medicine Vol. 26

Series Editor

T.N. Wise Falls Church, Va. Editors

G.A. Fava Bologna I. Fukunishi Tokyo M.B. Rosenthal Cleveland, Ohio

Consultation-Liaison Psychiatry in Germany, Austria and Switzerland Volume Editor

Albert Diefenbacher Berlin

11 figures and 24 tables, 2004

Basel · Freiburg · Paris · London · New York · Bangalore · Bangkok · Singapore · Tokyo · Sydney

Advances in Psychosomatic Medicine Founded 1960 by

F. Deutsch (Cambridge, Mass.) A. Jores (Hamburg) B. Stockvis (Leiden) Continued 1972–1982 by

F. Reichsman (Brooklyn, N.Y.) Library of Congress Cataloging-in-Publication Data A catalog record for this title is available from the Library of Congress.

Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents® and Index Medicus. Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. © Copyright 2004 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland) www.karger.com Printed in Switzerland on acid-free paper by Reinhardt Druck, Basel ISSN 0065–3268 ISBN 3–8055–7749–4

Contents

VII Foreword Wise, T.N. (Falls Church, Va.) IX Preface Diefenbacher, A. (Berlin) Consultation-Liaison Psychiatry 1 Consultation-Liaison Psychiatry in Germany Diefenbacher, A. (Berlin) 20 Consultation-Liaison Psychiatry in Austria Riessland-Seifert, A. (Vienna) 25 Consultation-Liaison Psychiatry in Switzerland Caduff, F. (Thun); Georgescu, D. (Windisch) General Section 31 Prevalence of Psychiatric Disorders in Physically Ill Patients Arolt, V. (Münster) 52 Mental Disorders in Primary Care Linden, M. (Teltow/Berlin) 66 Geriatric Consultation-Liaison Psychiatry in Germany Stoppe, G. (Basel); Staedt, J. (Berlin) 74 Screening Instruments for General Hospital and Primary Care Patients Wancata, J.; Weiss, M.; Marquart, B. (Vienna); Alexandrowicz, R. (Klagenfurt)

V

Special Section 98 Depression in Medical Patients Arolt, V.; Rothermundt, M. (Münster) 118 Alcohol-Related Interventions in General Hospitals in Germany: Public Health and Consultation-Liaison Psychiatry Perspectives Kremer, G.; Baune, B.; Driessen, M.; Wienberg, G. (Bielefeld) 128 Delirium in General Hospital Inpatients: German Developments Reischies, F.M.; Diefenbacher, A. (Berlin) 137 Suicide Attempts: Results and Experiences from the German Competency Network on Depression Lehfeld, H. (Nürnberg); Althaus, D.; Hegerl, U.; Ziervogel, A. (München); Niklewski, G. (Nürnberg) 144 Somatoform Disorders in Primary Care and Inpatient Settings Rief, W.; Nanke, A. (Marburg) 159 Therapeutic Approaches to Chronic Pain and the Role of the Consultation-Liaison Psychiatrist Radanov, B.P. (Zürich) 171 Are Sleep and Its Disorders of Interest for Psychiatric and Psychosomatic Medicine? Staedt, J. (Berlin-Spandau/Basel); Stoppe, G. (Basel) Debate Section 177 Consultation-Liaison Psychiatry and Psychosomatics in Germany: Futile Dispute or Lesson to Be Learned? Introductory Comment Diefenbacher, A. (Berlin) 181 Psychosomatic Medicine and Psychotherapy: On the Historical Development of a Special Field in Germany Deter, H.-C. (Berlin) 190 ‘Psychiatry and Psychotherapy’ and ‘Psychotherapeutic Medicine’. A Unique Situation in Germany Schmauss, M. (Augsburg) 192 Psychosomatic Medicine and Psychiatry: The German Situation Niklewski, G. (Nürnberg) 196 German Psychosomatic Medicine: An International Perspective Malt, U.F. (Oslo) 203 Author Index 204 Subject Index

Contents

VI

Foreword

It is fitting that the 26th volume in this series reviews Consultation-Liaison Psychiatry in Germany. In 1960 the first volume of Advances in Psychosomatic Medicine began with a statement from Prof. Jores: ‘The psychosomatic approach to disease is still fighting for genuine recognition and a firm place in the teachings of modern medicine’. Four decades later, the statement can still be considered valid. Nevertheless this is a very exciting time for consultation psychiatry in Germany as well as the rest of Europe. The vigorous role of the European Association of Consultation-Liaison Psychiatry and Psychosomatics underscores how significant a role this subspecialty plays in forming a bridge from psychiatry to the rest of medicine. The evolution of consultation psychiatry in Germany is unique within Europe due to the role of a distinct specialty of psychosomatics. Only because of pioneers such as Dr. Diefenbacher, has this distinct subspecialty of psychiatry itself become important in Germany today. While North American psychiatrists are familiar with the contributions of Griesinger, Kraepelin, Bonhoeffer and Schneider to psychiatry, they are rarely aware of the psychosomatic influence of German internists who founded psychosomatic divisions within their departments of medicine. Volume 11 of Advances in Psychosomatic Medicine reviews the German psychosomatic medicine model that utilizes internal medicine specialists and psychologists. Their clinical forums include dedicated inpatient units and outpatient clinics. Their theoretical model is strongly psychodynamic and psychophysiologic. The parallel medical liaison divisions were established in the United States, wherein internists, such as George Engel in Rochester and Franz Reichsman in Brooklyn, never achieved formal specialty status. Their role in the education of medical

VII

students, however spawned the biopsychosocial approach which continues today as an important message for health care personnel in providing comprehensive treatment. Within North America consultation-liaison psychiatrists evolved to carry on the biopsychosocial tradition and work as ambassadors of psychiatry to the rest of medicine. Dr. Diefenbacher trained with James Strain and returned to Berlin to lead this movement which is now a recognized subspecialty in the United States. This volume demonstrates his vigorous activity and tremendous achievements. It is thus that these dual traditions of a unique psychosomatic department and consultation-liaison psychiatry within traditional psychiatric departments lead to such interesting clinical and research experiences. Consultation-liaison psychiatry in Germany has received relatively less attention than psychosomatic medicine. To this end, it is a great delight to have this volume that reviews a wide variety of important topics that have become a focus in Europe, North America, Australia and Japan. The concluding section on the debate ‘The relationship of consultation-liaison psychiatry and psychosomatics in Germany’ should be a fascinating topic for those not familiar in the nature and history of these two parallel disciplines. Prof. Malt’s international perspective makes this a particularly valuable section. In conclusion, this 26th volume of Advances in Psychosomatic Medicine represents the extraordinary advances we have made in our field. Although Prof. Jores’ hopes have not been fully realized, we are far closer to them now than in 1960. Thomas N. Wise Series Editor

Foreword

VIII

Preface

As psychiatry is no longer confined to state mental asylums but has become integrated into general hospitals, consultation-liaison (C-L) psychiatry is increasingly being regarded as its foothold within the realm of somatic medicine. The beginnings of the field were in the USA during the 1920s and 1930s [1], but nowadays it can be regarded as an international approach to the treatment of patients with psychiatric and somatic comorbidity [2]. The publication of this volume coincides with the publication of the first German textbook on Psychiatry within Medicine, the first of its kind written in the German language [3]. It attempts an overview of the development of C-L psychiatry in Germany, Austria and Switzerland. First, the aspects of C-L psychiatric service delivery are presented, beginning with reviews of national developments within the 3 countries. Psychiatric comorbidity in general hospital inpatients as well as mental disorders in the outpatient setting are discussed, followed by psychogeriatric C-L service delivery in elderly patients. The section is concluded by an overview of screening instruments for psychiatric disorders in somatically ill patients. The Special Section features disorders relevant to C-L psychiatry, beginning with depression, alcohol abuse, and delirium, such disorders being crucial to inpatient (as well as outpatient) C-L service delivery. The chapter on suicide attempts delineates part of a nationwide effort in Germany to establish so-called competence centers for several psychiatric disorders, such as schizophrenia, dementia and, of special relevance to C-L psychiatry, depression and suicide. An important topic of outpatient service delivery, somatoform disorders, is presented by medical psychologists: The field of behavioral medicine that is

IX

about to emerge, at least in Germany, has been pushed forward mostly by this non-physician professional group [4]. The section is concluded by the topics of chronic pain syndromes and sleep disorders. Finally, there is a Debate Section. Non-German readers are usually not aware that in Germany there are two distinct board-certified physician specialties dealing with patients with psychiatric illnesses, usually referred to as ‘psychiatrists’ and ‘psychosomaticists’. Hence, C-L services in some hospitals may be provided by two different physician-run service types, e.g. ‘C-L psychiatry’ (what this book is about) and ‘C-L psychosomatics’. This special German way is not well understood abroad. The discussants, psychiatrists, as well as psychosomaticists, German as well as international, provide succinct viewpoints of this situation from different angles to enable the reader to form his or her own opinion about whether, or to what extent, this dichotomy is helpful or not in the practical clinical care of patients with psychiatric and somatic comorbidity. Finally, I would like to thank Thomas Wise and Steven Karger for the invitation to publish this book; Thomas Nold and the staff of Karger Publishers for their editorial assistance and, with special emphasis, my co-workers, Hans Hübner, MD, for translating and editing several chapters, and Kerstin Herrmann for her, as usual, exemplary way of running the secretariat. Albert Diefenbacher

References 1 2 3 4

Lipowski ZJ: Consultation-liaison psychiatry: The first half century. Gen Hosp Psychiatry 1986;8:305–315. Fukunishi I (ed): Consultation-Liaison Psychiatry in Japan. Adv Psychosom Med. Basel, Karger, 2001, vol 23. Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin – Konsiliarpsychiatrie, -psychosomatik und -psychotherapie. Darmstadt, Steinkopff, 2004. Ehlert U (ed): Verhaltensmedizin. Heidelberg, Springer, 2003.

Preface

X

Consultation-Liaison Psychiatry Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 1–19

Consultation-Liaison Psychiatry in Germany Albert Diefenbacher Abteilung für Psychiatrie und Psychotherapie, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Deutschland

Introduction

Consultation-liaison (C-L) psychiatry is the term used to describe the psychiatric care of patients who are primarily in medical treatment for somatic reasons in non-psychiatric departments of a general hospital or in ambulatory care of a non-psychiatric physician. ‘Consultation psychiatry’ means that the psychiatrist sees such patients only when called upon to give advice to the consultant, whereas ‘liaison psychiatry’ denotes a more direct involvement in the treatment of physically ill patients with psychiatric comorbidity, assuming more responsibility in joint patient care with the psychiatrist, e.g. having the prerogative of seeing patients admitted to an internal or surgical ward without being specifically endorsed to do so in every given case anew, as well as starting and following through psychiatric or psychotherapeutic treatments. In everyday practice there is a continuum between consultation and liaison approaches and a worldwide consensus has developed to use the phrase ‘consultation-liaison psychiatry’ (or C-L psychiatry), with the notable exception of Great Britain, where ‘liaison psychiatry’ is used for both approaches [1]. In this chapter, the history and current status of C-L psychiatry in Germany are described.

History of C-L Psychiatry in Germany

In Germany, as in many countries, the integration of psychiatric departments into general hospitals has paved the way for psychiatry to be increasingly taken

note of as a discipline by medical-surgical physicians and patients alike. This integration is the cornerstone of C-L psychiatry. Beginnings The first comprehensive report on the problems of integrated psychiatric services in a general hospital in the Federal Republic of Germany was presented by Radebold [2] from Berlin in 1971, and is reminiscent of the work of Henry [3] in the USA in 1929. It describes the path from initial opposition to a growing acceptance by the staff of somatic departments wherein, as important factors, elements of liaison activity are mentioned such as joint visits at the bedside. A first systematic overview of ‘practical’ consultation psychiatry was published in the second edition of the German handbook of ‘Contemporary Psychiatry’ in 1975 by Bönisch and Meyer [4] under the title ‘Extreme situations of medical treatment’. It entails the expectation for an increasing importance of psychiatric liaison activity in a general hospital in view of the technology of modern medicine. The first ‘conceptual presentation’ of modern consultation psychiatry in Germany stems from Böker [5–7] who, in a series of articles, attempted to delineate tasks and opportunities for psychiatry within the general hospital. He pointed out that the life-event crisis of acutely somatically ill individuals triggered by a faulty balance of habitual social communication in connection with, e.g., myocardial infarction or hepatitis or generally through the ‘entry into the technical labyrinth of the diagnostic mill’, represents a serious stress of adaptation for every sick individual. This may lead to severe psychopathological reactions especially in connection with ‘fears of being overwhelmed’ through the complex, increasingly anonymous diagnostic and therapeutic technology of the hospital environment, which shows characteristics of a total institution, the administrators of which have lost sight of the ‘anthropological framework’ (a phrase coined by the German medical historian Schipperges) of the encounter between patients and hospital employees [7]. With reference to US-American models and against the background of his own consultation activity at the Mannheim University Hospital in Baden-Württemberg, Böker postulated that it is not sufficient for modern psychiatry ‘to focus on the singular patient isolated from his environment. The traditional pattern of occasional visits by the specialist at the bedside appears not to be sufficient for the new tasks’. Collaboration with all workers in the hospital therefore was not a fashionable demand but an absolute necessity because it offered information for a more precise diagnosis and efficient therapy. In accordance with this paraphrased definition of psychiatric C-L activity, the psychiatric consultation team, which in Mannheim also included a social worker and a nurse, also increasingly offered services to the employees of the hospital and with this, a psycho-hygienic contribution, e.g., in the form of Balint groups [7].

Diefenbacher

2

Wherever, rarely enough in those days, psychiatric departments were installed in general hospitals, the opportunity to call a psychiatrist as a consultant was frequently used by the somatic disciplines. In 1970 at Steglitz University Hospital in Berlin, which at the time did not have a psychiatric department of its own, a psychiatric consultation service was created which, 6 years later, encompassed a volume of 1,571 initial consultations and 2,687 repeat consultations for 1,300 somatic beds [8]. ‘Psychiatrie-Enquête’ and the Implementation of Psychiatric Departments in General Hospital in Germany Different from the USA, where the establishment of psychiatric departments in general hospitals was already started to a larger extent in the 1920s [9], the establishment of such departments in general hospitals in Germany was an iron too hot to handle until the 1960s [10]. In the year 1970 there were just about 21 departments of this kind [11]. In view of the minimally satisfying situation at the large state mental hospitals, this started to change when, at the initiative of the German federal government, an expert commission was created to make an inquiry into the care of psychiatric patients in the Federal Republic of Germany at the time and make suggestions for improvement (this inquiry is one of the cornerstones of modern psychiatry in Germany and is widely known under the name of ‘Psychiatrie-Enquête’) [Niklewski, pp 192–195]. Among other things it was criticized that inpatient psychiatric treatment was almost completely absent near or close to communities (which meant that institutes could be reached with a maximum commute of 1 h using public transportation) [12]. The remote location of psychiatric hospitals interfered with the collaboration with other medical disciplines, which, due to the fact that approximately one third of psychiatric inpatients suffer from additional somatic illnesses, was tantamount to a loss of quality of care [13]. As a solution to the problem, the expert commission urgently recommended the establishment of psychiatric departments in general hospitals. In this context the implementation of permanent psychiatric C-L services was explicitly demanded for every larger hospital in which patients were treated after a suicide attempt [12]. Similarly the opportunity for a psychiatric-psychotherapeutic primary prevention of risk groups in somatic medicine was also recommended as an important service of the psychiatric consultation services: ‘A psychiatric and psychotherapeutic primary prevention for risk groups and for psycho-social stress situations in the area of somatic medicine should be further expanded. Within this realm belong the care of hospitalized children and adults, accident victims as well as the incapacitated or chronically ill. Large psychological problems also occur in the context of dialysis, the treatment with cardiac pacemakers, transplantation surgery and the aseptic isolation in the care of extensive burns. The increase in technology in medicine as is

Consultation-Liaison Psychiatry in Germany

3

practiced in intensive care units (ICU), the dependence of many patients on complicated, frequently poorly understood instruments, their forced isolation and immobility represent a significant psychic stress situation and make preventive care necessary which would be best handled by psychiatric-psychotherapeutic or psychosomatic departments at general hospitals’ [12, p 392].

In a status report 5 years after the ‘Psychiatry-Enquête’ Häfner [14] stressed that ‘the psychiatric department in a general hospital is not only a prerequisite for the elimination of the separation of inpatient psychiatric care. It also provides the mentally ill with simultaneous somatic illness a collaborative treatment through other medical disciplines and the somatically ill a psychiatric therapy of high standards’ [p 17].

The important role of the general hospital and local psychiatric consultation and emergency services as a path of entry into inpatient psychiatric care is emphasized by the example of the city of Mannheim in Baden-Württemberg [15]. In order to document the development which was initiated by the ‘Psychiatrie-Enquête’ and in order to check on the transformation as well as to take into account newer developments, a psychiatric model program was initiated by the German government in 1979. In its final report the expert commission focused again on the care of mentally ill in the general hospitals: ‘Through the community-centered location and also physical integration into the general hospital, the hurdle of admission is much lower than with regard to specialized psychiatric hospitals. … This is of significant importance because many patients after suicide attempts, alcohol- and drug-dependent individuals as well as old people with psychic disorders are treated in medical-surgical departments in general hospitals’ [16, pp 280–281].

In view of the high prevalence of mental disorders on medical-surgical units, the expert commission did not intend to establish additional psychosomatic/ psychotherapeutic inpatient units at general hospitals, but suggested another mode of cooperation: ‘Differing models are in existence: (1) the consultation model, (2) the liaison model and (3) the workgroup model (extended model of the liaison service that provides continuity). The consultation model is considered among experts as the least convincing because unrealistic faulty expectations give rise to later disappointment. For this reason the expert commission recommends the establishment of liaison services at general hospitals staffed by specialists. Under this term one understands physicians with specific areas of continuous education in psychotherapy or psychoanalysis who have qualified knowledge of the respective medical discipline to be served’ [16, pp 554f].

The commission pointed out that a (psychosomatic) liaison service close to a medical unit at the University of Ulm in Germany reached a relative consultation rate of 11% of all patients, whereas a year later a consultation project

Diefenbacher

4

away from a medical unit was only utilized by 4% of all patients at the same location [17]. Liaison models with part-time employment of medical psychotherapists who otherwise work out of their own ambulatory office were considered especially worthwhile under the aspect of continuity of care. From other psychiatrists, however, it was pointed out that in view of the faulty placement of 51.4% mentally ill patients in somatic hospitals, as was true for patients insured by the Allgemeine Ortskrankenkasse (Germany’s largest medical insurance organization) in Bavaria, from a specialty point of view these mentally ill should be treated in psychiatric institutions and that the contributions of C-L psychiatry in their care should not be overestimated [18, 19]. In the Wake of the ‘Psychiatrie-Enquête’ A survey of psychiatric units in general hospitals at the beginning of the 1980s showed the considerable extent of C-L psychiatric activities: for a typical psychiatric department with approximately 70 beds in a medium-sized hospital, one could assume approximately 600 consultations per year. In a large medical center, the frequency of consultations was found to be up to 4,000 per year [20]. But scientific contributions to consultation psychiatric themes remained rare until the end of the 1980s [21, 22]. They were confined mostly to the clinical aspects of singular disease entities, where the necessity of interdisciplinary studies, especially in areas of oncology, hemodialysis and heart surgery, with respect to the occurring psychopathological syndromes and psychological problems was proposed [23–26]. Occasionally an orientation towards the USAmerican model of C-L psychiatry was suggested [24]. Contributions on the organization and functioning of psychiatric consultation services remained rare [21]: some described the functioning of singular C-L psychiatric services [27] or investigated aspects of C-L service delivery in the context of models of inpatient crisis intervention in general hospitals [28]. A remarkable exception was the aftercare of suicidal patients: a series of publications urgently demonstrated the necessity of continuous aftercare of patients after suicidal attempts. This care seemed to be given most reliably in the context of a psychiatric liaison service which works with in- as well as outpatients [29, 30]. A survey performed in 1988–1989 attempted to give a representative overview on the extent of psychiatric, psychosomatic and medical psychological C-L activity in the Federal Republic of Germany. It turned out that 98% of the psychiatric departments at general hospitals offered C-L services. Predominantly (in 84%) a pure consultation model was used, and in 14% a C-L mode was practiced. The psychotherapeutic orientation at general hospitals was psychodynamic, only rarely behavioral therapeutic. An average of 29 h of C-L activities per week accumulated [31].

Consultation-Liaison Psychiatry in Germany

5

C-L Psychiatry in the German Democratic Republic In the former German Democratic Republic (GDR) C-L activity was practiced by neuropsychiatrists, whereas medical specialists for psychotherapy and inpatient psychosomatic-psychotherapeutic facilities, which also were located in centers for internal medicine, were utilized more rarely for C-L services [30]. A more biologically oriented psychiatric approach, with additional responsibility for neurological consultations, was the norm: The contributions of a workgroup around Greger in Gera belong to the few published reports on consultation psychiatric activity in emergency services at all [31, 32].

Recent Developments

Since the beginning of the 1990s the interest in C-L psychiatric questions has increased both in the university-based as well as general hospital-based psychiatric departments. A series of reports about the activities of psychiatric C-L services in Germany was published (table 1). Epidemiological studies regarding the prevalence of psychiatric comorbidities of internal medical and surgical patients were performed with a special focus on alcohol-dependent and geriatric patients [Arolt, pp 31–51]. In total an increase in academic involvement was observed in aspects of the care of special patient groups in the general hospital with increased mental comorbidity, e.g. geriatric [46–48; Stoppe and Staedt, pp 66–73; Reischies and Diefenbacher, pp 128–136], alcohol-dependent individuals [49; Kremer et al., pp 118–127], neurological-epileptological [50, 51], pain [52, 53] and oncological patients. For the care of the latter groups significant contributions also came from medical psychological services [54–56]. As the number of psychiatric departments in general hospitals doubled from 61 in 1979 to 125 in 1995, C-L psychiatric services increasingly lived up to the function of making the field of psychiatry with its diagnostic and therapeutic possibilities transparent for the somatic disciplines, also in order to reduce prejudice against the mentally ill and the (pessimistic) ignorance about psychiatric treatment success [57]. The workgroup of the directors of psychiatric departments at general hospitals (http://www.ackpa.de) has established a solid position for the theme of consultation psychiatry in the context of its annual meetings [58]. Since 1992 at the scientific meetings of the German Society for Psychiatry, Psychotherapy and Neurology (‘Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde’, DGPPN), a C-L psychiatric symposium has regularly been held [59]. Consultation psychiatry and psychotherapy are receiving increasing attention in psychiatric textbooks [60, 61]. Concise guides on ‘Practical Consultation Psychiatry and Psychotherapy’

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have been published [62, 63], as well as a comprehensive textbook [64]. With increasing tendency, consultation psychiatry is being conceptualized as part of a community psychiatric care system and emphasis is being placed on the filter function of the general hospital and implicit role of psychiatric consultation services in the diagnosis of heretofore unrecognized treatable mental disorders [36, 65, 66]. Also, reports on C-L activities performed by departments of child and adolescent psychiatry, which is a separate physician specialty in Germany, have been published [67, 68]. In a memorandum, the German Psychiatric Association (DGPPN) emphasized the importance of psychiatric-psychosomatic C-L services for the general hospital [69].

Other Approaches to C-L Service Delivery in Germany

It is not well understood that ‘psychiatry and psychotherapy’ and ‘psychotherapeutic medicine’ have in fact been two separate physician specialties in Germany since 1992. This two-stranded system has a long history. Other than in the USA [70] for instance, classical psychosomatic thinking in Germany largely developed, though not exclusively [22, 71], outside academic psychiatry, mostly in cooperation with some interested internal medical departments [72] (for further clarification see the chapters in the Debate Section of this volume). Psychosomatic Medicine and C-L Psychiatry in Germany Outside Germany, for many years there was the erroneous assumption that German psychosomatic medicine was responsible for C-L service delivery in general hospitals. In fact, this was never the case, and for a long time those psychosomatic specialists who were primarily active in C-L work even expressed their disappointment that ‘the psychosomatic consultation servicee … has to be regarded in several ways as the neglected child of psychosomatic medicine. Therefore many colleagues are glad when they can delegate this work which often appears senseless, frustrating, and does not seem to lead to much feedback’ [73].

Wirsching and Herzog [74] emphasized that the ‘so far rather problematic perhaps even neglected area of cooperation of psychosomatic medicine with general clinical medicine in so-called consultation-liaison services (experienced) an unexpected boost’ only at the end of the 1980s. Recently, guidelines for C-L psychosomatics and psychotherapy have been published [75]. Discussions between C-L psychiatrists and their psychosomatic counterparts in Germany remained rare during that period: single psychiatrists tried to define

Consultation-Liaison Psychiatry in Germany

7

Diefenbacher

8

23.9

25.5 (neurology, epilepsy, neurosurgery)

7.7

5.8 (gynecology)

Proportion of referrals from other specialties, %

31

40.7 13.2

29.3

Proportion of referrals from surgical specialties, %

23.5

About 3–5a

Deister [38] Bonn

20.7 34.8

58.8

Proportion of referrals from general medicine, %

Diagnoses, % Organic psychoses Neurotic, adjustment and somatoform disorders, personality disorders Affective disorders

3.6

Arolt et al. [37] Lübeck

Rate of referral to consultation psychiatric services, % of all admissions

Location of study:

15

13.9

30.2 19.5

–

20.3b (neurology)

11.8 63.6c

–

–

About 1e

Saupe and Diefenbacher Berlin [40] (2 hospitals)

11.6

29

2

Kapfhammer [39] Munich

16.9

23.3 32.3

17

12.5

47

1.52

Fiebiger et al. [41] Görlitz

9.9

49 44.7

4.3 (neurology)

25.5

58.7

2

Fleischhacker et al. [42] Innsbruck

–

About 2.4f

29.3

20.1 –

About 18

About 1 About 72h

–

–

About 10f

About 2.5f (dermatology)

About 1

Knorr et al. [44]g Berlin

0.8

Herzog et al. [43] Graz

4–62

1.6–57 2–48

1–26-9 (gynecology)

7–34.7

47.7–90

0.5–9.1

Hengeveld et al. [45] Literature reviewi

Table 1. Consultation psychiatry in general hospitals in Germany and Austria (with permission from Diefenbacher et al. [35])

Consultation-Liaison Psychiatry in Germany

9

– – –

19.8 –

–

–

28.7

–

–

41.3

25.1

–

28.3

19.1

24.6

–

– –

14.4

5.6

41.8

27.4

5.6

10.3

11.5 42.2

10

18

3 57

7

14

69

57e –

–

23.3

–

17.4

–

28.3 –

24.7

15.7

–

–

–

–

– –

–

26

72.4

9

7.9

b

General medical, surgical and neurological patients. Outpatient pain clinic and physical medicine 14.3% (liaison work). c Of these, 21.7% were somatoform disorders. d Data from 2 hospitals: Urban-Krankenhaus and the Universitätsklinikum Rudolf Virchow of the Freie Universität (FU) in Berlin. e Data only for the Universitätsklinikum of the FU in Berlin. f Percentages each refer to all hospital admissions. g Psychosomatic medicine consultation service of the Universitätsklinikum Benjamin Franklin of the FU in Berlin. h Somatoform disorders about 16%, organic mental disorders (ICD-10F5) about 22%. i Each entry gives the range of percentages in the reviewed publications.

a

Reasons for referral, % Suicide attempt/ suicidal ideation Addiction Acute psychiatric symptoms Physical symptoms with no organic explanation

Treatment recommendations, % Psychotherapeutic measures Psychotropic medication Transfer to a psychiatric ward

Substance-related disorders

55

0 31

2

3

About 2

12–22

– –

5.1–47

5–31

14–74.5

–

0.6–28

Table 2. Comparison of psychiatric and psychosomatic C-L services in Germany C-L services psychiatric Relative number of consultations Deliberate self harm Substance abuse Unexplained physical symptoms1, % Cancer1, % Delirium/dementia1, %

psychosomatic

8

1

Lübeck [37]

⫹⫹ ⫹⫹ 21

– – 48

[35, 44, 79] [35, 44, 79] ECLW [79]

12 22

6 5

ECLW [79, 77] ECLW [44, 79]

1 NB: Percentage of total number of patients referred to each kind of service, respectively (see also table 1 and figure 1).

their relationship to psychosomatic medicine in Germany, e.g. Blankenburg [22] who would have preferred to ‘see psychiatry as a subdiscipline in a larger psychosomatic field’, or Böhnisch and Meyer [76] who reported under the title ‘Psychosomatic medicine in clinical medicine’ on psychiatric-psychotherapeutic experiences with severe somatic diseases. But this did not initiate deeper cooperation. Only within the European Consultation Liaison Workgroup (ECLW) study, did an increased exchange of ideas take place, and some comparative studies about the activity of psychiatric and psychosomatic C-L services were presented [44, 77] (table 2). Of note, while nearly all university hospitals had both psychiatric as well as psychosomatic departments, this did not hold true for non-university general hospitals where there were (and still are) much more psychiatric than psychosomatic departments. The last survey (carried out by the end of the 1980s) found 11 psychosomatic as opposed to 78 psychiatric departments [31]. It was estimated that 95% of existing general hospital C-L services were provided by psychiatry and, with some overlap, 20% by psychosomatic specialists [78]. In the ECLW study, a cluster analysis on variations in the characteristics of patients referred to 56 C-L services in 11 European countries yielded two types of service delivery: one ‘psychosomatic’ and one ‘psychiatric’ [79, 80]. While the German psychiatric C-L services fit well into the European ‘C-L psychiatric cluster’, genuine psychosomatic service delivery remained a peculiarity of

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F0 (Organic mental syndromes) C-L psychiatry

F1 (Substance abuse)

C-L psychosomatics F2 (Schizophrenia) F3 (Affective disorders) F4 (*) F5 (**) F6 (Personality disorders) 0

10

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*Neurotic, adjustment and somatoform disorders. **Eating disorders, non-organic sleep disorders, sexual dysfunctions, etc. Fig. 1. Comparison of a psychiatric (280 patients) and a psychosomatic (100 patients) C-L service in Berlin [44].

the German psychosomatic C-L services, with such services virtually seeing no deliberate self-harm patients, only a small percentage of substance abuse patients and a very low percentage of patients with organic mental syndromes (table 2). Their main focus was dealing with unexplained physical complaints which, on the other hand, was also an important function of German psychiatric C-L services [37, 39, 81] (fig. 1). Psychosomatic and psychiatric C-L services differ with regard to the amount of psychotropic drug prescription for similar diagnostic groups, but the few comparative studies did not include measures of severity of the patients treated [44, 82]. While one might assume that the coexistence of both service types at a number of hospitals in Germany should have paved the way for comparative outcome studies of different approaches in a natural setting, this unfortunately was not the case. There are no scientific studies on differential indications for referrals to either service [37]. Patterns of respective referrals develop in everyday clinical practice, according to the given quality of cooperation of both services. This means, on the other hand, that mostly consultees do not have sound criteria on how to decide which way their referrals should go, with the consequence of getting double consultations, or switching C-L services according to whether one is satisfied with a given recommendation or not, with the ensuing risk of conflicting treatment recommendations and the prolongation of length of stay [36].

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Medical Psychological C-L Service Delivery In the last few years, medical psychology has become more visible in Germany, promoting behavioral medicine approaches in the treatment of patients with psychiatric and somatic comorbidity, or unexplained physical symptoms [Rief and Nanke, pp 144–158]. Their part still is small by comparison and limited mainly to university-based institutions [31]. The results of medical behavioral interventions tried out by medical psychological C-L services [83] are promising: medical behavioral approaches in the areas of treatment of patients with chronic pain and alcohol addiction are used with increasing frequency in the area of C-L psychiatry [49, 54–56].

Future Developments

DRGs and C-L Psychiatry As of 2004, a diagnosis-related group (DRG) reimbursement system will be introduced in all medical-surgical departments in Germany. For the time being, psychiatric and psychosomatic departments will be DRG-exempt [36, 66, 84]. Despite the urgent demands by several psychiatric associations, it is still not clear how psychiatric C-L services will be reimbursed under the DRG conditions [84, 85]. Of note, a recent study performed by the ‘Deutsche Angestellten Krankenkasse’, Germany’s second largest medical insurance organization, basically confirmed the data quoted above from the ‘Allgemeine Ortskrankenkasse’ [18]: 32.4% of their members receiving a main psychiatric diagnosis were admitted to the somatic wards of general hospitals (and not into specialized psychiatric care), most of them (19.3%) to internal medical wards [66]. Not surprisingly, the three largest groups came from the ICD-10 F10 (alcohol-related), F0 (organic mental syndromes), and F4 (neurotic, adjustments and somatoform disorders) diagnostic categories. These authors suggest an increase in psychiatric-psychosomatic C-L service activities, with special emphasis on and the introduction of short-term crisis intervention techniques for alcohol-abuse patients on internal medicine wards, but they are skeptical whether the DRG system, as it stands, would offer any incentive to do so [66]. Nevertheless, the fact that one of the largest health care insurance companies in Germany has discovered the probable benefits of C-L service delivery for the comorbid somatic-psychiatric patient in the general hospital is promising. Other Venues of C-L Service Delivery General hospitals in Germany without a psychiatric inpatient department are mostly served by ambulatory care office-based psychiatrists who usually do consultation work (and not a liaison approach) on a contract basis. As still most

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office-based psychiatrists are also trained in neurology, they usually perform both psychiatric and neurological consults, which is quite helpful, e.g., in the treatment of pain patients [86; Diefenbacher, pp 177–180]. This form of service delivery may gain further importance as, under a new legislation since January 1, 2004, small scale projects subsidized by health care insurance companies may help to implement C-L service delivery by office-based psychiatrists in hospitals without psychiatric departments. This should bridge the still existing gap between inpatient and outpatient care in Germany and provide the means for a continuous service delivery between hospital and private practice sector for patients with somatic and psychiatric comorbidity (Munzel H, personal commun.). Due to demographic development, the number of people living in homes for the elderly and nursing homes is steadily increasing. A large proportion of these patients suffer from physical illness, but also from mental disorders, especially dementia, with concomitant psychological and behavioral symptoms interfering with their care. Since the 1990s, a couple of initiatives have been initiated in Germany to improve the psychiatric care of nursing home residents, e.g. through the establishment of liaison psychiatric collaborative care between psychiatric hospitals and nursing homes [87; for a short overview see, 35, 88]. Today (2004), the number of psychiatric departments in general hospitals has risen to approximately 170, and is accompanied by increasing efforts of the additional 150 stand-alone psychiatric facilities to establish closer collaboration with nearby general hospitals, e.g. by establishing medical-psychiatric units (MPUs) [89] (Weig W, personal commun.). Though this term is not common within German psychiatry, MPUs have long been a feature of German psychiatric inpatient care, especially for geriatric-psychiatric wards, and also for younger patients with severe somato-psychiatric comorbidity [35, 88]. The advantages of MPUs in providing concurrent but not sequential care (as is the case with the classical consultation approach) are being discussed under the perspective of the upcoming DRG system [90]. Not all psychosocial interventions in the general hospital have to be carried out by physicians, as was already stated with the example of medical psychologists. Other than in, e.g., the Anglo-Saxon countries, however, C-L psychiatric nurses are very seldom part of C-L psychiatric services. Not the least due to budget constraints, it is proposed that they are more integrated into C-L service delivery, as is proposed for social workers and other health care professionals [91–93]. Organizational and Training Issues of C-L Psychiatry Especially during the last 15 years, German psychiatry has seen a tremendous incorporation and development of psychotherapeutic thinking, with a special interest on so-called disorder-specific psychotherapies that are also relevant

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to C-L psychiatric service delivery, such as interpersonal psychotherapy for depression [94]. Those forms of psychotherapy are appealing as they stand the test of empirically researched efficacy [95]. They are incorporated into the training curriculum for psychiatric residents. In German C-L psychiatry, there has been an increasing interest in empirical research into supportive psychotherapy [96], a very effective form of psychotherapy that, with some notable exceptions, has been neglected and, other than in the USA for instance, not necessarily been regarded as a distinct psychotherapeutic approach [95, 97]. At present, there is no compulsory rotation of psychiatric residents in C-L services, though in most general hospitals with psychiatric departments, psychiatric residents do some C-L work. Hence, a curriculum has been published as a tool for organizing seminars in C-L psychiatry and gives hints as to how to organize practical C-L training of residents [98]. At the annual meeting of the DGPPN, a C-L training seminar has been installed on a regular basis since 1996. Due to the interesting perspective of integrating behavioral medical approaches into C-L psychiatry, and with the DRG system looming large, at the end of 2003 the C-L psychiatric task force of the DGPPN was relaunched as the ‘Section of Behavioral Medicine and Consultation Psychiatry’ within the DGPPN (chaired by Manfred Fichter, E-Mail [email protected], and Albert Diefenbacher, E-Mail [email protected]). In order to foster C-L psychiatric activities in Germany within an international network, the DGPPN has an affiliation with the American Academy of Psychosomatic Medicine and supports the activities of the European Association of C-L Psychiatry and Psychosomatics [99].

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Collinson Y, Benbow SM: The role of an old age psychiatry consultation liaison nurse. Int J Geriatr Psychiatry 1998;13:159–163. Diefenbacher A, Saupe R: Neuropsychiatrische Krankenpflege auf der Intensivstation als Aspekt konsiliarpsychiatrischer Tätigkeit. Psychiatr Prax 1993;20:224–226. Härter M, Koch U (eds): Psychosoziale Dienste im Krankenhaus. Göttingen, Verlag für Angewandte Psychologie, 2000. Markowitz JC, Klerman GL, Perry SW, Clougherty KF, Josephs LS: Interpersonal psychotherapy for depressed HIV-seropositive patients; in Klerman GW, Weissman MM (eds): New Applications of Interpersonal Psychotherapy. Washington, American Psychiatric Press, 1993, pp 199–224. Grawe K, Donati R, Bernauer F: Psychotherapie im Wandel. Göttingen, Hogrefe, 1994. Arolt V, Driessen M, Schürmann A: Indikation zu psychotherapeutischen Interventionen bei somatisch Kranken – Ergebnisse der Lübecker Allgemeinkrankenhausstudie; in Mundt C, Linden M, Barnett W (eds): Psychotherapie in der Psychiatrie. Vienna, Springer, 1997, pp 269–273. Freyberger H, Freyberger HJ: Supportive psychotherapy. Psychother Psychosom 1994;61: 132–142. Niklewski G, Diefenbacher A, Hohagen F: Weiterbildung in der Konsiliarpsychiatrie – Vorschlag für ein Curriculum; in Diefenbacher A (ed): Aktuelle Konsiliarpsychiatrie und Psychotherapie. Stuttgart, Thieme, 1999, pp 197–215. Burian R, Diefenbacher A: Konsiliar-Liaisonpsychiatrie in Europa. Nervenarzt 2002;73: 1128–1129.

Prof. Dr. Albert Diefenbacher Abteilung für Psychiatrie und Psychotherapie Evangelisches Krankenhaus Königin Elisabeth Herzberge, Herzbergstrasse 79 DE–10365 Berlin (Germany) Tel. ⫹49 30 5472 4802, Fax ⫹49 30 5472 2913, E-Mail [email protected]

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 20–24

Consultation-Liaison Psychiatry in Austria Angelika Riessland-Seifert Psychiatric Consultation-Liaison Service, Department of Psychiatry, Sozialmedizinisches Zentrum Ost, Donauspital, Vienna, Austria

Austria is a German-speaking country like Germany and parts of Switzerland and shares much history and many traditions with its two neighbors. Nevertheless, the development of consultation-liaison (CL) psychiatry has to be described separately because of important differences and some special features.

Background I: History and Traditions

In Austria two main roots leading to the implementation of CL-services can be distinguished. On the one hand there was the psychiatric reform movement which started in the 1970s and reduced psychiatric beds and implemented complementary care. One of the aims of social psychiatry was to reduce the size of large psychiatric hospitals and to install general hospital psychiatry units (GHPUs). The first of these units was opened in Vienna in 1986, the second one 10 years later. Nowadays eight of 18 planned GHPUs in various parts of Austria exist. The opening of a GHPU always means taking over responsibility for psychiatric consultations, but it rarely means setting up a specialized CL service doing liaison work as well. That depends on many different local circumstances. In daily practice consultation work is done in addition to the regular workload within psychiatry; liaison activities are not as common [1]. On the other hand, a tradition of psychosomatics and medical psychology exists, which places much emphasis on CL work. In the early 1990s new CL services were launched at two universities, and they belong to the best staffed and best qualified CL services in Austria.

Background II: Legal Situation

To understand the Austrian situation of psychosocial care in a general hospital, it is necessary to know some laws, all of which were passed in the 1990s. The first ones to mention were passed in 1991 and determine the independence of health and clinical psychologists (Psychologengesetz) as well as of psychotherapists (Psychotherapeutengesetz). Second is the Austrian Hospital Law (Krankenanstaltengesetz, 1993) which defines that sufficient psychological and psychotherapeutic care has to be provided at every general hospital. This could be done by psychiatrists as well as members of other professional groups [2]. In 1994 the guidelines concerning post-graduate medical education and training were reformed (Ärztegesetz, Ärzteausbildungsordnung). Part of this law involved a change in training guidelines for psychiatrists and neurologists: up to then training was combined in both specialities, naming that specialty first in which the person received more training. For example, a physician specializing in psychiatry and neurology received training in psychiatry for 4 years and in neurology as well as internal medicine for 1 year, and a physician specializing in neurology and psychiatry received 4 years of neurological training and 1 year of training each in psychiatry and internal medicine. Since 1994 young physicians have to decide whether to become psychiatrists or neurologists, whereas the timetable of training in both specialities has not changed; for example a psychiatrist has 4 years training in psychiatry and 1 year each in neurology and internal medicine. This issue will have consequences on the psychiatric care delivery in general hospitals because until now a lot of psychiatric consultation work is done by physicians who are mainly neurologists [2].

State of Development

Psychiatric consultation activities in Austria started about 15 to 20 years ago at several sites. The first CL services were implemented at the beginning or in the middle of the 1990s in general hospitals in different parts of the country, partly not knowing about each other. All of these multidisciplinary teams still exist and are quite experienced now. The heads of these services are the driving force behind the idea of promoting CL psychiatry in Austria. Two of these teams belong to the Institutes of Medical Psychology at the Universities of Innsbruck and Graz and are named ‘Psychotherapeutic Consultation-Liaison Service’, the others are psychiatric and/or psychosomatic CL services at hospitals that are not university-based. All of these services are headed by a psychiatrist. As far as we know the provision of psychosocial help for general hospital inpatients in Austria is extremely diverse [1]: there are some established and

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well-staffed multidisciplinary CL teams as well as hospitals without any resources of psychiatric or psychological consultations. All departments of psychiatry, both university-based and not-university-based, provide psychiatric consultations, but only some of them offer a specialized multiprofessional team. Liaison services are offered quite rarely. However, the number of GHPUs is growing continuously and there are initiatives, e.g. in Vienna, to implement a psychiatric CL service in every large tertiary care hospital center (Schwerpunktkrankenhaus) independent of the existence of a department of psychiatry. The following figures may illustrate this point. All over Austria there are 13 large hospitals, by definition they include at least departments of internal medicine, surgery, traumatology, ENT, ophthalmology, neurology, gynecology and obstetrics, pediatrics, dermatology, orthopedics and urology. Additionally the country has at its disposal 6 central hospitals covering the whole range of medical specialities. These are located within the respective university hospitals in Vienna, Graz and Innsbruck, while the other ones are situated in Salzburg, Linz and Klagenfurt. The total number of all hospitals in Austria is 340. Psychiatric inpatient care is provided at 21 sites: 10 central psychiatric hospitals, 3 university hospitals and 8 GHPUs. According to the psychiatric reform plans another 10 GHPUs will be set up within the next few years. However, the great majority of general hospitals in Austria include neither a department of psychiatry nor a CL service. In some of these hospitals there are departments of neurology, which are responsible for psychiatric consultations as well, if their colleagues are neurologists and psychiatrists. Other hospitals employ psychiatrists or more often neurologists coming to the hospital once or twice a week to see all patients in need of them. Those psychiatrists/neurologists may work at another hospital or in their own practice. To complete the picture of the landscape of psychosocial care in general hospitals, one has to mention numerous psychologists and psychotherapists working as team members of various departments such as internal medicine, pediatrics, oncology, HIV, ENT, etc. In some hospitals, as a result of the Austrian hospital law in the 1990s, psychotherapeutic or psychological CL services have been installed which mostly consist of 1 or 2 psychologists and/or psychotherapists, who provide consultations for the entire hospital.

Associations, Meetings,Training, Funding

Since 2001 a workgroup on CL psychiatry and psychotherapy was founded as part of the Austrian Psychiatric and Psychotherapeutic Association (Österreichische Gesellschaft für Psychiatrie und Psychotherapie). Their members meet for a symposium usually twice a year. Another informal workgroup brings

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together CL workers from all professional groups, e.g. psychiatrists, psychologists, psychotherapists, social workers, and nurses. This cooperative group was launched 1997 and meets annually. Training in CL psychiatry, psychosomatic medicine and psychotherapy has become an important issue. At the moment theoretical training in CL psychiatry is obligatory for psychiatric residents; guidelines concerning practical training are being discussed. Therefore the number of experienced and well staffed CL services able to provide training for residents has to be increased. Recently, more attention has been paid to the topic of funding for CL services. As Austria has a social health care system, the physicians’ salaries are paid by the owner of the hospital which often is the local municipality or are county authorities. Until now, there is no direct connection between the workload and the level of income. Since 1997 we have the system of performanceoriented hospital financing (Leistungsorientierte Krankenhausfinanzierung LKF), which may be compared to the diagnosis-related group system in Germany. Within this system CL interventions do not play an important role on the financial level. The next step in the reformation of the Austrian billing system is that every department will have his own budget. CL specialists are concerned that the referring departments will perhaps not see the necessity of liaison activities. More efforts have to be made to promote greater awareness among non-psychiatrist physicians about the importance of CL care.

Discussion of Future Development

One of the goals is to gather more information about the actual situation of psychosocial care delivery in general hospitals. This includes the reality of daily work of Austrian psychiatrists and knowledge about their role as consultants. Secondly we need national guidelines on the distribution of tasks at the general hospital between psychiatrists, psychologists and psychotherapists. There is an ongoing discussion in Austria about the importance of giving meaning to psychosomatic issues, which might also be a chance to improve the development of CL psychiatry, psychosomatics and psychotherapy. The next aim is to give greater emphasis to education and training in topics relevant to CL settings [3, 4]. Some Austrian psychiatrists are members of a workgroup on post-graduate training within the European Association of Consultation Liaison Psychiatry and Psychosomatics. As a result of this workgroup, recommendations already exist to make it mandatory for psychiatry residents to rotate into CL services for 6 months at the end of their residency. In addition tutorials and expert courses should be provided for those who want

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to become CL specialists. Last but not least training and education of medical students, non-psychiatric physicians and nurses is very important. Research in CL psychiatry with its wide range of topics is also a challenge for Austrian psychiatrists and should be promoted. In summary, we have the goal to establish the necessary conditions to provide psychosocial care [5] to all general hospital patients. This could be done best by multiprofessional teams headed by psychiatrists who are best qualified for some purposes, e.g. forensic ones, and know best how to ‘move’ within the medical culture of a general hospital. For certain local requirements psychologists, nurses, social workers, and psychotherapists are valuable team members as has been proven at several sites in Austria.

References 1

2 3

4

5

Riessland-Seifert A: Konsiliar-Liaisonpsychiatrie – Ein neues Aufgabengebiet innerhalb der Psychiatrie; in Meissel T, Eichberger G (eds): Psychiatrie im Aufbruch. Linz, edition pro mente, 2000. Wancata J, Gössler R: Die Konsiliarpsychiatrische Versorgung in Österreich; in Diefenbacher A (ed): Aktuelle Konsiliarpsychiatrie und –psychotherapie. Germany, Stuttgart, Thieme, 1999, pp 177–195. Gitlin DF, Schindler BA, Stern TA, Epstein SA, Lamdan RM, McCarty TA, Nickell PV, Santulli RB, Shuster JL, Stiebel VG: Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs. A report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in Consultation-Liaison Psychiatry. Psychosomatics 1996;37:489–90. Niklewski G, Diefenbacher A, Hohagen F: Weiterbildung in Konsiliarpsychiatrie: Vorgaben, Inhalte und Durchführung – Vorschlag für ein Curriculum; in Diefenbacher A (ed): Aktuelle Konsiliarpsychiatrie und – psychotherapie. Stuttgart, Thieme, 1999. Smith GC: From consultation-liaison psychiatry to psychosocial advocacy: Maintaining psychiatry’s scope. Aust NZ J Psychiat 1998;32:753–761.

Angelika Riessland-Seifert Psychiatric Consultation-Liaison Service, Department of Psychiatry Sozialmedizinisches Zentrum Ost – Donauspital, Langobardenstrasse 122 AT–1220 Vienna (Austria) Tel. ⫹43 1 28802, Fax ⫹43 1 28802/3080, E-Mail [email protected]

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 25–30

Consultation-Liaison Psychiatry in Switzerland F. Caduff a, D. Georgescub a b

Psychiatrische Dienste Thun, Thun, Psychiatrische Klinik Königsfelden, Windisch, Switzerland

Introduction

Analogous to the situation in Germany, an institutional separation of somatic medicine and psychiatry also evolved in Switzerland starting with the middle of the 19th century. Medicine, which increasingly assumed a natural science orientation, settled in centrally located general hospitals in the 5 largest cities of Switzerland (Zurich, Basel, Bern, Geneva and Lausanne) and acquired an academic appearance through ties to the local universities. For the psychiatrically ill, in contrast, large institutions were built in the countryside or already existing buildings, mostly monasteries, were given a new function which made the asylum and caretaking character very apparent. In the 1910–1920s the first psychiatric outpatient clinics (Polikliniken), e.g. Zurich (1913), Basel (1921), were opened within or nearby a centrally located general hospital. However, the dichotomy between psychiatry and somatic medicine remained preserved for the outpatient clinics focused primarily on the ambulatory pre- and post-hospital care of ‘classical’ psychiatric patients and remained closely linked to psychiatric hospitals with regard to staffing and organizational structure. While setting up the social psychiatric care structures after 1960, a multitude of ambulatory services, psychiatric support units or integrated psychiatric services were founded all over the country. These were located close to the community in the mayor cities of the cantons or regions, and were often positioned on the grounds of the local general hospital which in turn intensified the contact to somatic medicine and non-psychiatric physicians. The field of consultation-liaison (CL) psychiatry nevertheless remained ill defined for a long time, was not well delineated from the traditional psychosomatic medicine, and

ultimately remained strongly dependent on single protagonists, e.g. Zumbrunnen [1] in Geneva, who already in 1992 had published his own textbook on liaison psychiatry. A further characteristic of CL psychiatry in Switzerland was and has remained the diverging development of the specialty within and outside university-based medicine. While university-based institutions, especially those in the French-speaking part of the country (the liaison services of Geneva and Lausanne were founded in 1963 and 1968), were able to connect to international projects, one was barely able to discover a trickling down of this development to the non-university-based CL institutions, e.g. only the CL service of the Lausanne University Hospital participated in the European multicenter studies and projects (e.g. the European Consultation-Liaison Workgroup collaborative studies on quality management, the “INTERMED” project). Accordingly rare remained national and regional cooperation projects as well as the number of publications about CL-specific themes [2–4]. If there was research and publishing at all, it was almost especially in the context of university-based CL units and pertained to questions especially in the area of psychosomatic and psychosocial medicine (communication skills, coping with illness, doctor-patient relationship, sexual medicine, etc.). Also the debates which were held in the USA and England about the structures and the goals of CL services found little use in Switzerland. A first loose gathering of Swiss CL psychiatrists took place in 1990 in the form of a study group. This group gathered on a half-yearly basis for specialtyrelated as well as informal exchange; common projects were not initiated. In 1992 there was a first attempt in the context of a doctoral thesis to survey in systematic fashion the ‘CL landscape’ of Switzerland. The results were published 1993 as ‘Listing of Psychosomatic and Psychosocial Institutions of Switzerland’ [4]. Even though the authors characterized the situation in Switzerland as ‘not better but not worse than elsewhere’ the Swiss CL psychiatry (with the exception of some CL services in the French-speaking part of Switzerland, e.g. Lausanne) did not fare well in surveys on an international scale [6]. Especially criticized was the by comparison small research activity in this area. These global judgments also largely pertain to Swiss geriatric CL psychiatry. A relatively limited number of university-based (e.g. in Basel) and notuniversity-based psychiatric institutions offered CL psychiatric services, especially in nursing homes. The establishment of specific old age psychiatric CL services or counseling sessions in hospitals remained the exception; these services were usually offered by the consultation units in general adult psychiatry. Equally rare remained research activity in this area. A positive exception is the geriatric psychiatric CL service in Lausanne which was founded by Wertheimer in 1992. This service supplies care for Lausanne University Hospital as well as several nursing homes in the region. In connection with this service intensive research activity occurs to which the many scientific publications testify. Main themes are

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the research of confusional states as well as the characteristics and the organizational structures of old age psychiatric CL services [7–9].

Results of a Survey of Swiss CL Psychiatry from the Year 1999

In the context of a survey pertaining to all of Switzerland in 1999, all the then known CL services of Switzerland were contacted and asked in detail about structure, resources, activities, problems and projects. In this survey, the results of which were published in the beginning of 2002 [10], the authors concluded that Swiss CL psychiatry presented itself in a very heterogeneous way. The following items were especially emphasized. 1. All university hospitals, all hospitals of the cantons, as well as practically all medium-sized and small regional hospitals of Switzerland (defined as hospitals with more than 150 beds) offered the opportunity to call a consultation psychiatrist within reasonable time. Most of these CL psychiatrists were employed in a psychiatric polyclinic service or in a psychiatric ambulatory service and were only active part-time in consultation psychiatry; some were psychiatrists with their own practice in the town near the general hospital. Accordingly small was the degree of specialization of the CL psychiatrist. Because of limited staff, most of them worked on the basis of a consultation model although many colleagues wished for more liaison psychiatric elements. 2. Psychiatric emergencies in general hospitals were often, but not always, taken care of by CL psychiatrists. This occurred mostly in medium–sized hospitals. In the smaller hospitals, if a psychiatrist was not available, this task was the responsibility of non-psychiatric physicians; at the university hospitals the physicians on duty in the psychiatric polyclinic services were responsible. 3. The delineation of CL psychiatry from psychosomatic medicine was often unclear. In several general hospitals this seemed to be primarily a semantic problem since the CL service was called ‘psychosomatic service’ for historical reasons or for reasons of positive ‘labeling’. In those university hospitals which also had a psychosomatic service of their own next to a CL service, it came to a division so that psychosomatic medicine, from an organizational point of view part of internal medicine, devoted itself more to the routine care of the ‘classical’ psychosomatic disorders (psycho-oncology, eating disorders, chronic pain) while the specific CL activity (including emergency care) was provided by the CL psychiatrists of the psychiatric polyclinic services. 4. Psychiatric beds in the general hospital were available only in specialized departments of some university hospitals. Moreover, the rule was,

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especially in small, peripherally located hospitals, to admit psychiatric patients to inpatient units as far as they were no danger for patients or personnel. 5. Many CL psychiatrists were also engaged in interdisciplinary specialty practice for ‘pain-prone patients’, for ‘gastric-banding-candidates’, as well as in ‘memory-clinics’ or similar services. 6. Most CL psychiatrists had an office in the general hospital, had access to a specialized library or to a medical database, used (although irregularly) standardized assessment forms, as well as neuropsychological or test psychological instruments. Research was performed only rarely and if so then almost exclusively in the context of a university. 7. Most CL psychiatrists rated the collaboration with non-psychiatric physicians as good and had the impression that their recommendations were accepted and applied. The remainder complained especially about the tendency of non-psychiatric physicians to dump ‘difficult patients’ onto psychiatric services. 8. Most CL psychiatrists were of the opinion that their non-psychiatric colleagues wished faster availability of the consultant as well as better emergency coverage. The consultation psychiatrist themselves, however, wished more liaison psychiatric elements, therefore including a stronger participation in standard hospital services. This contradiction of demand (by the somatic physician) and supply (by the psychiatrist) did not seem to strike the CL psychiatrist as troubling. 9. As far as the remuneration for CL activities was concerned, it was apparent that in university and larger hospitals either no or at best a lump sum payment occurred, whereas in the medium-sized and smaller hospitals consultation activities were paid for on the basis of a fee schedule which definitely correlated positively with the degree of satisfaction of the CL psychiatrists. Summing up, it can be said that in Switzerland consultation psychiatric care in general hospitals appeared to be provided, even in the small and rural ones. However, CL psychiatry as a whole seemed to lack an identity of its own. Criticized was not only the marginal position of psychiatry within the field of medicine but also the marginal position of CL psychiatry within psychiatry; e.g. in the postgraduate education program to obtain the Swiss specialty title Psychiatry/Psychotherapy CL experience was explicitly mentioned, practical experience in this area, however, was not required. The authors pointed out the contrast of this dually marginal position of Swiss consultation psychiatry within non-psychiatric medicine and within psychiatry to some impressive developments in the field in other countries (USA, Great Britain, the Netherlands) and on a supra-national level (e.g. in the

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context of the European Association of Consultation Liaison Psychiatry and Psychosomatics).

Development in Recent Years and Ongoing Projects

A small group of interested CL psychiatrists pressed on with the restructuring of the Study Group of CL Psychiatrists into an association. In May 2001 the founding meeting of the Swiss Society for CL Psychiatry occurred with 21 founding members. In view of the multiplicity of the mother tongues of this country, the English term ‘Swiss Society of Consultation-Liaison Psychiatry’ (SSCLP) was purposely chosen as the official name. The 3–4 information newspapers per year, however, are published in German and French. The society created an internet site in 2002 and can be found under the domain name www.ssclp.ch. The SSCLP was purposely founded as an association of psychiatric specialty physicians. Therefore, it was logical that the SSCLP made efforts to quickly join the Swiss Society of Psychiatry and Psychotherapy (SSPP). This indeed occurred, and in the spring of 2002 the SSCLP was officially adopted as a member society of the SSPP, with attendance and voting rights in the assembly of delegates. The SSCLP currently has approximately 70 members. Approximately 2/3 of the members are employed in institutions, the remaining psychiatrists work in private practice. Most members are employed in Swiss-German hospitals; there are however increasing efforts to include the CL colleagues in the Frenchspeaking part of Switzerland, not only by arranging the half-yearly meetings alternatively both in the German and the French-speaking parts of Switzerland. A brief survey which took place shortly after the founding meeting revealed that of topmost interest is specialty-specific continuous education, but also the promotion of regional, national and international contacts. However, the idea to promote the sub-specialization of CL psychiatry in the direction of an official supplementary certification through the Swiss Medical Association has to date found only a few supporters. For the immediate future, therefore, only the establishment of a regularly occurring continuous education course for CL psychiatrists as well as for other interested psychiatrists is planned. Similarly national contacts (e.g. both to the Academy and the Swiss Society for Psychosocial and Psychosomatic Medicine and to the university-based CL services) as well as international contacts (e.g. to the European Association of ConsultationLiaison Psychiatry and Psychosomatics) will be intensified. The goal is a qualitative enhancement of local CL psychiatry and its integration into international collaborative projects.

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References 1 2 3

4 5 6

7 8

9

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Zumbrunnen R: Psychiatrie de liaison. Paris, Masson, 1992. Stiefel F, Cochand P, Guex P, Herzog T, Stein B: Premières expériences d’un programme de gestion de qualité dans un service de consultation/liaison. Méd Hyg 1997;55:237–242. Stiefel FC, de Jonge P, Huyse FJ, Guex P, Slaets JP, Lyons JS, Spagnoli J, Vannotti M: “INTERMED”: a method to assess health service needs. II. Results on its validity and clinical use. Gen Hosp Psychiatry 1999;21:49–56. Stiefel FC, Cochand P, Guex P, Herzog T, Stein B: Qualitätsmanagement in der Konsiliarpsychiatrie: welche «Produkte» können verbessert werden? Schweiz Ärzteztg 1997;78:790–792. Buddeberg C, Kaufmann P, Radvila A (Hrsg): Psychosomatische und psychosoziale Medizin in der Schweiz. Bern, Bäbler, 1993. Huyse FJ, Herzog Th, Malt UF: International perspectives on consultation-liaison psychiatry; in Rundell JR, Wise MG (eds): Textbook of Consultation-Liaison Psychiatry. Washington, American Psychiatric Press, 1996. Camus V, de Mendonça Lima CA, Simeone I, Wertheimer J: Geriatric psychiatry liaison-consultation: The need for specific units in general hospitals. Int J Geriatr Psychiatry 1994;9:933–935. Camus V, Viret C, Porchet A, Ricciardi P, Bouzourene K, Burnand B: Effect of changing referral mode to C-L psychiatry for non cognitively impaired medical inpatients with emotional disorders. J Psychosom Res 2003;54:579–585. Camus V, Burtin B, Simeone I, Schwed P, Gonthier R, Dubos G: Factor analyis supports the evidence of existing hyperactive and hypoactive subtypes of delirium. Int J Geriatr Psychiatry 2000;15:313–316. Georgescu D, Caduff F: Konsiliar- und Liaisonpsychiatrie in der Schweiz: aktueller Stand und Perspektiven. Schweiz Arch Neurol Psychiatr 2002;153:12–24.

Dr. F. Caduff Spital Thun CH–3600 Thun (Switzerland) Tel. ⫹41 33 226 47 00, Fax ⫹41 33 226 47 10, E-Mail [email protected]

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General Section Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 31–51

Prevalence of Psychiatric Disorders in Physically Ill Patients Volker Arolt Department of Psychiatry, University of Münster, Münster, Germany

Introduction: Epidemiology of Psychiatric Disorders in Physically Ill Patients

The aim of psychiatric epidemiology is to investigate the prevalence, the distribution and the conditions of psychiatric disorders in populations. The prevalences and distributions of disorders form the basis of evidence-based planning of psychiatric care. Research into the circumstances of illness and into the determinants of pathogenesis permits epidemiological findings to be applied to the prevention and treatment of disorders. Prominent studies on psychiatric morbidity in the population in general have been of great significance not only in scientific terms but also with respect to health policy. In many countries they have had a fundamental impact on the development and design of psychiatric care systems. A trailblazing function can be attributed to field studies such as the Midtown Manhattan study in the USA [1], the Stirling County study in Canada [2], the Samsö study in Denmark [3], the Lundby study in Sweden [4–6] and, based on a criteria-oriented classification (DSM-III) and a structured interview technique, the Epidemiological Catchment Area study in the USA [7]. In the wake of World War II, it was only from 1973 onwards that psychiatric epidemiology in the Federal Republic of Germany was accorded the scientific status due to it with the founding of research field 116 (SFB 116: psychiatric epidemiology). With respect to the assessment of prevalence rates in the overall This is an abridged version of V. Arolt: Häufigkeit psychischer Störungen bei körperlich Kranken; in Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin. Konsiliarpsychiatrie, -psychosomatik und -psychotherapie. Darmstadt, Steinkopff, pp 19–53.

population and the psychiatric treatment need, special significance was achieved by the Upper Bavaria study [8] as a selective project of the SFB, whose findings were later not only confirmed but also supplemented in some aspects by Fichter [9]. The prevalence of neurotic and psychosomatic disorders in an urban population was investigated in two elaborate studies by Schepank [10, 11], with a major emphasis in the latter study on illuminating causal correlations in the pathogenesis. Important findings in the German-speaking regions have also been provided by the Zurich cohort study [12] and the Munich study on the course of treated and untreated depressions and anxiety disorders [13], and more recently by the Transitions in Alcohol and Smoking study [14]. It has to be assumed that approximately 15–25% of all persons in the overall population suffer in the course of time from a mental disorder requiring treatment (point prevalence: presence of a disorder at the time of the examination or within the 7 days preceding it). Approximately 35% suffer at some time in their lives from a disorder requiring treatment (lifetime prevalence). The prevalences of disorders in medical care systems are, however, distinctly higher. The higher prevalence of psychiatric disorders in medical care systems offers a special opportunity for their early diagnosis and treatment (secondary prevention). However, this opportunity is still exploited too infrequently at the present time. The recording of epidemiological data on psychiatric disorders in physically ill patients and in particular its practical application, e.g. within the framework of psychiatric/psychosomatic consultant/liaison services lags far behind the circumstances surrounding the care of the population as a whole. The disregarding, flawed detection and diagnosis, and inadequate treatment, if any, of psychiatric disorders in physically ill patients are in unacceptable contrast to the state-of-the-art knowledge relating to the diagnosis and treatment of psychiatric disorders [15, 16]. With respect to physically ill patients, the main questions confronting psychiatric epidemiology are: (1) How often do psychiatric disorders occur in specific samples of somatic patients (e.g. inpatients or outpatients) or in specific somatic syndromes (e.g. cardiac disorders, cancer; prevalence)? (2) How often do psychiatric disorders occur under conditions of physical illness (incidence)? (3) What course do psychiatric disorders take in specific groups of physically ill patients? (4) What are the biological, psychological and social determinants contributing to the development of psychiatric disorders in physically ill patients? (5) Do preexisting psychiatric disorders contribute to the development of physical illnesses? (6) In what way do psychiatric disorders influence the course of physical illnesses? Although we are far from finding an answer to many important questions, it is becoming clear that the tasks and possibilities of psychiatric epidemiology extend far beyond the demonstration of mere prevalences and their distributions. In particular, analytic-epidemiological questions relating to the determinants

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of pathogenesis offer a promising research perspective. The studies performed in the 1990s on the association between depression and coronary heart disease [Arolt and Rothermundt, pp 98–117] form a good example. On the other hand the primarily descriptive-epidemiological aspect, i.e. a description of the prevalence and distribution of psychiatric disorders in specific patient groups, also provides important basal information, especially with respect to the implementation of and research into care systems, including the secondary prevention of psychiatric disorders in physically ill patients. The Problem of Diagnosing Psychiatric Disorders in Primary Care Various studies carried out in the past two decades have shown that both general practitioners and doctors working in internal departments of hospitals regard only a certain proportion of their physically ill patients as cases of psychiatric comorbidity. The ‘case detection rate’, i.e. the rate at which patients were assumed globally to be suffering from a psychiatric disorder (regardless of the accuracy of a specific diagnosis!) is subject to substantial inter-study and intra-individual variation and ranges from 10 to 60% [17, 18]. In Germany, however, the ability of medical practitioners to diagnose depressive disorders appears to have undergone a welcome improvement to over 50% [19]. On the other hand, it is disputed whether the inability to detect cases and the lack of specific diagnostic security are due solely to qualification deficiencies among those doctors working in the primary medical care system. Other important factors are likely to be the characteristics of the respective working field (concentration on the main physical findings under intense pressure of time) and the abilities of the patients themselves to describe their symptoms. A further important aspect is to be seen in the observation that psychiatric disorders in patients within the primary medical care system have a different symptomatology from those in psychiatric care contexts, in part less pronounced and more diversified, and integrating essentially physically induced symptoms [20, 21]. The results of a recently performed study [22] show that the case detection rate among general practitioners was dependent upon 3 factors: (1) the extent of psychiatric-psychotherapeutic postgraduate training that the general practitioners had undergone (mainly, for example, within the framework of ‘psychosomatic basic care’); (2) the dominance with which the respective physician determined the course of the interview (with less dominant physicians being more successful in their diagnoses), and (3) the extent to which the patients themselves could verbalize their symptoms. The study has a trailblazing character in that the authors obtained a far more profound insight than other studies into the mechanisms underlying inadequate case detection among doctors working in primary health care.

Prevalence of Psychiatric Disorders in Physically Ill Patients

33

Prevalence of Psychiatric Disorders in Hospital Patients

In view of the partially substantial differences in the health care systems of different countries, findings recorded in other countries (primarily in the USA and the United Kingdom) cannot simply be applied to German circumstances. For this reason, the results of German studies are presented below, in some cases in greater detail, not least because it is imperative from the perspective of care epidemiology to support corresponding research approaches in Germany too. A comparison of the prevalence rates of psychiatric disorders from the Lübeck General Hospital study with the corresponding prevalence distributions of the diagnoses in the overall population [9, 23] shows that 3 groups of disorders are substantially more often represented in samples of patients referred to departments of internal medicine and surgery: (1) depressive disorders; (2) alcohol abuse/dependence, and (3) psycho-organic disorders. These groups of disorders are accordingly dealt with in more detail than other disorder units. One point of special interest is, however, that the diagnostic distribution is again different in general medical practices, where not only alcoholic disorders and depressive disorders but also somatoform disorders and anxiety disorders are very frequently diagnosed [Linden, pp 52–65; Rief and Nanke, pp 144–158]. Problems of Data Collection Methodology Studies on prevalences of psychiatric disorders should not be compared without account being taken of the respective data collection methodology. One important fundamental aspect of assessments of prevalence rates of psychiatric disorders is the question of whether they are based on dimensional or categorical criteria. For example, the assessment of the dimension ‘depression’ (rated on the basis of a standardized psychopathologic rating instrument and a plausible cutoff score) leads to different results (including distinctly higher rates of positive results) from the interview-based diagnosis of a depressive disorder, e.g. a depressive episode. When formulating the question it is therefore important to decide whether information on the prevalence of the dimensions ‘depression’ or ‘somatization’ is to be obtained or whether the prevalence of the disorder categories ‘depressive episode’ or ‘somatization disorder’ is of significance. From the epidemiological aspect, however, the current scientific standard complies with the concept of criteria-defined disorder units. Gradings can be undertaken towards all criteria being met (disorder present), only some of the criteria being met (subthreshold, so-called ‘subclinical’ disorder present), or only one or few criteria being met (limiting range). Dimensional scales are therefore used today either for screening a population or for assessing the severity of symptoms or of the illness in the case of an already diagnosed disorder unit. Combining

Arolt

34

several disorder units from the very outset (e.g. in terms of ‘psychosomatically disturbed’) is pointless and misleading from the epidemiological perspective. Treatment Need One special methodological problem is the assessment of the treatment need. This aspect is possibly of greater importance in the planning of medical care structures than knowledge of the mere prevalence of disorders. Disorder prevalence and treatment need cannot be seen as congruent, however, but have rather to be regarded as semi-dependent findings. For patients who are already in good psychiatric care, often in an inpatient or outpatient general practitioner setting, there is thus no further treatment need despite the presence of a potentially severe psychiatric disorder. On the other hand, the number of patients in whom a psychiatric disorder in the real sense cannot be diagnosed but for whom a psychotherapeutic or even a psychopharmacologic intervention can be seen to be of potential benefit is far from small. This applies on the one hand to patients with ‘subthreshold’ disorders. These are disorders for which not all criteria essential to a criteria-oriented diagnosis in accordance with ICD-10 or DSM-IV are met. The introduction of oriented diagnostic systems entailed in some respects the drawing of an artificial border to a collateral development of a new disorder group, the ‘subthreshold disorders’. These disorder units are, however, to be taken seriously in their personal as well as in their socioeconomic implications [24, 25]. A further constellation where psychiatric disorder and treatment need fail to coincide results from the fact that people are subject to ongoing conflict situations from which they suffer, though without decisive, specific symptoms or even a psychiatric disorder developing. This is often the case in partnership conflicts, for instance. Yet psychotherapeutic treatment may prove valuable. Assessment of the treatment need is methodologically problematic in that the indication for specific therapeutic procedures is based on a wealth of variables from a total of 3 groups: (1) illness-related variables (e.g. type of illness, severity, duration); (2) person-related variables (e.g. age, gender, education, emotional differentiation, motivational level), and (3) context-related variables (e.g. therapeutic offer, temporal and material restrictions). This gives rise to an extremely complex condition structure which has to be taken carefully into account in each individual case when making the diagnosis and which has so far evaded any unequivocal operationalization. The fact that existing studies on the prevalence and distribution of psychiatric disorders among physically ill inpatients differ substantially also with respect to the selected research field should not be overlooked. Samples have been most frequently drawn from departments of internal medicine, with a distinction having to be made even here between emergency wards, regular

Prevalence of Psychiatric Disorders in Physically Ill Patients

35

wards and areas of maximum care or special units (for the performance of specific, elaborated diagnostic or therapeutic procedures). There is also a certain degree of variation in that patients were recruited both on admission and during treatment. The sources of most information and the most reliable data, also with respect to the stated methodological problems, are departments of internal medicine. Patients on neurological wards were also examined with reference to various neurological syndromes, but patients on surgical wards very rarely [26, 27]. Depressive Disorders Depressive syndromes of varying diagnostic classification often occur in physically ill inpatients and outpatients. In comparison with the overall population, the prevalence rate is estimated to be two to three times higher [Arolt and Rothermundt, pp 98–117]. Approximately 15% of inpatients on internal wards can be estimated to be suffering from a depressive disorder, about half of them from severe disorders (in terms of a major depression). Table 1 shows the prevalence rates of depressive disorders in departments of internal medicine. These are based on a clinical examination or a structured interview, e.g. Clinical Interview Schedule (CIS), or on a standardized interview, Composite International Diagnostic Interview (CIDI) and Schedules for Clinical Assessment in Neuropsychiatry (SCAN). In comparison with the ascertained rates, studies in which interviews were used show a surprising degree of conformity in terms of a 15% prevalence rate for all forms of (non-organic) depressive disorders, even in patients aged over 65 years. The variation of these prevalence rates in different studies is comparatively low (in comparison with studies on overall incidences of illness); however, it is above all substantially lower than the variation in those prevalence rates determined from the large number of dimensionally designed studies. The rate of severe depressions in terms of ‘major depression’ (DSM-IV) was recorded in 4 studies by means of standardized instruments. Silverstone [32] reported a rate of 7.7%, falling to only 5.1% when modified diagnostic criteria were applied. Arolt et al. [31] determined a rate of 8.5%, falling to only 6.5% when only the CIDI was applied. Wancata et al. [38] reported 4.1%, and Hansen et al. [34] stated that 8 of 18 depressive patients (from 217 patients) were suffering from a moderate to severe depressive episode (3.7%). While a certain degree of conformity is thus apparent in estimates of the prevalence of depressive disorders on internal wards, the situation concerning data from other departments is considerably less consistent [27]. Neurological wards: The prevalence of depressive disorders on neurological wards seems to be distinctly higher than on internal wards and can be estimated

Arolt

36

Table 1. Prevalence of depressive disorders among inpatients on internal medical wards in general hospitals Authors

Population

Number

Depression in patients aged 18 years and older Maguire et al. [28], New 170 (1974) admissions Feldman et al. [29], Wards 453 (1986) Hengeveld et al. [30], New 220 (1987) admissions Arolt et al. [23, 31], Wards 200 (1995, 1997)1 Silverstone [32], Emergency 343 (1996) admissions Wacanta et al. [33], New 121 (1996)1 admissions Hansen et al. [34], New 157 (2001) admissions Depression ⬃in patients aged 65 years and older Rooymans [35], 65
years 90 (1985) Johnston et al. [36], 65
years 204 (1987) Cooper and Bickel [37], 65–80 years 626 (1987)1 Arolt [27], 65
years 114 (1997)1

Methods

Prevalence, %

GHQ-60, CIS
medical history GHQ-30 (4/5)
PSE BDI (12/13)
clinical interview CIDI
clinical interview SCAN

15

CIS

4 (MDD) 11 (minorD) 8 (incl. Dys.) 4 (⬃MDD)

SCAN

BDI (12/13)
clinical interview GHQ-28 (4/5)
clinical interview Screening
CIS CIDI
clinical interview

15 32 10 9 15 8 (MDD)1

16 13 17 12

The percentages have been rounded up or down. GHQ  General Health Questionnaire in various versions (28, 30, 60), always given with the threshold values used; BDI  Beck Depression Inventory; CIS  Clinical Interview Schedule (interview); PSE  Present State Examination (interview); SCAN: Schedules for Clinical Assessment in Neuropsychiatry. The threshold values used to evaluate the respective self-assessment questionnaire are given in parentheses. 1 Studies from German-speaking countries.

at 30–50% [39]. In the methodologically most convincing study to date, Carson et al. [40] from Edinburgh report the following prevalence rates for a sample of 300 patients with various neurological diseases: major depression 26%; less severe (minor) depression 8%, and dysthymia 15%. Surgical wards: Although surgical wards belong to the core area of the health care offer of almost all general hospitals and large-scale specialist hospitals, with

Prevalence of Psychiatric Disorders in Physically Ill Patients

37

a correspondingly high number of beds therefore being reserved for surgical patients, it is largely unknown how many surgical inpatients are suffering from psychiatric disorders. Mayou and Hawton [26] suggested in their well-known overview, with reference to the scant data available, that the corresponding prevalence rates were lower on surgical than on internal wards. The few studies available on this aspect, whose differing methodology is not conducive to comparison, suggest a prevalence of approximately 9–18% for depressive disorders. The Lübeck General Hospital study [23, 27, 31] looked into this problem by investigating a total of 200 patients on 8 general surgical wards at 2 hospitals. This showed virtually identical prevalence rates for almost all disorders in comparison with internal wards. A depressive disorder (including depressive reactions) was registered in 14.5% of patients, and a major depression in 8.5%. The rate recorded by Wancata et al. [38] was 10.3% (2.4% major depression). A comparison of the studies is problematic due to their differing underlying circumstances. On the one hand, patient selection is subject to a substantial selection bias, with emergency admissions to internal wards, regular admissions, already admitted inpatients, or mixed samples from internal, surgical and gynecological wards as well as patients from different age groups being investigated. Another factor subject to variation is the applied investigation method, depending on whether preference has been given to a dimensional or a categorical approach. The selection of various diagnostic instruments also contributes to the variation in prevalence rates. The studies moreover differ in whether they were preceded by a screening phase involving the premature selection of false-negative patients or whether this was not the case (single-stage procedure without prior screening) [23, 31–34]. Especially in view of the large number of potential variants, the comparatively low variation in prevalence rates reported for depressive disorders in patients on internal wards supports the validity of the findings, i.e. that depressive disorders do indeed occur at the stated prevalence rates in inpatients on internal wards overall. Addictive Disorders Alcohol abuse and alcohol dependence are the most frequent forms of addiction in physically ill patients. They are therefore registered very frequently also on general hospital wards, especially in male patients (male: female ratio 3–4:1). Together with the clinical-psychiatric examination, a physical examination and the evaluation of laboratory findings (blood alcohol concentration, liver enzymes, mean erythrocyte volume), standardized diagnostic instruments have stood the test on an international scale. In particular, the Michigan Alcoholism Screening Test (MAST) [41], which is available in

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38

two versions (13 and 25 items), has found widespread use, as has the CAGE [42]. In Germany the Munich Alcoholism Test (MALT) [43] has asserted itself. Although the stated procedures are not validated for application in general hospitals, there are indications of acceptable sensitivity with still deficient specificity [44, 45]. McIntosh [46] compiled a detailed overview of all studies performed on internal patients up to that time (n  53). The point prevalence in those studies ranged from 13 to 48%. The inclusion of previous alcohol consumption or alcoholinduced physical sequelae, i.e. indications of a lifetime prevalence, yields a range of 24–51%. Table 2 lists studies not taken into account by McIntosh [46] including studies from non-internal health care areas and those performed since 1982 also in the Federal Republic of Germany. A methodological comparison of the studies shows that: (1) samples were drawn from various patient collectives, often from emergency wards; (2) different examination methods were used; (3) screening procedures were used as standard methods in almost all studies, and (4) screening was based essentially on three different methods (CAGE and MAST/SMAST in Anglo-American studies, MALT in studies from the German-speaking regions). The prevalence of alcohol dependence in emergency admissions (all specialist wards) is between 12 and 32%. Similarly high prevalence rates (11–30%) are recorded in samples not drawn from emergency wards but from regular admissions. The rates are thus 2–4 times higher than in the population in general [64]. Gender-specific prevalence rates revealed that the rate among men was 2–4 times higher. In comparison with the situation in the overall population, where the male:female alcoholism ratio is approximately 10:1, the gender-related difference tends to be leveled out in the hospital situation. Data from two studies performed independent of each other in Lübeck have shown that an alcohol problem is to be expected in almost 1 in 3 men on internal and surgical wards, and that 1 in every 4 or 5 men is alcohol-dependent. A comparison of more recent investigations, the 2 Lübeck studies, is of special interest concerning the situation in Germany. These 2 studies, the Lübeck General Hospital study [23, 27, 31, 65, 66] and the study on alcohol-induced disorders in the general hospital by John et al. [63, 67] have substantial differences in their methodology (table 2). Yet there is surprisingly good conformity between the reported prevalence rates. The values set out below relate to patients aged between 18 and 65 years in whom alcohol abuse or alcohol dependence (ICD-10) was diagnosed. John et al. [67] reported rates of 20.7 and 16.0%, respectively, on internal and surgical wards, whereas Arolt et al. [31] recorded (including secondary diagnoses) rates of 20.9 and 14.6%, respectively. In the study by John et al. [67] a definitive dependence was reported in 13.9% of all patients on internal and surgical wards, compared with 14.2% in the Lübeck General Hospital study. Prevalence of Psychiatric Disorders in Physically Ill Patients

39

Table 2. Prevalence of alcohol-related illnesses in patients treated in general hospitals Authors

Population

Jariwalla et al. [47], 1979 Athen and Schranner [48], 19811 Auerbach and Melchertsen [49], 19811 Holt et al. [50], 1980

Internal medicine admissions Internal medicine admissions

Barrison et al. [51], 1982 Beresford et al. [52], (1982) Lloyd et al. [53], 1982 Martin et al. [54], 1983

Number Methods 545 849

Consumption
13 medical examination 27 MALT
11 questionnaire

Internal medicine/ surgery admissions

247

MALT
clinical examination

I: 14 C: 7

Emergency admissions

702

Serum concentration
clinical examination CAGE
consumption CAGE
interview Interview

32

General hospital/ 520 admissions 18–65 219 Orthopedics/ 87 admissions injuries Internal medicine 275 admissions Internal medicine/ 648 admissions medical examination Lefkowitz et al. General medicine/ 368 [55], 1985 admissions Corrigan et al. Internal medicine 158 [56], 1986 Curtis et al. Admissions: internal 258 [57], 1986 medicine Surgery 198 Feldman et al. Internal medicine/ 453 [28], 1986 admissions Taylor et al. Emergency admissions 2,598 [58], 1986 internal
surgery
orthopedics Möller et al. Surgery 600 [59], 19871 Moore et al. University hospital 2,002 [60], 1989 all departments Schofield General hospital 331 [61], 1989 Watson et al. All general admissions 145 [62], 1991 all departments/women Arolt et al. Internal medicine
400 [23], 19951 surgery

Arolt

Prevalence, %

MAST, Serum concentration

23 16 14 F: 11 M: 27 M: 20

b-MAST/CAGE

8

MAST/CAGE

23

SMAST


30

DSM-III CAGE
consumptiom MAST
case history

18 F: 4 M: 18 12

MALT

14

CAGE
SMAST
interview CAGE

20 5

Interview
F: 15 GGT, MCV CIDI 5 clinical examination 9

40

Table 2 (continued) Authors

Population

Number Methods

John et al. [63], 19961 Silverstone [32], 1996 Wancata et al. [33], 19961 Hansen et al. [34], 2001

Internal medicine
surgery Internal medicine

1,309

Internal medicine surgery, gynecology Internal medicine/ admissions

Prevalence, %

343

CAGE
MAST
F: 7 clinical examination M: 17 SCAN 5

265

CIS

5

217

SCAN

7

F  Female; M  male; SMAST and b-MAST  short versions of MAST; CIS  Clinical Interview Schedule; SCAN  Schedules for Clinical Assessment in Neuropsychiatry. See the text for further abbreviations. 1 Studies from German-speaking countries.

The male:female ratio was approximately 1:4 in both studies. The surprisingly high conformity in prevalence rates despite the methodological differences between the two studies suggests a comparatively valid (‘true’) assessment of the actual point prevalence in the hospital clientele. Other Addictive Disorders

Only a few studies determining the prevalence of addictions without alcohol dependence as the primary factor have been published. Data on the frequency of illegal drug intake, especially of heroin and cocaine, have hardly undergone systematic analysis and are subject to extreme variations depending on the respective sample. Whereas drug dependence is an extremely frequent problem in the admission sections of city hospitals [68], this phenomenon obviously plays no major role in regular care on internal wards. Thus the Lübeck General Hospital study, which reflects a catchment area of medium-sized towns, found multiple substance consumption (including opioids, abuse of/dependence on cannabis, solvents and other substances) among 2.8% of 400 patients on internal and surgical wards. The more recent study from Aarhus [34] reported illegal drug consumption in 7 patients (3%). The studies by Wancata et al. [69] from Vienna provide important information on the use of benzodiazepines in general hospitals. These studies show that 15.9% of all patients had been prescribed anxiolytics or hypnotics (primarily benzodiazepines) during the 3 months preceding admission to internal, Prevalence of Psychiatric Disorders in Physically Ill Patients

41

surgical or gynecological wards. 50.4% of the patients were given such medication during their hospitalization, and 26.1% were given a corresponding prescription on being discharged. Although these studies do not permit a statement to be made on the prevalence of benzodiazepine dependence in the general hospital, they provide empirical evidence not only that a substantial proportion (about 16%) of subjects take benzodiazepines regularly prior to being admitted to hospital, but also that the threshold for benzodiazepine prescription in the general hospital is comparatively low. Even if many patients can be expected to discontinue this medication after their discharge, the possibility of addictions being furthered in this way cannot be discounted. At least the Vienna study suggests that the consumption of benzodiazepines is not counteracted, especially in view of the more limited possibilities for psychiatric diagnosis and psychopharmacology by physicians without psychiatric postgraduate education. Psycho-Organic Disorders Like depressive disorders and addictions, acute and chronic psycho-organic syndromes are among the most frequent psychiatric disorders in hospital patients. Many studies have been aimed at determining the prevalence of acute psycho-organic syndromes and dementia-type developments (table 3). A striking aspect of these studies too is that greatly differing methodological procedures were selected. In the earlier studies, i.e. up to about 1980, assessment of the prevalence of disorders was based mainly on single-stage procedures, providing an impression of the frequency of the dimension ‘cognitive impairment’, e.g. through application of the Mini-Mental Status (MMS) [81]. Later studies made use of correspondingly constructed instruments, mainly in terms of a screening procedure followed by a clinical or an interview-based structured or standardized examination. The corresponding scales are, however, also applied meaningfully to validate the clinical or interview-based diagnosis. Besides the MMS, the Clifton Assessment Schedule (CAS) [82] has an excellent track record. A survey of the applied methods is given in various overviews [26, 27]. A comparison of the studies listed in table 3 shows that application of the MMS obviously leads to very similar results in markedly different samples. For example, Knights and Folstein [71] and Cavanaugh [75] reported a cognitive restriction rate of 33 and 28%, respectively, in patients on internal wards. This prevalence figure corresponds approximately to the 24% reported in the study by Kolbeinsson et al. [79]. The group of acute psycho-organic syndromes can initially be divided from that of dementia-type developments on the basis of additionally applied investigation methods. Acute psycho-organic syndromes also occur in approximately 6–9% of patients from typical (i.e. not age-stratified) samples collected from studies

Arolt

42

Table 3. Occurrence of physically defined disorders (organic psychosyndrome) in hospital patients Authors

Population

Number Methods

Bergmann and Eastham [70], 1974 Knights and Folstein [71], 1977 Cheah et al. [72], 1979 Schucki et al. [73], 1980

Internal medicine 65 years

100

Internal medicine 50% 50 years

57

Prevalence (%)

Clinical Dementia examination AP

7 16

MMS

33

Geriatrics

136

DSM-II

All

54

280

Feighner criteria

Dementia

15

Anthony et al. [74], 1982

Internal medicine/ surgery, men, 65 years Internal medicine 29% 60 years

Cavanaugh [75], 1983 Roca et al. [76], 1984

Internal medicine 37% 65 years Internal medicine 46% 65 years

335

MMS
Dementia clinical AP examination combined MMS

13 9 1 28

Dementia

15

Heeren and Rooymans [35], 1985 Feldman et al. [29], 1986

Internal medicine 65 years

90

Internal medicine all 70 years

451

MMS
clinical examination MMS
clinical examination CASE
files

Erkinjuntti et al. [77], 1986 Johnston et al. [36], 1987 Cooper and Bickel [37], 19871 Francis et al. [78], (1990)

Internal medicine 55 years 65 years

2,000

SPMSQ

Dementia AP combined Dementia AP combined All Dementia

3 6 3 3 6 3 29 9

Internal medicine 65–80 years

626

CASE
CIS

All Dementia

9 5

New general admissions, 70 years Internal medicine 70 years

229

MMS
DSM-III-R

AP

22

331

MSQ
MMS
DSM-III-R

All AP Dementia

32 14 18

Kolbeinsson et al. [79], 1993

97

380

Prevalence of Psychiatric Disorders in Physically Ill Patients

43

Table 3 (continued) Authors

Population

Number Methods

Arolt et al. [23], 19951

Internal medicine
surgery

400

Silverstone [32], 1996 Wancata et al [33], 19961

Internal medicine

343

Internal medicine/ surgery/gynecology

265

CIDI clinical Dementia examination AP SCAN Dementia AP CIS All

Prevalence (%) 20 12 7 3 6 28

AP  Acute organic psychosyndrome; combined  combined acute and chronic organic brain psychosyndrome; SCAN  schedules for clinical assessment in neuropsychiatry. For further abbreviations see the text. See Bickel [81] for CASE. 1 Studies from German-speaking countries.

published since 1980. Thus there is very good conformity between more recent studies, e.g. by Silverstone [32] and Arolt et al. [23], whose results also correspond to those of Feldmann et al. [83], whereas the figure quoted by Anthony et al. [74] is somewhat higher at 9%. However, the data vary more markedly in patients over the age of 65 years, ranging from 5 [37] or 9 [85] to 22% [78]. There is also a substantial discrepancy in the rates quoted for dementia of varying etiology. Variations in the study population naturally also play a major role, especially in the determination of these prevalence figures which range from 5 to 18%. Dementia-type developments are most frequent in patients aged over 65 years, in terms of senile dementia. In view of the irregular case distribution, the predictive potential of a mean value referring to the total distribution is misleading. From the clinical aspect too, it is far more sensible to report corresponding prevalence rates for samples, e.g. of patients aged over 65 years. However, the determined prevalence rates are found to vary substantially even when an attempt (limited by the data in the publications) is made to form homogeneous samples based on the variable ‘age’. The data collected in the Lübeck General Hospital study show an overall rate of 18.0% for dementia (internal medicine 17.5%, surgery 18.6%) in a subsample of 211 patients aged between 65 and 97 years. The inclusion of organically induced behavioral disorders raises these rates by about 5% [23, 65]. These results are in very good conformity with those of Schuckit et al. [73] and Feldman et al. [83]; the results reported by Erkinjuntti et al. [77] are also still within the confidence range.

Arolt

44

Correlations between Psychiatric and Somatic Disorders

The fact that many important questions, whose answers might be of potential medical benefit from an epidemiological perspective, remain open has to be seen in a critical light. Little is known of the biological, psychological and social determinants contributing to the pathogenesis of psychiatric disorders in physically ill patients. Our knowledge of the course of psychiatric disorders in physically ill patients, and especially of the reciprocal influences of physical and mental illness, is also incomplete. It is suspected, for example, that those psychiatric disorders persisting after discharge from hospital or after primary medical treatment have a negative impact on the development of chronic physical diseases in particular [86]. However, very few studies have been published, e.g., on the further course of psychiatric disorders after discharge from hospital [73, 86–88]. Empirical knowledge of possible correlations between mental and physical illness is still scant. Various attempts have been made to systematize the correlations between psychiatric and physical disorders [89], with the following three types having proved practicable: (1) psychiatric and physical disorders are concomitant but unrelated; (2) a psychiatric disorder is induced essentially by a physical disorder, and (3) a physical disorder is induced essentially by a psychiatric disorder. The unrelated concomitance of mental and physical illness is likely to be the most frequent case, without this being borne out adequately by systematic investigations. In the Lübeck study no causal relationship was found between psychiatric and somatic disorders in 55% of cases of comorbidity [27]. In contrast, the development and deterioration or chronification of psychiatric disorders through somatic disorders is empirically better documented. Weyerer [90], for example, lists a series of investigations showing that chronically ill children are at greater risk than healthy children of developing psychiatric disorders (relative risk 1.44–2.97). Various epidemiological studies have also illustrated that the risk of suffering from a psychiatric disorder is markedly higher in physically ill than in healthy adults (relative risk 1.41–3.55) [8, 91]. The study by Wells et al. [91] reports prevalence rates approximately twice as high for patients suffering from various physical illnesses in comparison with healthy patients. In studies of specific patient samples, e.g. with specific neurological diseases, diabetes mellitus, coronary heart disease or cancer, increased rates of psychiatric disorders are regularly found, but without it being clear whether these psychiatric disorders actually developed in connection with the physical illness or in what way they were exacerbated. In the Lübeck General Hospital study, on the basis of an expert opinion, an attempt was made to assess to what extent a psychiatric disorder was merely reinforced or was even caused by a physical illness and in particular what kind of psychiatric disorder was involved (table 4).

Prevalence of Psychiatric Disorders in Physically Ill Patients

45

Table 4. Relationship between psychatric and physical illnesses according to the Lübeck General Hospital study [27] Diagnosis group

F01–03 F04–07 F10 F11–19 F2 F32/33 F34 F40/41 F43 F44–48 F51

Dementias (44%)1 Other organic disorders (24%) Alcohol abuse (25%) Other substance abuse (7%) Schizophrenia (2%) Depressive episodes (15%) Continuous affective disorders (17%) Anxiety disorders (4%) Reactions (29%) Dysfunctional/somatoform disorders (14%) Non-organic sleep disorders (4%)

Relationship strengthened (n  26)

caused (n  67)

independent (n  94)

11.4* 8.3 4.0* 28.6 0.0 20.0 35.3

36.4 75.0* 0.0* 14.3 0.0 26.6 0.0*

52.3 16.6 96.0 57.1 100.0 53.3 64.7

0.0* 3.4* 28.6

0.0* 65.5 14.3

100.0 31.1 57.1

0.0*

0.0*

100.0

The most important disorder groups and subgroups are shown in the table with the percentages given in parentheses. It must be note that throughout the table the correlation type ‘independent’ was only indicated when, at the time of treatment, the prominent somatic disorder was in no way related to the psychiatric disorder. *Significant difference in the occurrence of ‘strengthened’ and ‘caused’ as opposed to ‘independent’ (Sokal-Rohlf test).

This revealed that organic disorders and depressive reactions in particular were caused by underlying physical illnesses. Substance abuse and persistent affective disorders (dysthymias) were reinforced by organic diseases. Approximately 50% of depressive episodes developed regardless of physical disorders, while 50% were either reinforced or even caused by them. Although these data are subject to the uncertainties inherent in expert opinions, they were checked for plausibility to the extent that they were compared with the respectively registered time points at which physical and mental disorders occurred. This comparison showed that the assessment of the impact of the physical illness on the psychiatric disorder conforms essentially with the assessed incidence of psychiatric disorders [27]. In the medical world, however, one important remaining question, which is relatively unclarified in scientific terms, is whether psychiatric disorders can

Arolt

46

also be a cofactor in the etiology of physical illnesses. Although this type of correlation was still largely rejected as purely speculative during the previous decade, there is increasing empirical evidence that psychiatric disorders have a significant impact on the pathogenesis and course of physical illnesses. While findings relating to correlations between depressive disorders and various types of cancer are still highly inconsistent and difficult to interpret, the influence of depressive disorders on cardiac morbidity and mortality in patients with existing coronary heart disease can be considered empirically well documented [Arolt and Rothermundt, pp 98–117]. However, some epidemiological findings also suggest that depressive disorders are to be seen as an independent risk factor for coronary heart diseases in subjects with a previously sound heart. In the corresponding studies, confounding variables such as hypertension, smoking, visceral overweight and alcohol abuse were controlled [92–94].

Conclusions

The prevalence of psychiatric disorders has been investigated especially in internal and partly also in neurological, surgical and gynecological samples, using both dimensionally and ultimately also categorically oriented instruments. Similarly, many studies have been published on psychiatric disorders in patients with specific somatic syndromes. Findings permitting a meanwhile relatively valid assessment of the prevalences of such illnesses and therefore revealing the scale of the problem are thus available. At least one third of all patients in hospital or in the care of a general practitioner are suffering from psychiatric disorders that need to be diagnosed and treated where necessary. Although the scale of the potential health care problem is impressive, important questions remain unanswered both from the descriptive-epidemiological and from the analyticepidemiological perspective: (1) What are the course characteristics of psychiatric disorders in somatic patients discharged from hospital? How many and which disorders persist, and what are their specific characteristics? (2) To what extent are existing therapy offers utilized in the further course, and what are the factors determining the utilization of therapy offers? (3) What influence have therapy offers on the further course of the psychiatric disorder? Justified though these questions may seem from the scientific perspective, it is questionable in view of current developments in the health care system in Germany and the introduction of diagnosis-related groups whether the significance of psychiatric disorders in the overall treatment context is appreciated and considered cost-relevant and whether the field of consultant/liaison psychiatry and psychosomatics can thus also break away from its neglected status in medical practice and research. The medical treatment of the population is subject to

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intense cost pressure, with short-term cost-cutting obviously being given priority over longer-term planning stages. But research policy too has developed justification dynamics not conducive to the investigation of care-oriented epidemiological issues. It is therefore to be feared that the relatively time-intensive tasks involved in the proficient diagnosis and treatment of psychiatric disorders in physically ill patients will not be adequately performed in clinical practice in the future either, and that scientific developments in this field will also remain marginalized. References 1 2

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Cheah D, Paulo JR, Folstein MF: Psychiatric disturbances in neurological patients: Detection, recognition and hospital cause. Ann Neurology 1978;4:225–228. Schuckit MA, Miller P, Berman J: The 3-year course of psychiatric probands in a geriatric population. J Clin Psychiatry 1980;41:27–32. Anthony JC, Leresche l, Niaz U, von Korff MR, Folstein MF: Limits of the ‘Mini-Mental-State’ as a screening test for dementia and delirium among hospital patients. Psycho Med 1982;12: 397–408. Cavanaugh SA: The prevalence of emotional and cognitive dysfunction in a general medical population: Using the MMSE, GHQ, and BDI. Gen Hosp Psychiatry 1983;5:15–24. Roca RP, Klein LE, Kirby SM, McArthur JC, Vogelsang GB, Folstein MF, Smith CR: Recognition of dementia among medical patients. Arch Intern Med 1984;144:73–75. Erkinjuntti T, Wikström J, Palo J, Autio L: Dementia among medical in-patients. Arch Intern Med 1986;146:1923–1926. Francis J, Martin D, Kapoor WN: A prospective study of delirium in hospitalized elderly. JAMA 1990;263:1097–1101. Kolbeinnsson H, Jonsson A: Delirium and dementia in acute medical admissions of elderly patients in Iceland. Acta Psychiatr Scand 1993;87:123–127. Bickel H: Psychogeriatrisches Screening im Allgemeinkrankenhaus. Z Geronto Psychol Psychiat 1988;1:259–275. Folstein MF, Folstein SE, McHugh PR: ‘Mini-Mental-State’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198. Pattie AH, Gilleard CJ: Manual of the Clifton Assessment Procedure for the Elderly. Sevenoaks, Hodder & Stoughton Educational, 1979. Feldmann E, Mayou R, Hawton K, Ardern M, Smith EBO: Psychiatric disorders in medical inpatients. Q J Med 1987;241:405–412. Bickel H, Cooper B, Wancata J: Psychiatrische Erkrankungen von älteren Allgemeinkrankenhauspatienten: Häufigkeit und Langzeitprognose. Nervenarzt 1993;64:53–61. Lustman PJ, Griffith LS, Freedland KE, Clouse RE: The course of major depression in diabetes. Gen Hosp Psychiatry 1997;19:138–143. Trzepacz PT, Teague GB, Lipowski ZJ: Delirium and other organic mental disorders in a general hospital. Gen Hosp Psychiatry 1985;7:101–106. Mayou R, Hawton K, Feldman E: What happens to medical patients with psychiatric disorder? J Psychosom Res 1988;32:541–549. Bickel H, Cooper B, Wankata J: Psychische Erkrankugen von älteren Allgemeinkrankenhauspatienten: Häufigkeit und Langzeitprognose. Nervenarzt 1993;64:53–61. Mayou R, Sharpe M: Psychiatric problems in the general hospital; in Judd FK, Borrows GD, Lipsitt DR (eds): Handbook of Studies on General Hospital Psychiatry. Amsterdam, Elsevier, 1991. Weyerer S: Relationships between physical and psychological disorders; in Sartorius N, Goldberg D, de Girolamo G, Costa e Silva JA, Lecrubier Y, Wittchen HU (eds): Psychological Disorders in General Medical Health Settings. Toronto, Hogrefe & Huber, 1990. Wells KB, Golding JM, Burnam MA: Psychiatric disorder in a sample of the general population with and without chronic medical conditions. Am J Psychiatry 1988;145:976–981. Burg MM, Abrams D: Depression in chronic medical illness: The case of coronary heart disease. J Clin Psychol 2001;57:1323–1337. Musselman DL, Evans DL, Nemeroff CB: The relationship of depression to cardiovascular disease: Epidemiology, biology, and treatment. Arch Gen Psychiatry 1998;55:580–592. Hesslinger B, Harter M, Barth J, Klecha D, Bode C, Walden J, Bengel J, Berger M: Komorbidität von depressiven Störungen und kardiovaskulären Erkrankungen. Implikationen für Diagnostik, Pharmako- und Psychotherapie. Nervenarzt 2002;73:205–217.

Prof. Dr. Volker Arolt Department of Psychiatry University of Münster, Albert-Schweitzer-Strasse 11 DE–48129 Münster (Germany) Tel.
49 251 83 56604, Fax
49 251 83 56988, E-Mail [email protected] Prevalence of Psychiatric Disorders in Physically Ill Patients

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 52–65

Mental Disorders in Primary Care Michael Linden Research Group Psychosomatic Rehabilitation, Charité and Department of Behavioral Medicine, Rehabilitation Centre Seehof, Teltow/Berlin, Germany

Epidemiology of Psychiatric Disorders in Primary Care

Both in Germany and internationally, epidemiological studies have repeatedly shown that 15–25% of the general population suffer from psychiatric illnesses [1–5]. As most persons regularly consult general practitioners [6] and as those with psychiatric disorders contact doctors about twice as often as other patients [7, 8], it is not surprising that about every 4th patient in general practice is suffering from a psychiatric disorder [9–14]. Women, divorced people, middle-aged individuals and those of low social status are found to have elevated rates of psychiatric disturbance [7–15]. Comparisons between industrialized and developing countries indicate that in poorer countries the rate of psychiatric disorders among patients in primary care is similar or even higher than in richer countries [16–19]. According to a recent study, which was carried out under the leadership of the World Health Organization (WHO) [14, 20], the most important psychiatric disorders are depressive illnesses in about 10% of patients, followed by generalized anxiety disorders (8%), neurasthenia (7%), alcohol abuse (3%), somatization (2%) and panic disorders, agoraphobia, and dysthymia in about 2% each. About 10% of the patients meet criteria for more than one ICD-10 diagnosis, indicating a high rate of psychological comorbidity. The probability of suffering from psychiatric illnesses rises with the level of severity of physical illnesses. Patients whose physical health was classified as poor had a 1.4-fold higher risk of also suffering from a psychiatric disorder. This corresponds to the findings of a series of similar studies which, in some cases, have indicated that the risk is as much as a 3.6-fold [12, 21].

With regard to the significance of psychiatric disorders in general and those encountered in general practice in particular, it is well established that they directly impair quality of life and this to a greater extent than physical illnesses. Further, it has been shown that even less severe psychiatric disorders have substantial social costs because of impairment in social adjustment and role performance at work and in the family [22–25]. This can especially be shown by data on days of sick leave. Patients in general practice who have been diagnosed according to ICD-I0 as having a psychiatric disorder had about 6 days of sick leave in the previous month as compared with 2 for other patients. This is still true when followed up 1 year later. It is furthermore of special interest that even sub-threshold disorders lead to a doubling of time of sick leave [26, 27].

Diagnosis of Psychiatric Disorders in Primary Care

One topic which has found extensive coverage in the literature is the problem of ‘underdiagnosis’ or ‘hidden psychiatric morbidity’ [7, 28, 29]. Some authors suggest that this is due to a lack of psychiatric knowledge on the part of the practitioners. Another explanation is that it is a reflection of the distinctive characteristics of the disorders concerned, the specificity of the presented complaints, the particular ways in which patients present themselves in primary care and the lack of consequences from structured diagnoses. Classification systems for mental disorders have traditionally been developed in the context of psychiatric hospitals or services with a special focus on psychotic illnesses. These very distinct disorders present with symptoms of clear diagnostic meaning such as delusions or hallucinations. They are in most cases also very prominent and difficult to overlook or misinterpret. In contrast, disorders in primary care tend to be of mild to moderate severity and cannot be diagnosed on the basis of single characteristic symptoms but rather on the basis of patterns of unspecific symptoms and often only by observing the course of illness over longer periods of time. Anhedonia, disturbances in concentration, lack of motivation, loss of appetite, sleep disorders or disturbances of energy may be manifestations of depression, but also of many other psychiatric disorders and even more of a large variety of somatic illnesses as well. This unspecificity of symptoms can also explain the phenomenon of psychiatric ‘co-morbidity’, as many patients fulfill the criteria for several disorders such as anxiety, depression, neurasthenia or somatization at the same time. For example Stein et al. [30] found that in primary care the prevalence of mixed anxiety and depression was greater than that for pure cases of either, and as a result of this the mixed category has even been adopted as a distinct diagnosis in ICD-l0. Similarly difficult is the delineation to somatic illnesses. Linden et al. [31] showed that the

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average score on the Hamilton Depression Scale fell by half when symptoms of depression were not counted if internists, who also had seen these patients, interpreted these as symptoms of physical illnesses. Finally, it has to be acknowledged that such minor or unspecific complaints can also be prodromal symptoms or indicators of relapse in a still wider range of disorders, so that it may only be possible to arrive at a valid differential diagnostic classification after prolonged periods of observation. Because of these difficulties in establishing reliable boundaries of specific categories for many disorders as they present in primary care, the WHO has developed a special classification for psychiatric disorders in primary care [32]. Its principal characteristic is that diagnostic categories are broader. A further problem which is typical for general practice is how to establish thresholds for making diagnoses [33, 34]. Severe psychopathological symptoms, such as hallucinations or delusions, are to a large extent categorical either/or phenomena. Their presence always reflects an illness and must always be interpreted in psychopathological terms. In contrast, the symptoms of disorders typical for primary care are dimensional phenomena which, without any discontinuity, make the transition from normality to psychopathology, e.g. the transition from an excellent ability to concentrate to a somewhat impaired ability to concentrate to a complete inability to concentrate [35]. Epidemiological data show that less severe manifestations of such symptoms are more common than severe ones. Minor alterations in the threshold at which a symptom is seen as being of clinical significance will therefore necessarily lead in primary care settings to substantial shifts in prevalence figures. The dimensional nature of the complaints has consequences for the recognition of disorders. Severe disorders are easily detected while threshold or minor disorders, which do not yet impair social functioning or do not lead to immediate therapeutic consequences are not diagnosed [36]. From such theoretical considerations, it follows that diagnostic conclusions regarding the disorders as seen in primary care settings, carry by their very nature a greater diagnostic uncertainty than cases seen in psychiatric settings. Thus agreement rates between 2 observers or between observations based on different methodologies will necessarily show great variability. We may even ask who is nearer to the ‘truth’ when researchers and general practitioners arrive at different conclusions about diagnoses, since the lack of specificity of symptoms is not taken into account when using standardized survey instruments. In the WHO primary care study, the general practitioners arrived at a rate of psychiatric disorders among their patients of 23.4%, which is almost identical with the prevalence of 24.0% arrived at using the Composite International Diagnostic Interviews (CIDI), but falls below the overall rate for the CIDI of 32.5% arrived at when the sub-threshold CIDI patients were also included [37]. The CIDI is a structured and standardized interview to diagnose

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mental disorders. However, agreement in making a diagnosis was less satisfactory. Only 3.3% of practice attendees were detected both by the doctor and the research interview. Apart from the jointly diagnosed patients, there are not only those who are ill according to the CIDI but are not recognized by the doctors, but also 10.9% who, according to the doctor’s evaluation, are mentally ill without being detected by the CIDI. Interestingly, the correlation is greater between medical diagnoses and the self-rating instrument GHQ (r ⫽ 0.83) than between the CIDI diagnosis and the GHQ (r ⫽ 0.73). Finally, another fundamental problem in the diagnosis of psychiatric disorders in primary care lies in the fact that, in less severe disorders, unlike for example psychotic illnesses, patients themselves have a substantial influence on how a symptom is seen. It is up to them which complaints they experience as burdensome and which they wish to report. Patients who go to a general practitioner will be more inclined to report physical than psychological problems as compared to patients who seek help from a psychiatrist. All studies in this area show that only a few patients with psychiatric disorders complain about psychological problems to general practitioners but rather about somatic symptoms [38]. In the international WHO study [20], 32.8% of practice attendees presented with complaints relating to physical conditions, and a further 29.3% complained about a variety of pains; 6.9% complained of tiredness and sleeping problems. Tyler et al. [39] showed that the diagnosis of a mental disorder was approximately eight times higher when psychological complaints were reported by the patient at the beginning of a consultation in contrast to patients who only later on talk about such problems. It must be accepted that the task of general practitioners is primarily not to manage psychiatric disorders but to treat illnesses of all kinds. Another aspect which needs to be considered when discussing recognition of mental disorders are the consequences of diagnosis. Minor disorders have a high chance of spontaneous remission, so that waiting instead of treating is a clinically sound alternative [40, 41]. Additionally one has to consider, that under diagnostic uncertainty, as already discussed, any shift in diagnostic thresholds will lead to substantial alterations in the sensitivity and specificity of diagnostic signs, and therefore not only increase the rates of properly detected cases but also of false-positive diagnoses. Making a diagnosis can therefore harm as well as help because of the possibility of unnecessary therapeutic interventions or stigmatization of patients.

Treatment of Psychiatric Disorders in Primary Care

Pharmaco-epidemiological studies indicate that general practitioners rather than psychiatrists prescribe the largest total quantities of psychotropic

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drugs [42]. This can be explained by the fact that there are about 20 times as many general practitioners as psychiatrists [43] treating per doctor a significantly larger number of patients. There are substantial differences between regions and between professional groups [44–46]. Such data show that the choice of treatment and prescribing behavior are not only dependent on medical factors as such, but also on gender or attitudes of patients and doctors, organizational and political guidelines, and ethical and cultural contexts [47–54]. In the WHO primary care study [37, 55, 56], it was found across all international sites that 11.5% of practice attendees were treated pharmacotherapeutically for psychiatric disorders, with considerable variations from 2% in Shanghai to 29.6% in Santiago. Surveys by other authors have arrived at comparable or even higher rates of variation [57, 58]. Among patients who were mentally ill in the view of doctors, an average of 51.3% were treated with psychotropic drugs in the wider sense. These data indicate that psychotropic drugs are a first-line method of treatment by general practitioners for psychiatric disorders. Tranquilizers and sedatives are the most often prescribed psychotropics with 26.3% of patients recognized as mentally ill, followed by antidepressants in 15.0%, and herbal and tonic substances in 13.2%. These data indicate that treatment is primarily symptomatic and nonspecific. This can be confirmed by looking at patients with acute depressive episodes according to ICD-10 who had been diagnosed by the treating physician. Only 22.2% received an antidepressant. A further 27.6% received tranquillizers and another 23.2% other psychotropic drugs. Recognition is an important factor to explain who is treated how. In the WHO study, only 27% of patients who had been diagnosed as suffering from a mental disorders by the researcher were receiving treatment while 51.3% of those who had been diagnosed by the general practitioner got some prescription. Goldberg [59] was one of the first to show that an improved diagnosis which also influenced treatment application could shorten the course of the illness. This effect became more marked with increasing severity of the disorder. Ormel and Giel [60] reported that, in comparison to undiagnosed patients, diagnosed patients received psychotropic medication 4.5 times more often, psychotherapy 12.2 times more often and a referral to a specialist 3.3 times more often. This was accompanied by a sixfold better psychopathological status and a fivefold better level of social functioning. Hoeper et al. [61], who carried out a similar study which was based only on giving doctors feedback about the diagnosis, without making sure that some therapeutic action followed, found that there was no alteration in the course of illness. Similarly Tiemens et al. [36] found that higher recognition rates did not by themselves lead to a better course of illness.

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Schulberg et al. [62] carried out a comparative study with the question to what degree routine primary care can be improved. A total of 92 depressive patients remained in routine treatment (RT) by the general practitioner, 91 were treated with nortriptyline (NT) at a daily dose of 190–270 mg over 8 months according to a research protocol, and a further 93 patients received interpersonal psychotherapy (IPT). After 8 months, 48% of the NT and 46% of the IPT group were symptom-free as compared to 18% of the RT group. The differences are even clearer when only those who remained in treatment are considered. The percentage of symptom-free patients was 67% in the NT group, 72% in the IPT group and 20% in the RT group, while the proportion of patients whose score on the Hamilton Depression Scale was just as high after 8 months as at the beginning of treatment (⬎12) was 13% in the NT group, 15% in the IPT group and 48% in the RT group. These data confirm that the specificity of the treatment, the adequacy of its implementation and the consistency with which it is carried out are important requirements for treatment success. However, it should be borne in mind that, while these data refer to patients from general practice, they were specifically selected for this research project and the treatment was also carried out by specialists. A more realistic study was carried out by Callahan et al. [63], who randomized 103 general practitioners and 175 depressive patients aged over 60 in equal numbers in RT and an intervention group. The intervention consisted of the doctor receiving detailed information about their patients’ depression and recommendations for treatment. In the intervention group, significantly more antidepressants were prescribed. In contrast to Schulberg et al. [62], they did not find a difference between groups in respect to mental status. Similarly Katon et al. [64] tried to improve patient management by offering targeted counselling for patients. In comparison with the routine therapy group, the patients in the intervention group were significantly happier with treatment, were more likely to receive a prescription for psychotropic drugs and above all were significantly more compliant with the medication. Further, their status improved to a significantly greater degree in the course of treatment, above all in the more serious cases. A study by Linden et al. [65] shows how difficult it can be to improve routine care in a positive way. They tried to improve the prescribing of antidepressants by giving general practitioners extensive information on the proper dosis. Practitioners were randomized in an information and a control group. This intervention resulted in a small increase in prescribed daily doses, which were still much less than the dosage ranges recommended in text books. Clinical results showed that the intervention group had worse outcomes which could be explained by the fact that physicians tend to prescribe higher dosages for severe cases and lower doses for minor cases. The experimental intervention

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Table 1. Topics of physician–patient encounters (%) Topic

Psychological problem

Physical problem

General-unspecific Some advice Discussion of problems Counseling Psychotherapeutic intervention

32 18 20 4 6

62 2 6 2 0

resulted in an increase in dosages for the less severe patients with overall negative results. Apart from pharmacotherapy also psychotherapeutic interventions are of great importance in the treatment of minor psychological disorders. Supportive psychotherapy and counselling of patients are indispensable in basic care. In the WHO primary care study [37], 52.4% of patients who had been recognized as mentally ill received such forms of counselling by their physicians. A great variety of topics are discussed in such consultations. Zwernemann [66] studied type and frequency of topics discussed during 100 general practitioner contacts. Table 1 summarizes these data, comparing patients with and without psychiatric disorders. In a further study, Olfsson et al. [67] studied the forms of psychological intervention used by general practitioners. They carried out some form of psychological intervention with 24.1% of all patients, including listening to problems (22.4%) and giving advice (19.0%). Such interventions were used in 66.7% of patients with psychiatric disorders. Fletcher et al. [68] studied whether an increased rate of counselling is associated with a reduced rate of drug prescribing. Their results showed the opposite. The more counselling was given because of personal problems, the more antidepressants and tranquillizers were prescribed.

Cooperation between General Practitioners and Mental Health Specialists

Medical care is not only the result of medical knowledge, but depends just as much on the setting in which it is delivered or on which treatment strategies are permitted or available within a particular treatment institution. Economic considerations nowadays have a great influence on medical practice. Physicians are required not to do what is medically thinkable or optimal, but what is necessary and sufficient, and sometimes merely what is practicable. In this respect,

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the general practitioner has a key position in many health care systems. He or she is responsible not only for basic care, but also for either mobilizing or avoiding the involvement of specialists and sometimes for coordinating specialist input. Significant facets of general practitioner treatment thus includes both the initial contact and first treatment and also continuing care following specialist medical intervention. Williams and Clare [69] have described three models of cooperation between general practitioners and specialists: the referral, substitution and consultation models. The referral model envisages general practitioners as the primary treatment provider who, depending on the type of disorder, may send the patient on to a specialist for additional and further treatment. In the substitution model, the specialist is seen as the primary doctor for illnesses which fall under his or her area of competence and is also approached directly by patients if they suffer from disorders in this category. The consultation model sees the treatment of a patient as almost entirely in the hands of the general practitioner, while in difficult cases the patient is presented to a specialist for advice. There are substantial international differences in the ways in which primary medical care is organized. While in Germany a patient is free to go to whatever doctor he or she chooses, in Holland the patient first has to go to a general practitioner and can see a specialist only on referral from a general practitioner. This is the so-called gatekeeper function of the primary care physician which has direct consequences on the utilization of care. In Holland, over 95% of patients who present in general practice have never been in treatment elsewhere for the problem concerned, whereas the proportion in Germany is only about 75% [70]. Surveys show that about 1–2% of general practice patients are sent to specialists and that about 10% had respective contacts in the past [10, 11, 13, 71]. Patient-related factors which make referral more likely are a psychiatric history, psychiatric primary complaints, social problems and the family doctor making a respective diagnosis [72, 73]. Older patients also have a tendency to remain with their general practitioner and not to seek the help of an additional doctor such as a psychiatrist [74, 75]. Variables associated with the doctor are that he or she might be narrowly focussed on the management of physical disorders or is feeling competent or not to manage mental disorders [73, 76]. Studies on the needs for referral have as a rule concluded that the rate of referral is too low [10]. Criteria for when a specialist should be involved by the general practitioner according to Helmchen [77] are: (a) doubts about the psychiatric diagnosis and problems of differential diagnosis in multi- and comorbidity; (b) severity of illness and threat of complications such as suicide; (c) length of illness, degree to which it has become chronic and treatment-resistant; (d) requirement for long-term medication; (e) unwanted side effects of medication,

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and (f) need for specific psychological treatments. In studies in which psychiatrists directly examined patients in family practices, half of the patients seen were in need of psychiatric treatment [10, 13]. In a newer study by Schulberg et al. [78] on depressive illnesses in primary care, it was found that among 283 patients with depression 70% could be appropriately treated by the general practitioner, 13% needed referral to a psychiatrist and 17% had other disorders in need of other forms of treatment. Empirical studies on when general practitioners make referrals show that this is done after some first-line treatment has been applied. According to Maguire et al. [79] in 61% of referred patients drug treatment had already been given and 67% had received some form of advice or counselling. In 30% the reason for referral was that some form of treatment was not available in the primary care setting, in 20% because of treatment resistance and in 14% for a sharing of the burden of care in chronic disorders. This corresponds to guidelines for the management of depressive illnesses such as those issued by the Agency of Health Care Policy and Research of the USA [80], which recommends that general practitioners should generally make a first attempt at treatment, including drug treatment. However, some psychiatrists are critical of such recommendations and advocate earlier referral [81]. Empirical evidence is required as to when referral results not only in additional costs but also in a better clinical outcome. According to the studies available, the types of disorders which are seen in general practice are not necessarily managed better by a specialist than by general practitioners themselves. Jenkins and MacDonald [82] randomly allocated 65 older depressive patients, who bad been diagnosed during a screening program in general practices, for 9 months either to a multiprofessional psychogeriatric team or to continued management as usual by the general practitioner. They found no difference in outcome between the 2 groups. In a study by Katon et al. [83], half of a group of patients of 18 general practitioners who had in the past been heavy users of medical services were randomized to receive a psychiatric consultation. After 6 months, there was a significant increase in antidepressant prescriptions for the referred patients. However, there were no significant differences with regard to the psychopathological status, the degree of disability or the continuing use of medical services. In a similar study by the same authors [84], patients with depression were randomly allocated to join management with a psychiatrist. At follow-up, the intervention patients were receiving significantly more antidepressants. Overall, there was a significantly better course of illness only for those with major depression, while the improvement rate for minor depression was the same in the intervention and the control group. In a study by Scott and Freeman [85], 121 patients were randomized either to a psychiatrist, a behavior therapist, a social worker or treatment by a general practitioner alone. After 4 and 16 weeks, independent raters saw improvements in all

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patient groups, but no difference between the treatment groups. But the treatments of the specialists resulted in four times higher costs. Patients were most satisfied with the psychological treatment and the management by the social workers [85, 86]. Thus, not all referrals to specialists will lead to a better course of illness.

Conclusion

The primary care setting is important for the treatment of patients with psychiatric disorders and is providing care to the greatest number of such patients. Both theoretical considerations and evidence in practice indicate that knowledge from psychiatry cannot be simply transferred to general care. Instead, there is a need for setting-specific knowledge about diagnostic and treatment peculiarities. It also is neither rational nor feasible to refer all respective patients to specialists. Instead, the cooperation between specialists and general practitioners should be intensified and to this end new models of cooperation should be developed. Finally, this area needs more research, to make sure that the patient is treated where he or she can receive the best form of help.

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Katon W, VonKorff M, Lin E, Bush T, Russo J, Lipscomb P, Wagner E: A randomized trial of psychiatric consultation with distressed high utilizers. Gen Hosp Psychiat 1992;14:83–85. Katon W, VonKorff M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J: Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995; 273:1026–1031. Scott AIF, Freeman CPL: Edinburgh primary care depression study: Treatment outcome, patient satisfaction, and cost after 16 weeks. Brit Med J 1992;304:883–887. Scott J, Moon CA, Blacker CV, Thomas JM: A.I.F. Scott & C.P.L. Freeman’s “Edinburgh Primary Care Depression Study”, Brit J Psychiat 1994;164:410–415.

Prof. Dr. Michael Linden Rehabilitationsklinik Seehof Lichterfelder Allee 55, DE–14513 Teltow/Berlin (Germany) Tel. ⫹ 49 3328 345678, Fax ⫹49 3328 345555, E-Mail [email protected]

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 66–73

Geriatric Consultation-Liaison Psychiatry in Germany Gabriela Stoppea, Jürgen Staedtb a Psychiatric University Hospital, Basel, Switzerland, and bDepartment of Psychiatry, Vivantes Klinikum Spandau, Berlin, Germany

Structures of Geriatric Psychiatry in Germany

German universities and medical schools usually do not provide special education in geriatric medicine or geriatric psychiatry. Of more than 30 ‘schools’ there are only 4 universities with special departments for geriatric medicine and also only 4 specialized units for geriatric psychiatry. Recently one of few tenure professorships for geriatric psychiatry has been given up. Since all medical students are trained at these institutions, there is not much chance for them to receive systematic training in geriatrics. After passing the state examination, future neurologists and psychiatrists do an obligatory residency of at least 4 years. According to our tradition at least 1 of these 4 years has to be completed in the other discipline. This means that every psychiatrist in Germany has at least 1 year experience in clinical neurology. Depending on the size of the department young physicians will be confronted with specialized geriatric psychiatry wards or not. Large state hospitals usually provide separate departments for addiction disorders and geriatric psychiatry. Smaller departments at general hospitals or at university hospitals (see above) usually do not provide this specialization. Recently we analyzed whether these institutions and the kind of care (separate versus integrated) has an impact on patient selection, diagnosis and therapy [1, 2]. However, one has to keep in mind that the chance to gather experience regarding geriatric patients may be greater in smaller departments. Large hospitals do not provide routine training in geriatric psychiatry for specialization. The curriculum for psychiatry (and psychotherapy) tends to be ‘age-unspecific’ and makes it possible to be trained as a psychiatrist without seeing many geriatric psychiatric patients [3]. According

to international institutions [4] and to a German expert recommendation, the ‘Psychiatrie Enquête’ [5], so-called Geriatric Psychiatry Centers (consisting of an inpatient department, day care center and outpatient counselling), day care centers and memory clinics should be build to enhance early diagnosis and treatment of psychiatric disorders in old age and to keep patients integrated in their social networks as far as possible. Though their numbers are increasing there are still few [3]. To give an example, the ratio between the capacity of day clinics and that of geriatric psychiatric inpatient wards is about 1 in 45 places with a high variety regarding the federal structure. Overall there are 11.6 treatment places for 100,000 inhabitants, while the German recommendation is 20 per 100,000 inhabitants [6]. Just to compare, the Royal College of Psychiatry (UK) regards 1 day clinic place per 500 elderly people as adequate [7]. It is quite interesting that the increase in elderly people in the German population is not reflected by an increase in geriatric inpatient treatment in psychiatry. In an analysis of all inpatient treatment data of the years 1994 and 1997, the number of patients over 65 increased from 30.9 to 33.2%, especially in disciplines like internal medicine, surgery or neurology. During the same time in psychiatry, the number of elderly decreased from 16.6 to 15.1% [8]. A careful analysis concludes that geriatric psychiatry patients do not reach a specialist or a geriatric psychiatric ward but seem to be directly admitted to other institutions like nursing homes [9]. There is an increasing number of demented patients among the institutionalized elderly, making about two thirds of all nursing home inhabitants [10]. Since there is no obligatory psychiatric or geriatric investigation before admission to a nursing home, patients often reach these expensive homes without optimal or at least adequate diagnosis and treatment. Outpatient care is provided by primary care physicians and specialists. As in other countries German surveys show that only a minority of the elderly visit a neurologist or psychiatrists [11]. Besides the well-known stigmatization of psychiatry, for the present elderly generation the history of cruel practices for psychiatric patients, especially during the 1930s and 1940s, seems still to be frightening. However, there are also capacity limits. About 4,700 specialists for nervous diseases, psychiatry and psychiatry and psychotherapy are working in private practice (table 1). If we only considered dementia patients, each of these specialists would have to treat 200 dementia patients in his/her practice [12, 13]. A representative survey of the over 65-year-olds in the city of Mannheim showed that only 28% had been investigated with regard to dementia [14]. The number of memory clinics is steadily increasing. Meanwhile more than 80 institutions are working according to this interdisciplinary concept. They add competence to direct ambulatory treatment (mostly) without the necessity of a transfer by the responsible primary care physician or a specialist [15].

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Table 1. Number of specialists in neurology, psychiatry, psychotherapy working in Germany Discipline

Number of practicing physicians

Private practice

Hospital

Administration or insurance companies

Neurology and psychiatry Psychiatry Psychiatry and psychotherapy

5,042 3,335 1,848

2,977 1,113 638

1,628 1,876 1,105

229 184 60

Official statistics of the German Federation of Physicians (Bundesärztekammer) from 31, December 2001.

Empirical Studies regarding the Prevalence of Geriatric Psychiatric Disorders in German Hospitals

Only a few studies focussed especially on geriatric psychiatry. The study by Bickel et al. [16] provides data on the prevalence and prognosis of 626 patients aged 65–80 years in 6 departments of internal medicine in the cities of Mannheim and Ludwigshafen. With a response rate of 81.4% and the comparison to a similar study in the general population of that area, this study gives reliable data on the German situation, especially as, e.g., the prevalence rates of different psychiatric disorders are in line with those published by other authors from other countries. Patients who did not live independently before admission and those in a lethal condition were excluded. They were given a psychogeriatric screening followed by a psychiatric interview. Overall the risk of a psychiatric illness was 2.5-fold higher for inpatients compared to the elderly in the community. Psychiatric illness could be diagnosed in 30.2% of patients. The largest group were affective disorders making up 13.1% and organic brain disorders accounting for 9.1%. Eight percent exhibited other functional disorders. These data are in line with those published for other countries [17–19]. A similar rate of 30.5% prevalence of psychiatric disorders could be found in an Austrian study in the medical, surgical and gynecological departments of 2 hospitals [20]. The Mannheim study also provided a follow-up after 1 year for 100 patients with and without psychiatric disorders. Eighty-five patients, who were still alive after about 5 years were also available for a second follow-up. Both groups were randomized and controlled for age, socioeconomic situation, size of household and somatic illness and prognosis. In 75% the psychiatric disorders persisted. Even after control of other relevant data, patients with psychiatric illness had an increased risk of mortality (⫹43%) and nursing home admission (⫹157%).

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Investigations of Geriatric Consultation Psychiatry in Germany

Arolt et al. [21, 22] investigated patients of the general hospitals in Lübeck. The majority of patients (52.75%) were more than 65 years of age. Compared to the general population there were significantly more diagnoses of organic brain disorders, alcohol-associated disturbances and adjustment disorders. As to be expected, the frequency of psychotic/schizophrenic disorders was similar in younger and older patients. While the diagnoses of the younger ones were predominantly adjustment disorders and addiction, the major diagnosis for the elderly was organic brain syndrome. Delius et al. [23] from the Lübeck group reported that in cases of depression the responsible physicians asked for a transfer to psychiatry in 71.6% of all cases. On the contrary, the liaison psychiatrist wanted two thirds of them to stay in the somatic department. In another investigation [24] 824 consecutive psychiatric consultations at a large general hospital (Klinikum Nuremberg) were documented according to the standardized methodology of the European Consultation-Liaison Workgroup (ECLW) [25]. Six hundred (72.8%) consultations were done in patients at aged 60 years and older. As to be expected there was an increase in diagnoses of organic brain disorders and a decrease in substance abuserelated disorders with increasing age. Previously unexpected, however, was the finding that there was a significant difference with regard to the announcement of a psychiatric liaison service. While 43% of the younger patients were informed that psychiatric counselling had been requested, this was the case in only 9.8% of the over 80-year-old patients. Excluding organic brain symptoms did not alter this result (48.7 and 12.8%, respectively). There was also a significant decrease in the time spent with the patient for consultation without an increase in time spent with, e.g., the patients’ families or the nurses. Again, the same result could be obtained after excluding patients with dementia or delirium. In another recent investigation, Wetterling and Junghanns [26] describe a geriatric psychiatric consultation service in the elderly and the impact of changes in relevant legal rules for them. Of all elderly patients in that hospital about 3% received psychiatric consultation. This was about one third of all psychiatric consultations in the hospital. The main diagnosis was delirium and dementia (together 49.3%), followed by affective disorders (17.9%) and (acute) adjustment disorders (15.3%). Drug abuse or addiction were diagnosed in 5.9% of all cases. Most of the liaison service was requested for diagnosis and therapy. 7.6% were intended to provide help in competency assessment regarding nursing home admission and legal guardianship.

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Own Investigations of Geriatric Consultation-Liaison Psychiatry

In a retrospective analysis of all psychiatric consultations performed between 1994 and 1996 in our university hospital for patients above the age of 60, we tried to analyze some of the problems occurring in the geriatric liaison service. The University Hospital of Göttingen is a large hospital providing care in all relevant disciplines. The Department of Psychiatry provides a consultation service which is usually done by experienced residents and/or supervising specialists of the department. In the relevant time frame, one third of all patients of the university hospital were over 60 years old. This age group accounted for 30.3% of all psychiatric consultations (n ⫽ 278). This is a lower number than that reported from non-university hospitals (see above). Two thirds of the patients belonged to the younger old with ages between 60 and 75. Eighty-two percent lived in their own household before admission, only 5% were admitted from nursing homes. Oncology and gynecology had to be excluded since both departments have a special liaison service on their wards. We compared the number of geriatric psychiatric consultations to the number of elderly patients in the special departments. More consultations than expected were requested from ophthalmology, dermatology, urology and orthopedics. Less than expected was the number of consultations in internal medicine, surgery, neurology and anesthesia. However overall consultations in internal medicine (47%), surgery (18%) and neurology (13%) made up the majority of all consultations. The interrelationship between the time of occurrence of psychiatric symptoms and hospitalization was of special interest. In 54% of all cases psychiatric symptoms had been present at the time of admission. This indicates that they had been present previously and hospitalization offered a chance or a reason to receive psychiatric service. An additional 16% had an acute disorder and further 15% developed their symptomatology within 2 weeks after hospital admission. Diagnoses were dementia and delirium in one third of the cases and affective disorders in 19.9%. No psychiatric disorder at all was diagnosed in 7.2%. The somatic conditions present in the psychiatric patients is given in figure 1. The spectrum underlines the special interrelation between cardio- and cerebrovascular disorders and psychiatric disorders [27–30]. The consultants recommended psycho-active drugs in 41% of all cases. A time limit for the treatment was only given in few cases, in 23.18% drugs were recommended on demand. The physicians followed the recommendation in 69.4% of all cases, in at least 10% they chose a completely different regimen. Because of many missing data due to documentation problems, the data regarding outcome are limited. However, even after the end of the hospital treatment, continued psychiatric treatment was recommended in about 20%.

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30.94%

14.39% 8.63% 8.99% 2.16% 7.19%

27.70% 66.55%

None Not known Cardiovascular Postoperativ e Endocrine CNS Chronic pain Liver

Fig. 1. Somatic conditions in patients seen in geriatric psychiatric consultations at the University Hospital in Göttingen (for details see text).

Two thirds of these cases should be in an inpatient setting. Therefore we could not answer the question whether psychiatric consultation led to a reduced nursing home admission or similar results. However, there was a trend that a better outcome was achieved in patients who benefited from the psychiatric service.

Outlook

Overall, the available studies in Germany show that about 30% of all psychiatric consultations are carried out in the geriatric population. This underlines previous recommendations that at least psychiatrists working in the field of consultation and liaison psychiatry should have special training in geriatric psychiatry [31]. This holds especially true because the number of old age patients is increasing, at least in Western countries [32]. This can also be confirmed with regard to the great potential of this field. Perhaps more than in other age groups, somatic and psychic health and mobility are closely related. Recent studies showed that depression is not only a consequence of somatic disorders but also an independent risk factor for cardiovascular and cerebrovascular disorders. Comorbidity with depression, dementia and delirium leads to prolongation of inpatient treatment with higher costs and to increased rates of nursing home admission, of falls and mortality [16, 33–35]. Especially in this age group there is much rationale in combining internal geriatric medicine and psychiatric geriatric medicine into a close liaison service in order to develop an old age medicine with a greater impact on future public health.

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16 17 18 19 20

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Stoppe G, Koller M, Hornig C, Lund I, Sandholzer H, Staedt J: Gerontopsychiatrische Behandlung im Vergleich zwischen integrierter Versorgung an einer Universität und separierter Versorgung an einem Landeskrankenhaus. I. Patientencharakteristik. Psychiatr Prax 1999;26:277–282. Stoppe G, Koller M, Lund I, Hornig C, Sandholzer H, Staedt J: Gerontopsychiatrische Behandlung im Vergleich zwischen integrierter Versorgung an einer Universität und separierter Versorgung an einem Landeskrankenhaus. II. Diagnosen und Behandlung. Psychiatr Prax 1999; 26:283–288. Hirsch RD: Gesundheitspolitische Aspekte der Gerontopsychiatrie. Psycho 1997;23(suppl):14–24. WHO Bureau régional de l’Europe: La gérontopsychiatrie dans la collective. La Santé publique en Europe 10. Copenhagen, WHO, 1981. Psychiatrie-Enquête: Bericht über die Lage der Psychiatrie in der Bundesrepublik Deutschland. Zur psychiatrischen und psychotherapeutisch/psychosomatischen Versorgung der Bevölkerung. Bonn, Deutscher Bundestag, 1975, Drucksache 7/4200. Wolter-Henseler DK: Gerontopsychiatrie in der Gemeinde. Bedarf und Realisierungsmöglichkeiten für ein Gerontopsychiatriches Zentrum am Beispiel Solingen. Cologne, Kuratorium Deutsche Altershilfe, 1996. Jenkins R, Jolley DJ: The development of day hospitals and day care; in Copeland JRM, AbouSaleh MT, Blazer DG (eds): Principles and Practice of Geriatric Psychiatry. New York, Wiley, 2002, pp 677–679. Reister M: Diagnosedaten der Krankenhauspatienten 1994–1997; in Arnold M, Litsch M, Schwartz FM (eds): Krankenhausreport 99. Stuttgart, Schattauer, 2000, pp 273–288. Gutzmann HH: Psychisch kranke alte Menschen: Wo sind sie geblieben? Spektrum 2001;2:31–33. Bickel H: Demenzkranke in Alten- und Pflegeheimen: Gegenwärtige Situation und Entwicklungstendenzen; in Forschungsinstitut der Friedrich-Ebert-Stiftung (ed): Medizinische und gesellschaftspolitische Herausforderung: Alzheimer Krankheit. Der langsame Zerfall der Persönlichkeit. Bonn, Friedrich-Ebert-Stiftung, 1995, pp 49–68. Mayer KU, Baltes PB: Die Berliner Altersstudie. Berlin, Akademie Verlag, 1996. Bohlken J: Demenz. 2010:1,5 Millionen Patienten erwartet. Neurotransmitter 2001;(suppl 1):32–36. Stoppe G: Kapazität und Aufgabe fachärztlicher Versorgung; in Hallauer J, Kurz A (eds): Weissbuch Alzheimer: Versorgungssituation relevanter Demenzerkrankungen in Deutschland. Stuttgart, Thieme, 2002, pp 59–61. Weyerer S, Hönig T, Schäufele M, Zimber A: Demenzkranke in Einrichtungen der voll- und teilstationären Altenhilfe. Epidemiologische Forschungsergebnisse; in Sozialministerium BadenWürttemberg (ed): Weiterentwicklung der Versorgungskonzepte für Demenzerkrankte in (teil-) stationären Altenhilfeeinrichtungen. Stuttgart, Sozialministerium Baden-Würtemberg, 2000, pp 1–58. Stoppe G: Gedächtnissprechstunden/Memory Kliniken; in Hallauer J, Kurz A (ed): Weissbuch Alzheimer: Versorgungssituation relevanter Demenzerkrankungen in Deutschland. Stuttgart, Thieme, 2002, pp 85–86. Bickel H, Cooper B, Wancata J: Psychische Erkrankungen von älteren Allgemeinkrankenhauspatienten: Häufigkeit und Langzeitprognose. Nervenarzt 1993;64:53–61. Johnston M, Wakeling A, Graham N, Stokes F: Cognitive impairment, emotional disorder and length of stay of elderly patients in a district general hospital. Br J Med Psychol 1987;60:133–139. Koenig HG, Meador KG, Cohen HJ, Blazer DG: Detection and treatment of major depression in older, medically ill hospitalized patients. Int J Psychiatr Med 1988;18:17–31. Bergmann K, Eastham EJ: Psychogeriatric ascertainment and assessment for treatment in an acute medical ward setting. Age Ageing 1974;3:174–188. Wancata J, Benda N, Hajji M, Lesch OM, Müller C: Psychiatric disorders in gynecological, surgical and medical departments of general hospitals in an urban and a rural area of Austria. Soc Psychiatry Psychiatr Epidemiol 1996;31:220–226. Arolt V, Driessen M, Bangert-Verleger A, Neubauer H, Schürmann A, Seibert W: Psychische Störungen bei internistischen und chirurgischen Krankenhauspatienten. Prävalenz und Behandlungsbedarf. Nervenarzt 1995;66:670–677.

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Arolt V, Gehrmann A, John U, Dilling H: Psychiatrischer Konsiliardienst an einem Universitätsklinikum: eine empirische Untersuchung zur Leistungscharakteristik. Nervenarzt 1995;66:347–354. Delius P, Schürmann A, Wetterling T: Ältere Patienten im psychiatrischen Konsiliardienst. Krankenhauspsychiatrie 1994;5:61–65. Niklewski G, Lehfeld H, Pelzl S, Simen S, Stein B, Herzog T: Sind ältere Patienten eine im Konsiliardienst vernachlässigte Gruppe? Ein Vergleich psychiatrischer Konsiluntersuchungen bei Patienten unterschiedlicher Altersgruppen (English abstract). Eur J Ger 2001;3:122–130. Lobo A, Huyse FJ, Herzog T, Malt U, Opmeer BC: The ECLW collaborative study II: Patient registration form (PRF) instrument, training and reliability. J Psychosom Res 1996;40:143–156. Wetterling T, Junghanns K: Psychiatrischer Konsiliardienst bei älteren Patienten. Nervenarzt 2000; 71:559–564. Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, Brutsaert DL: Personality as independent predictor of long-term mortality in patients with coronary heart disease. Lancet 1996;347: 417–421. Ford DE, Mead LA, Chang PP, Cooper-Patrick L, Wang NY, Klag MJ: Depression is a risk factor for coronary artery disease in men: The precursors study. Arch Intern Med 1998;158:1422–1426. Sesso HD, Kawachi I, Vokonas PS, Sparrow D: Depression and the risk of coronary heart disease in the Normative Aging Study. Am J Cardiol 1998;82:851–856. Adamis D, Ball C: Physical morbidity in elderly psychiatric inpatients. Prevalence and possible relations between the major mental disorders and physical illness. Int J Geriatr Psychiatry 2000;15: 248–253. Lipowski ZJ: The need to integrate liaison psychiatry and geropsychiatry. Am J Psychiatry 1983;140: 1003–1005. Jeste DV, Alexopoulos GS, Bartels SJ, Cummings JL, Gallo JJ, Gottlieb MD, Halpain MC, Palmer BW, Patterson TL, Reynolds CF, Lebowitz BD: Consensus statement on the upcoming crisis in geriatric mental health. Arch Gen Psychiatry 1999;56:848–853. Holmes JD, House AO: Psychiatric illness in hip fracture. Age Ageing 2000;29:537–546. Tinetti ME, Williams CS: Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 1997;337:1279–1284. Hosaka T, Aoki K, Watanabe T, Okuyama T, Kurosawa H: Comorbidity of depression among physically ill patients and effect on the length of hospital stay. Psychiatry Clin Neurosci 1999;53: 491–495.

Prof. Dr. Gabriela Stoppe Psychiatrische Universitätsklinik Basel Wilhelm-Klein-Strasse 27 CH–4025 Basel (Switzerland) Tel. ⫹41 61 325 56 46, Fax ⫹41 61 325 55 82, E-Mail [email protected]

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 74–97

Screening Instruments for General Hospital and Primary Care Patients J. Wancataa, M. Weissa, B. Marquart a, R. Alexandrowiczb a

Department of Psychiatry, University of Vienna, Vienna, and Institute of Psychology, University of Klagenfurt, Klagenfurt, Austria

b

What Are Screening Instruments?

The majority of mental disorders are treated by non-psychiatric physicians such as general practitioners or general hospital doctors. Only a very small proportion of all mentally ill are in contact with psychiatric services. Thus, the main work of recognition, exact diagnosis and treatment has to be done by nonpsychiatric physicians. Goldberg and Huxley [1] reported from the United Kingdom that about a quarter of the adult population suffers at any time during a year from any psychiatric disorder. More of 90% of the affected were in contact with their primary care physician, and only about 7% were treated by psychiatric services. In general hospitals between 20 and 45% suffer from any psychiatric disorder [2, 3]. Both in primary care and in general hospitals, studies have shown that nonpsychiatric physicians often do not recognize the psychiatric disorders of their patients [4–6]. In last decades, a considerable amount of scientific literature has been published concerning the question how this problem could be solved [7–10]. Besides improving postgraduate training, use of practice guidelines and training programs for non-psychiatric physicians, the use of screening instruments has been discussed in order to improve the ability to correctly identify those suffering from mental disorders. Many authors favored the use of screening instruments because they are usually fast and easy to use in busy clinical settings [8, 11]. Most screening instruments are questionnaires consisting of about 12–30 questions [12, 13]. Usually, they ask for psychological symptoms (e.g. being unhappy or depressed, feeling nervous) and for possible consequences of psychiatric morbidity (e.g. a reduced number of social contacts). Then, the positive responses are added and result in a sum score. Persons who are above

a given cutoff value of this sum score are the ‘screening positives’. Yet, screening instruments are not equal to diagnostic tools. A positive screening result is only a reference for an increased probability of a mental disorder, a negative screening result for a high probability of the absence of such a disorder. Thus, for every screening instrument, there are a number of persons who are not correctly identified (overall misclassification rate or OMR). Some screening instruments cover several psychiatric diseases (e.g. GHQ) while others are ‘specific’ (e.g. BDI). It must be mentioned, however, that also ‘specific’ instruments capture only symptom groups which are not equivalent to diagnoses. Symptoms of depression, for example, such as sleep disturbances, restlessness, or anxiety, do not only occur in major depression, depressive adjustment disorders, or depressive neuroses, but may also occur during alcohol withdrawal. Other symptoms like loss of appetite or lack of energy may be signs of physical illness as well [14, 15]. For these reasons, positive screening results demand that the physician clarifies if any and which psychiatric disorder really exists.

Screening Instruments – for What Purpose?

Besides the purpose of improving the detection of psychiatric disorders by non-psychiatric physicians, screening instruments are often used for epidemiological research. For epidemiological studies large numbers of persons have to be investigated to assess whether or not they suffer from any psychiatric disorder. Since it is very expensive to investigate large samples, many authors used a first-stage screening to identify those with a ‘probable’ disease and thus reduced the number requiring a full diagnostic assessment [16–18]. Using screening instruments for such two-stage surveys has a different requirement on the criterion validity of screening instruments than the routine use to assist physicians’ recognition of mental disorders. For the routine use in clinical work very high validity coefficients are necessary to avoid a false classification of the patients. For epidemiological work validity indices may be lower because a second stage psychiatric interview is the definite case criterion. When using screening instruments to help non-psychiatric physicians to detect psychiatric disorders some general aspects must be considered [19–21]: (1) Importance of the disease: there must be a negative impact of the disease that poses a substantial burden on those affected. For the patient this negative impact includes, for example, severe impairment, productivity loss, risk of suicide, health costs and grief. (2) Acceptable methods of screening must be available at reasonable costs to detect the disorder. (3) Acceptable methods of treatment must be available.

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(4) After screening, treatment of the disorder must yield a therapeutic result superior to that obtained when no screening is performed. (5) The use of screening procedures should not be harmful to the patient. Concerning the importance of mental disorders, a lot of studies have shown that they occur frequently and often have severe negative consequences for the affected. Psychiatric disorders are usually associated with grief and a reduced quality of life. In addition, persons suffering from psychiatric disorders show higher rates of unemployment and frequently have difficulties in coping with everyday life [22, 23]. Most of the available screening instruments have been used in a lot of studies and have been proved acceptable [13, 24, 25]. In contrast, psychiatric disorders and their treatment are sometimes not well accepted. Several studies have shown that compliance with psychiatric interventions is often low [26, 27]. Psychiatric disorders and their treatment are often stigmatized [28], and some authors concluded that this stigma leads to reluctance to seek help [29].

Criterion Validity

The questions of whether routine screening is harmful and whether the patients benefit from screening are influenced by the indices of criterion validity of the screening instrument. Criterion validity means the different aspects of agreement of the screening procedure when compared with an exact diagnosis of the disorder (usually yielded from psychiatric research interviews). Every screening procedure results in a number of persons who were correctly identified as mentally ill (true positives) and who were correctly identified as mentally well (true negatives). In addition, there are some persons for whom the screening procedure falsely identifies them as being mentally ill (false positives) or falsely as being mentally well (false negatives). The sensitivity is the proportion of true positives of all mentally ill, and the specificity the proportion of true negatives of all mentally well. But, beside these two frequently used indices other coefficients are important. The positive predictive value (PPV) means the proportion of true positives of all those who were positive in the screening procedure, and the negative predictive value (NPV) means the proportion of true negatives of all screening negatives. It must be mentioned, however, that the PPV, the NPV and the OMR do not merely depend on the sensitivity and specificity of the screening instrument, they are influenced by the prevalence of the disorder, as well. The PPV and the NPV are of outstanding importance when analyzing the question of whether routine screening is harmful. All screening instruments identify a proportion of the mentally well falsely as suffering from a psychiatric disorder. Thus, if a non-psychiatric physician makes his psychiatric diagnoses

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merely on the results of a screening procedure he will give psychiatric treatment to some persons who are not mentally ill. Considering that all psychiatric interventions have the risk of adverse effects a number of mentally well persons will suffer from side effects without having any benefits. Further, some of the false positives might have disadvantages due to the stigma of a psychiatric label [19, 25]. A similar problem exists with false negatives. An individual suffering from a psychiatric disorder which is not captured by the screening instrument might have disadvantages if his physician merely relies on screening results: this could lead to inappropriate neglect of psychiatric issues by the physician. Unfortunately, it must be stated that these problems have not been investigated sufficiently [25]. In the last decades, a large number of screening instruments for nearly all psychiatric disorders have been developed. For most of these instruments a lot of studies have investigated the criterion validity in different languages, cultures and clinical settings. For the present overview, we decided to concentrate on two instruments developed to detect depression in non-psychiatric health care. In addition, we report the results of some studies conducted in German-speaking countries.

General Health Questionnaire among Non-Psychiatric Inpatients

The General Health Questionnaire (GHQ) [13, 30] is a self-report instrument developed for the detection of psychiatric morbidity in primary health care. The GHQ attempts to detect depression, anxiety, neurotic and psychosomatic disorders. It was not intended by the authors [13] to detect substance abuse, schizophrenia, mania or organic mental illnesses. The GHQ has been used in a lot of studies among primary health care attendees, among general hospital outand inpatients [18, 31]. In addition, it was frequently suggested as a screening tool for psychiatric case identification in busy clinical settings [8, 11]. The GHQ refers to the severity of psychological complaints in relation to the person’s normal situation. For each item it offers 4-point response scales. Usually, it is scored in a bimodal fashion (0–0–1–1) with higher sum scores representing higher levels of distress [13]. Alternatively, it can be scored using a 4-point ‘Lickert’ format (0–1–2–3). Since the response scales compare the actual complaints with the individual’s normal situation, some authors criticized that long-standing disorders might be missed. For this reason, Goodchild and Duncan-Jones [32] suggested the ‘chronic’ scoring method to make it more likely to detect long-standing disorders (0–0–1–1 for ‘positive’ items, 0–1–1–1 for ‘negative’ items). The original version of the GHQ consisted of 60 items. Shorter versions with 30 and 12 items were developed by removing those items often endorsed

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by physically ill persons [13]. In addition, some authors suggested the use of an 20-item version [33]. Finally, on the basis of a principal component analysis a version with four subscales was developed (28 items). For the different GHQ versions a review of more than 50 validity studies available until the mid 1980s [13] reported a median sensitivity between 0.79 (GHQ-60) and 0.86 (GHQ-28, GHQ-12), and a median specificity between 0.80 (GHQ-30, GHQ-12) and 0.87 (GHQ-60). This review includes validity studies in the general population, among out- and inpatients. The GHQ has frequently been used in surveys investigating psychiatric morbidity among general hospital inpatients. While a lot of studies have confirmed that the GHQ has an acceptable performance as a psychiatric screening instrument among primary health care attendees in different cultures and different languages [11, 13, 34], the overall number of validity studies in general hospitals is markedly lower. Some of these studies [2, 34] reported that among nonpsychiatric inpatients both sensitivity and specificity are relatively low compared to studies among those attending primary health care services. Tables 1 and 2 give an overview of studies investigating the criterion validity of the GHQ among non-psychiatric in-patients. This overview is based on a Medline search and on the references of several review articles. Studies were included only if the GHQ was compared to an external case criterion (usually a psychiatric research interview). For this overview we excluded studies which applied the research interview only to those who were above the cutoff point of the GHQ because in such studies it is impossible to calculate sensitivity and specificity accurately. Further, we excluded studies which included psychiatric patients and studies which investigated the validity among children or adolescents. Finally, studies with samples of less than 50 persons were excluded. According to these criteria, we identified 14 studies among non-psychiatric inpatients (table 1). Most of these studies have been done in European countries. Patients from medical and surgical wards had been investigated most frequently. Surprisingly, several studies included psychoses or substance abuse disorders despite the fact that the GHQ was not designed to detect these disorders. Table 2 gives the validity indices of the different GHQ versions. If the authors reported sensitivity and specificity for several cutoff points we selected that cutoff where sensitivity and specificity were closest together (except when the authors suggested the use of a specific cutoff). If the authors reported prevalence, sensitivity and specificity we calculated from these data the PPV and NPV and the OMR. (For some papers not reporting data on prevalence we were able to find such information from related papers. We performed these calculations only if we could confirm, without any doubts, that the results from the different papers were based on exactly the same patients.)

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79

Wancata et al. [46]

House [41] Lobo et al. [42] Lykouras et al. [43] Malt [33] Morris and Goldberg [44] Ramsay [45]

Medical, surgical, gynecological, rehabilitation

F, M

F, M

F, M

Medical ⫹ surgical

Medical elderly

F, M F, M F, M

Medical ⫹ Surgical General medical Neurology

F, M F, M F, M F, M F, M

F, M

Medical ⫹ Surgical

Renal Endocrine Neurology Trauma unit Gastroenterology

F, M F, M

Medical ⫹ surgical Medical ⫹ surgical

Abiodun [35] Abiodun and Ogunremi [36] Arolt [2]

Bell et al. [37] Botega et al.[38] Bridges and Goldberg [39] Clarke et al. [40]

Gender

Sample

Authors

46.3

83

57.7

46.3 41.1 43.7

54

37.6 43.2

39

Mean age years

Table 1. Validity studies of the GHQ among inpatients

DSM-III-R DSM-III DSM-III

DSM-III

DSM-III-R

ICD-9

ICD-10

ICD-9 ICD-9

Diagnostic system

BAS DSM-III-R (Depression) CIS DSM-III-R

PSE CIS SCID-R CPRS Clinical

SCID-R

CIS CIS-R CIS

CIDI

PSE PSE

Research interview

Austria

UK

UK Spain Greece Norway USA

Australia

UK Brazil UK

Germany

Nigeria Nigeria

Country

Depression, anxiety, neurotic, psychosomatic

Including substance abuse

Including substance abuse

Including substance abuse and psychoses

Including substance abuse and psychoses Including substance abuse and psychoses Including substance abuse

Psychiatric diagnoses included

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Bridges and Goldberg [39] Clarke et al. [40] Lobo et al. [42] Lykouras et al. [43] Morris and Goldberg [44] Clarke et al. [40]

Abiodun and Ogunremi [36] Clarke et al. [40] Ramsay et al. [45] Wancata et al. [46] Clarke et al. [40] All inpatient GHQ-30 studies (median) Goldberg and Williams [13] median

GHQ-60-B GHQ-60-B GHQ-60-B GHQ-60-C GHQ-60

Bell et al. [37] Clarke et al. [40] House [41] Clarke et al. [40] All inpatient GHQ-60 studies (median) Goldberg and Williams [13] median

GHQ-28-B GHQ-28-B GHQ-28-B GHQ-28-B GHQ-28-B GHQ-28-C

GHQ-30

GHQ-30-B GHQ-30-B GHQ-30-B GHQ-30-L GHQ-30-C GHQ-30

GHQ-60

GHQ

Authors

70 179 100 107 100 179

263 179 85 511 179

100 179 80 179

n

11/12 8/9 5/6 5/6 8/9 11/12

4/5 14/15 4/5 32/33 11/12

13/14 19/20 12/13 32/33

Cutoff

0.389 0.320 0.910 0.523 0.400 0.320

0.302 0.320 0.100 0.131 0.320

0.370 0.320 0.300 0.320

Prev

0.802 0.600 0.923 0.870 0.770 0.750

0.810

0.859 0.390 1.000 0.686 0.740 0.740

0.790

0.860 0.560 0.800 0.670 0.735

Sens

0.807 0.790 0.777 0.770 0.750 0.740

0.800

0.729 0.940 0.500 0.673 0.760 0.729

0.870

0.730 0.830 0.540 0.830 0.780

Spec

0.726 0.573 0.977 0.800 0.670 0.576

0.578 0.754 0.190 0.240 0.592 0.580

0.655 0.608 0.427 0.650 0.629

PPV

0.865 0.808 0.500 0.850 0.830 0.863

0.923 0.766 1.000 0.934 0.861 0.920

0.899 0.800 0.863 0.842 0.853

NPV

0.195 0.271 0.090 0.178 0.240 0.257

0.232 0.236 0.450 0.325 0.246 0.250

0.222 0.256 0.290 0.221 0.239

OMR

0.860

0.880

0.728

ROC-AUC

Table 2. Validity studies of the GHQ among general hospital inpatients as compared to the median validity indices reported by Goldberg and Williams [13] for out- and inpatients

Screening Instruments for General Hospital and Primary Care Patients

81

All

275 224 78 179 511 179

110 110 511 110

2/3 1/2 5/6 7/8 12/13 6/7

2/3 17/18 23/24 9/10

0.352 0.468 0.360 0.320 0.131 0.320

0.131

0.710

0.860

0.887 0.600 0.710 0.320 0.656 0.610 0.633

0.620 0.750 0.671 0.580 0.646

0.860

0.786

Prev ⫽ Prevalence; Sens ⫽ sensitivity, Spec ⫽ specificity. Values calculated by us from the data given in the papers are printed in italics.

All inpatient GHQ studies (median)

GHQ-12-B GHQ-12-B GHQ-12-B GHQ-12-B GHQ-12-L GHQ-12-C GHQ-12

Abiodun [35] Arolt [2] Botega et al. [38] Clarke et al. [40] Wancata et al. [46] Clarke et al. [40] All inpatient GHQ-12 studies (median) Goldberg and Williams [13] median GHQ-12

GHQ-20-B GHQ-20-L GHQ-20-L GHQ-20-C GHQ-20

GHQ-28

GHQ-28

Malt [33] Malt [33] Wancata et al. [46] Malt [33] All inpatient GHQ-20 studies (median)

All inpatient GHQ-28 studies (median) Goldberg and Williams [13] median

0.760

0.800

0.833 0.650 0.760 0.950 0.631 0.830 0.795

0.830 0.650 0.655 0.770 0.713

0.820

0.774

0.610

0.743 0.601 0.620 0.751 0.209 0.628 0.624

0.620 0.440 0.252 0.470 0.455

0.698

0.860

0.250

0.152 0.373 0.250 0.252 0.366 0.240 0.251

0.342

0.873 0.931 0.649 0.950 0.748 0.930 0.819 0.875

0.342

0.218

0.873

0.840

0.730

0.820

0.743

The varieties of different scoring methods (bimodal, Lickert, chronic), differing external case criteria and different diagnostic systems limit the comparability of these studies. Lobo et al. [42] investigating inpatients with endocrine disorders found an extremely high prevalence of 91% and a very low misclassification rate of only 9%. All other studies reported higher misclassification rates, most between 20 and 30%. The highest OMR was found among elderly inpatients (45%). The median PPV of all GHQ studies among inpatients was only 61% meaning that more than a third of all screening positives were falsely classified as mentally ill. If we compare the median sensitivity and specificity of the studies conducted among non-psychiatric inpatients with those reported by Goldberg and Williams [13], it seems that among inpatients the GHQ does not work as well as among outpatients. The high proportions of false positives are usually attributed to a number of symptoms which are common among those who have marked physical disorders [5]. For this reason, Goldberg and Williams [13] pointed out that if the GHQ is used on patients with severe physical illness it may be necessary to raise the threshold. But, it must be considered that raising the cutoff threshold to improve specificity reduces sensitivity. Thus, it might be that changing the cutoff does not improve the overall accuracy. Therefore, Wancata et al. [46] hypothesized that several GHQ items cannot help to distinguish between mentally well and mentally ill among general hospital inpatients. Since these symptoms contribute to the sum score, they suggested excluding them by using a novel statistical procedure (Stepwise Hierarchical Variable Selection).

Geriatric Depression Scale

The Geriatric Depression Scale (GDS) is one of most frequently used screening tools for depression among the elderly [12]. The GDS is a 30-item questionnaire in which responses consider questions relative to a 1-week time frame. The response format is yes/no. A 15-item short form of the GDS which correlates highly with the long form has been developed [47]. In general, several problems have been reported in the use of self-report instruments for assessing depression in old age [48]. For example, one of the most frequent sources of error when using self-report in the elderly is the content of somatic symptoms of depression in some scales. Such somatic symptoms (e.g. loss of appetite or loss of energy) might be due to both depression and physical disorders. Thus, it is uncertain whether such symptoms can help to distinguish between mentally well and mentally ill. The GDS does not contain somatic symptoms and thus avoids such problems.

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The following overview of studies investigating the criterion validity of the GDS (tables 3–5) is based on a Medline search and on the references found in review articles. For this overview we used the same inclusion and exclusion criteria as mentioned above. We identified 21 validity studies of the GDS (table 3). Most of these studies were done in English-speaking areas. Outpatients were investigated most frequently while only a small number of studies included inpatients or persons staying in nursing homes. Some studies investigated the screening performance of the GDS separately for major and for minor depression, but most studies included all types of depression. The validity indices of the GDS-30 and of the GDS-15 are given in tables 4 and 5. Since many different external case criteria (diagnostic systems, research interviews, subtypes of depression) and several cutoff point of the GDS were used, the comparability of these studies is limited again. Only a small number of studies reported the area under the receiver operating curve (ROC-AUC) which is a measure of criterion validity on all possible cutting points. While several studies reported relatively high areas under the ROC-curve, Rovner and Shmuely-Dulitzki [68] found that the screening performance of the GDS-30 among visually impaired persons was less than chance (0.44). Several authors reported a very low PPV for both GDS versions: e.g. a PPV of only 12% [64], means that 7 of 8 patients who screen positive had been classified falsely as suffering from depression. Other studies reported markedly higher rates of the PPV. However, considering all validity studies of both GDS versions it shows that the median PPV is about 50% or below. In contrast, the NPV was usually very high (median 0.90 and 0.95, respectively). Van Marwijk et al. [64] concluded from their study that instruments with such low PPVs and very high NPVs seem to be better suited for exclusion than for inclusion purposes of depression. The use of screening tools has been suggested to improve the accurate identification of depression by non-psychiatric staff members. Evans and Katona [55] reported that the accuracy of GDS-30 in identifying depression was 77% while the accuracy of primary care physicians was only 65% (table 6). In contrast, Kafonek et al. [59] reported from their nursing home study that the GDS-30 was not better than the nursing staff in correctly classifying the patients into depressed and mentally well (accuracy 68.6 versus 70.7%).

Validity Studies in German-Speaking Countries

Again based on Medline searches and on the references from review articles we tried to identify all studies from German-speaking countries investigating

Screening Instruments for General Hospital and Primary Care Patients

83

Wancata/Weiss/Marquart/Alexandrowicz

84

F, M F, M F, M F, M M F, M F, M

Geriatrics outpatient Primary care outpatient Nursing home Geriatrics outpatient Medical inpatient Visually impaired outpatient Geriatrics inpatient

Mahoney et al. [63] Van Marwijk et al. [64] McGivney et al. [65] Rait et al. [66] Rapp et al. [67] Rovner and Shmuely [68] Shah et al. [69]

F, M F, M F, M F, M F, M F, M F, M F, M F, M F, M F, M M F, M F, M

Medical outpatient Medical outpatient Geriatrics outpatient Primary care outpatient Geriatrics inpatient Primary care outpatient Geriatrics outpatient Visually impaired outpatient Nursing home Post-stroke outpatient Nursing home Medical ⫹ neurological inpatient Medical inpatient Medical outpatient

Abas et al. [49] Arthur et al. [50] Burke et al. [51] Carrete et al. [52] Clement et al. [53] D’ath et al. [54] Evans and Katona [55] Galaria et al. [56] Gerety et al. [57] Johnson et al. [58] Kafonek et al. [59] Koenig et al. [60] Koenig et al. [61] Lyness et al. [62]

Gender

Setting

Authors

Table 3. Validity studies of the GDS

86 (median)

83 61.1 69.3 77.4

74 71.0

71.7 80.6 74.1 73 77.4 78.9 71 77

68.3 79 (median)

Mean age

BAS

GMS SADS Checklist

SADS DIS (6 months)

SCID

GMS SCAN Clinical Clinical Clinical GMS GMS Checklist SCID PAS Clinical DIS and SADS DIS, clinical diagnosis SCID

Research interview

DSM-III-R AGECAT RDC DSM-III-R

DSM-III-R DSM-III-R DSM-III-R DSM-III DSM-III DSM-III DSM-III-R DSM-III-R (for major depression) DSM-IV (for minor depression) RDC

AGECAT ICD-10 DSM-III-R DSM-IV ICD-10

Diagnostic system

Screening Instruments for General Hospital and Primary Care Patients

85

Primary care outpatient Primary care outpatient Medical outpatient Medical outpatient Geriatrics outpatient Geriatrics outpatient Geriatrics outpatient Visually impaired outpatient Post-stroke outpatient Medical inpatient Medical inpatient

Carrete et al. [52] Van Marwijk et al. [64] Lyness et al. [62] Lyness et al. [62] Burke et al. [51] Evans and Katona [55] Mahoney et al. [63] Rovner and Shmuely [68]

Johnson et al. [58] Koenig et al. [61] Rapp et al. [67]

Setting

Authors

9/10 9/10 13/14 9/10

English English English English English English

Major depression Minor depression Major depression Depression Depression Major depression

10/11 6/7

English English

Major depression Depression

10/11

English

Depression

10/11

10/11

6/7

Netherlands

Depression

10/11

Cutoff

Spanish

Language

Depression

External case criterion

Table 4. Validity studies of the GDS-30

150

109

120

70

55

144

182

130

130

586

169

n

0.153

0.100

0.310

0.386

0.240

0.370

0.210

w.s.

w.s.

0.056

0.128

Prev

0.740

0.820

0.840

0.630

0.540

0.850

0.590

0.700

1.000

0.790

0.880

Sens

0.790

0.760

0.660

0.770

0.930

0.680

0.770

0.800

0.840

0.670

0.820

Spec

0.390

0.270

0.530

0.630

0.580

0.609

0.405

0.120

0.418

PPV

0.940

0.970

0.900

0.768

0.860

0.885

0.876

0.980

0.979

NPV

0.218

0.234

0.280

0.284

0.164

0.230

0.268

0.323

0.172

OMR

0.440

0.810

0.855

0.936

0.790

ROCAUC

Wancata/Weiss/Marquart/Alexandrowicz

86

13/14

English English

Depression

66

66

131

128

n

0.450

0.230

0.260

0.120

Prev

0.830 0.770

0.790

0.750

0.680

0.890

Spec

0.630

0.470

0.890

0.920

Sens

0.494

0.752

0.360

0.494

0.530

PPV

0.900

0.733

0.826

0.946

0.990

NPV

0.260

0.260

0.314

0.265

0.106

OMR

0.910

ROCAUC

Prev ⫽ Prevalence; Sens ⫽ sensitivity, Spec ⫽ specificity; w.s. ⫽ since the sample was weighted by the screening results it is impossible to calculate PPV, NPV and OMR. Values calculated by us from the data given in the papers are printed in italics.

9/10

10/11

10/11

Cutoff

English

English

Language

Major depression Depression

Major depression

Medical ⫹ neurological inpatient Nursing home Nursing home Nursing home

Koenig et al. [60]

Gerety et al. [57] Kafonek et al. [59] McGivney et al. [65] Median of all GDS-30 studies

External case criterion

Setting

Authors

Table 4. (continued)

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87

Primary care outpatient Primary care outpatient Medical out patient Medical outpatient Medical outpatient Medical outpatient Geriatrics outpatient Visually impaired outpatient Nursing home

D’ath et al. [54]

Major depression

Major depression

Major depression Minor depression Depression

English

English

English

English

English

English

English

Depression Depression

Netherlands

English

Language

Depression

Depression

External case criterion

5/6

4/5

3/4

4/5

4/5

3/3

4/5

2/3

5/6

Cutoff

131

70

130

130

130

201

164

586

120

n

0.260

0.386

0.100

w.s.

w.s.

0.060

0.200

0.056

0.380

Prev

0.815

0.880

0.740

0.923

0.800

0.920

1.000

0.815

0.670

0.780

Sens

0.730

0.620

0.720

0.709

0.780

0.810

0.719

0.815

0.730

0.820

Spec

0.450

0.449

0.624

0.261

0.184

0.530

0.130

0.726

PPV

0.950

0.936

0.815

0.988

1.000

0.950

0.970

0.870

NPV

0.270

0.312

0.272

0.270

0.264

0.185

0.273

0.195

OMR

0.880

0.820

0.935

0.910

0.882

0.730

ROCAUC

Prev ⫽ Prevalence; Sens ⫽ Sensitivity, Spec ⫽ Specificity; w.s. ⫽ since the sample was weighted by the screening results it is impossible to calculate PPV, NPV and OMR. Values calculated by us from the data given in the papers are printed in italics.

Median of all GDS-15 studies

Gerety et al. [57]

Galaria et al. [56]

Rait et al. [66]

Lyness et al. [62]

Lyness et al. [62]

Arthur et al. [50]

Van Marwijk et al. [64] Abas et al. 49]

Setting

Authors

Table 5. Validity studies of the GDS-15

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88

Setting

Nursing home Nursing home

GDS-30 Nurses

Depression

Doctor

Depression

Depression

GDS-30

Screening instrument

Depression

External case criterion

English

English

English

English

Language

13/14

9/10

Cutoff

Prev ⫽ Prevalence; Sens ⫽ sensitivity, Spec ⫽ specificity. Values calculated by us from the data given in the papers are printed in italics.

Kafonek et al. [59] Kafonek et al. [59]

Evans and Geriatrics Katona [55] outpatient Evans and Geriatrics Katona [55] outpatient

Authors

66

66

136

144

n

0.230

0.230

0.370

0.370

Prev

Table 6. Ability to identify depression (⫽ validity) of the GDS compared to that of staff

0.530

0.470

0.780

0.850

Sens

0.760

0.750

0.600

0.680

Spec

0.397

0.360

0.534

0.609

PPV

0.844

0.826

0.823

0.885

NPV

0.293

0.314

0.350

0.230

OMR

Table 7. Validity studies from German-speaking countries Authors

Sample

Gender

Arolt [2]

Inpatient (medical and surgical) Inpatient postpartum

F, M

Primary care outpatient

Bergant et al. [70] Goldberg et al. [31, 71] Katschnig et al. [72] Loerch et al. [73]

Muzik et al. [74] Schmitz et al. [75] Schmitz et al. [11] Wancata et al. [46]

Research interview

Diagnostic system

Psychiatric diagnoses included

CIDI

ICD-10

All

clinical

ICD-10

Depression

F, M

CIDI-PC

ICD-10

Primary care outpatient

F, M

SADD

All CIDI-PC diagnoses Depression

Primary care outpatient (in part psychiatric sample, excluded from following analyses) Outpatient postpartum

F, M

46.1

CIDI

DSM-IV

All

F

28

SCID

DSM-III-R

Major depression

Primary care outpatient

F, M

42.7

SCID

DSM-III-R

All

Primary care outpatient

F, M

42.7

SCID

DSM-III-R

All

Inpatient (medical, surgical, gynecological, rehabilitation)

F, M

46.3

CIS

DSM-III-R

Depression, anxiety, neurotic, psychosomatic

F

Mean age

28.6

the validity of screening tools for depression. Again we used the same inclusion and exclusion criteria as mentioned above. We found 9 different validity studies conducted in Austria and Germany (table 7). Most of these studies were done among primary care outpatients. Two studies investigated the validity of screening tools to identify postpartum depression, and two others included general hospital inpatients. The screening instrument most often investigated was the GHQ (table 8). As part of the WHO primary health care study [31, 71] patients were investigated with the GHQ in two German cities (Berlin and Mainz). While the NPV was high in all subsamples of this study the PPV was about 50% or below. Schmitz et al. [11, 75] reported from their primary care sample slightly better rates for the PPV but lower rates for the NPV. Arolt [2] and Wancata et al. [46] investigated general hospital inpatients and found that all the different GHQ versions misclassified more than a third of all patients.

Screening Instruments for General Hospital and Primary Care Patients

89

Wancata/Weiss/Marquart/Alexandrowicz

90

Any diagnosis

Berlin Mainz Berlin Mainz

Diagnosis or subgroup GHQ-12-B EPDS GHQ-12-B GHQ-12-B GHQ-28-B GHQ-28-B GHQ-30-B PRIME-MD EPDS SDS SCL-90-R GHQ-12-L GHQ-12-B SCL-90-R GHQ-30-L GHQ-20-L GHQ-12-L

Screening instrument

10/11 49/50 62/63 11/12 1/2 0.5 32/33 23/24 12/13

1/2 9/10 2/3 2/3 5/6 5/6 3/4

Cutoff

224 110 400 400 400 400 77 479 50 50 50 421 408 408 511 511 511

n

0.131 0.131 0.131

0.468 0.20 0.198 0.22 0.198 0.22 0.545 0.33 0.18 0.18 0.18

Prev

Prev ⫽ Prevalence; Sens ⫽ sensitivity, Spec ⫽ specificity. Values calculated by us from the data given in the papers are printed in italics.

Wancata et al. [46]

Schmitz et al. [75] Schmitz et al. [11]

Katschnig et al. [72] Loerch et al. [73] Muzik et al. [74]

Arolt [2] Bergant et al. [70] Goldberg et al. [31, 71]

Authors

Table 8. Validity studies from German-speaking countries

0.60 0.960 0.726 0.735 0.819 0.807 0.833 0.640 0.87 0.89 0.78 0.700 0.680 0.640 0.686 0.671 0.656

Sens

0.65 1.000 0.750 0.812 0.729 0.729 0.771 0.680 0.87 0.77 0.87 0.680 0.650 0.740 0.673 0.655 0.631

Spec

0.601 1.000 0.418 0.524 0.427 0.456 0.813 0.500 0.595 0.459 0.568 0.560 0.530 0.580 0.240 0.252 0.209

PPV

0.649 0.990 0.917 0.916 0.942 0.931 0.794 0.790 0.968 0.970 0.947 0.80 0.780 0.770 0.934 0.873 0.930

NPV

0.325 0.342 0.366

0.373 0.008 0.255 0.205 0.253 0.254 0.195 0.330 0.130 0.208 0.146 0.319

OMR

0.760 0.730 0.750 0.728 0.743 0.730

ROC-AUC

Bergant et al. [70] compared the EPDS with ICD-10 diagnoses of depression (table 8). They reported that the EPDS is an excellent screening instrument to identify depression among postnatal women. However, it must be considered that the diagnoses of depression were not the result of a psychiatric research interview but were made by gynecologists. Keeping in mind that non-psychiatric physicians are often not accurate in diagnosing mental disorders [6], these results must be viewed with caution. In contrast, Muzik et al. [74], using a psychiatric research interview in their postpartum study, reported validity indices which were in agreement with the international literature. Loerch et al. [73] investigated the validity of the Primary Care Evaluation of Mental Disorders (PRIME-MD), a short structured diagnostic interview. The PRIME-MD intends to assist primary care physicians in assessing several types of mental disorders. Interestingly, the authors reported validity indices from both, the PRIME-MD and the physicians’ clinical judgment (table 9). For all diagnoses taken together, the proportion of those misclassified by the PRIME-MD is slightly below that of the physicians. This means that overall the PRIME-MD slightly improves the physicians’ diagnostic accuracy. For mood disorders, all validity indices of the PRIME-MD are superior to those of the physicians. But for somatoform disorders, the PRIME-MD shows a markedly higher proportion of false positives than the physicians. Despite the fact that the proportion of false negatives is lower for PRIME-MD, the proportion of those misclassified in any way is 10% higher for the PRIME-MD. Thus, the German version of the PRIME-MD might be a useful tool for primary care doctors to better diagnose affective disorders, but not somatoform disorders.

Do Depressed Patients Benefit from Routine Screening?

It has been demanded that screening must yield a therapeutic result superior to that obtained when no screening is performed [19–21]. Recently, two reviews of randomized controlled trials investigating this question for depression have been published. Of the studies reviewed by the US Preventive Services Task Force [25] some have shown benefits in terms of a shorter duration of illness or a decreased number of symptoms after screening, but other studies did not show such effects. The results of meta-analyses led to the conclusion that screening for depression is probably effective when screening is coupled with additional activities such as educational programs for primary care physicians. The authors emphasize that their conclusions are limited to adults in primary care and should not be applied to other medical settings (e.g. inpatients [10]).

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92

0.33 0.64 0.68 0.21 0.21 0.12 0.46 0.50 0.79 0.33

0.33 0.49 0.72 0.16 0.19 0.17 0.48 0.46 0.74 0.36

0.17 0.56 0.89 0.10 0.09 0.08 0.74 0.51 0.91 0.17

0.17 0.43 0.83 0.07 0.14 0.10 0.69 0.34 0.88 0.24

physician

PRIME-MD

PRIME-MD

physician

Any mood disorder

Any diagnosis

0.04 0.40 0.91 0.02 0.09 0.02 0.87 0.16 0.97 0.11

PRIME-MD 0.04 0.24 0.94 0.01 0.06 0.03 0.90 0.14 0.97 0.09

physician

Any anxiety disorder

All rates, except prevalence, sensitivity and specificity, were calculated from information given by the authors.

Prevalence Sensitivity Specificity True positives False positives False negatives True negatives PPV NPV OMR

Diagnosis

0.16 0.47 0.74 0.08 0.22 0.09 0.62 0.26 0.88 0.30

PRIME-MD

0.16 0.09 0.93 0.01 0.06 0.15 0.78 0.20 0.84 0.20

physician

Somatoform disorder

Table 9. Accuracy of identification of psychiatric disorders according to PRIME-MD and according to primary care physicians as compared to CIDI results [73]

The same group reported that until now there is insufficient evidence for other mental disorders (e.g. drug abuse or dementia) to recommend for or against routine screening. Similarly, a British research group published a review of randomized controlled trials of the routine administration of screening instruments for depression [7]. Their meta-analysis led to the conclusion that the routine use of screening instruments did not show an effect on patient outcome. Thus, their conclusions are in contrast to those of the US Task Force. However, considering the multiple limitations reported by both reviews it seems that additional research is urgently needed to clarify this question.

Conclusions

For this short overview we have arbitrarily selected some screening instruments and condensed the information on their criterion validity. Comparing the validity indices of the GHQ among non-psychiatric inpatients with those of the overview published by Goldberg and Williams [13], it seems that the GHQ works better among out- than among inpatients. The GDS, which was especially developed for the elderly, often shows very weak validity indices. To our knowledge the validity of the GDS was investigated predominantly in English-speaking samples and rarely in other languages. For example, we could not find a published validity study of the GDS in the German language. But, beside the necessity of performing validity studies of the translations of the original instruments, it seems that other factors influence the validity. Goldberg and Williams [13] reported for the GHQ that, aside from language and culture, several factors such as gender, education and severity of physical illness predict the proportion of those correctly identified. Some studies [51, 59] have shown that cognitive impairment among the elderly increases the frequency of misclassification. Most of the studies reviewed here did not report such potential predictors of the screening accuracy. We assume that more research is needed to analyze the influence of such potential predictors in order to better understand why the results of one validity study are better than that of another. The use of screening tools has repeatedly been suggested to improve the recognition of mental disorders. Analyzing the results of the extremely small number of studies comparing the accuracy of screening instruments with that of non-psychiatric physicians shows that it is not possible to draw general conclusions. Again, we need more studies to accurately investigate this question.

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Taking all these aspects together, we must conclude that until now many questions remain open. Perhaps, research guidelines for the future investigation of the criterion validity of psychiatric screening tools might be helpful.

References 1 2 3

4 5 6 7 8 9

10

11

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Prof. Johannes Wancata, MD University of Vienna Department of Psychiatry, Währinger Gürtel 18–20 AT–1090 Vienna (Austria) Tel. ⫹43 1 40400 3546, Fax ⫹43 1 40400 3714, E-Mail [email protected]

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Special Section Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 98–117

Depression in Medical Patients Volker Arolt, Matthias Rothermundt Department of Psychiatry, University of Münster, Münster, Germany

Introduction

There is a great diversity in the psychological and biological relationships between physical illnesses and various depressive syndromes. The psychological coping with physical illnesses and the involvement of psychological factors in their pathogenesis are issues that, in Germany, have so far been dealt with mainly in the field of psychosomatics and medical psychology [1]. It is only in recent years that the connecting line between psychiatric disorders and physical illness has become the object of intensive research activity focusing not only on health care epidemiology but also to an increasing extent on (neuro)biological issues. The latest findings from the interface of physical and mental illness are put into practice primarily in consultant/liaison psychiatry. The diagnosis and therapy of depressive disorders in connection with physical illnesses necessitates the integration of various therapeutic approaches. In particular, the treatment of depressions in medical patients shows the need for qualified psychotherapeutic interventions, which have very often to be accompanied by state-of-the-art antidepressant pharmacotherapy [2–5]. Physical approaches such as targeted sporting activities have an important status, as does the strengthening of social integration [6–8]. The ability to perform these tasks on an integrated basis is a crucial qualification for advisory/liaison activity with both inpatients and outpatients. This is an abridged version of Arolt V, Rothermundt M: Depression bei körperlichen Erkrankungen; in Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin. Konsiliarpsychiatrie, -psychosomatik und -psychotherapie. Darmstadt, Steinkopff, 2004, pp 349–388.

Approximately 15% of all medical patients are prone to depressions, resulting in additional, often substantial suffering and having a generally negative impact on the course of the physical illness. The extent and consequences of this comorbidity and its socioeconomic implications as well as the effective therapeutic options available are in surprising contrast to the still inadequate diagnosis and therapy of depressive disorders in medical patients.

Diagnosis of Depressive Disorders in Medical Patients

Classification of Grief and Depression A number of different factors contribute to the inadequacy of the diagnosis (and therapy) of depressive disorders in medical patients. One exceptionally problematic factor is likely to be the apparently widespread concept that doctors have to grant a severely ill medical patient the right to ‘his’ depression in view of the given circumstances concerning his illness and life. This attitude implies among other things the blurring of the distinction between grief and depression, and results ultimately in therapeutic inactivity with all its consequences in a situation where patients could quite well be given an increased quality of life. In medical patients, especially those suffering from severe and chronic illnesses, the first important step is to draw a distinction between traumatic grief and depression. Although the scientific debate on the validation of grief reactions is an ongoing one [9, 10], the classification of these states is of major significance in practical terms. Grief is a normal and ultimately health-promoting process, whereas traumatic (‘pathologic’) grief and above all a depressive disorder are accompanied by qualitatively significant psychopathologic symptoms, marked restrictions in experience and behavior, and a risk of chronification [11, 12]. Difficult though it may be to define the borders between grief, traumatic grief and depression, this distinction should be made meticulously in each individual case, as the therapeutic consequences are of great importance. Grief is a ‘natural’ reaction to a loss, during which the grieving subject is preoccupied with the lost object, with different phases being typically experienced [13]. Among other things this process is associated with separationinduced pain, frequent preoccupation with what has been lost (in terms not only of a person but also of the patient’s own living circumstances and desires), and intensive yearning. However, it ultimately gives way to emotional and cognitive acceptance of the loss and inward detachment from the lost object. This may refer equally well to a loved one or to the patient’s own physical health and integrity. Traumatic (pathologic) grief differs from the normal grief reaction in that this process is accompanied by more intensive symptoms, is of longer duration,

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and does not lead to inward detachment. It is associated with significant impairments in the patient’s way of life, which may have a negative impact on his further lifestyle. The typical symptoms include: intrusive thoughts and memories of the lost object; a sense of loneliness; emotional emptiness and lack of purpose; feelings of emotional numbness and indifference, and refusal to accept the loss [14–17]. Depressive disorders are characterized by the presence of a depressive core syndrome with sad-suppressed mood and lack of pleasure, reduced interest and activity, and psychomotor impairments. This may be accompanied by somatic and cognitive complaints and symptoms or by psychotic characteristics. In particular, defining the borders between normal grief and a depressive reaction in terms of an adaptive disorder (ICD 10: F 43.20/21) may present substantial problems, as the extent of the lack of pleasure, of the drive disorder and of vital disorders is comparatively small in the depressive reaction and the experience-reactive precipitation is evaluated as a diagnosis-constituting element. When defining the borders between traumatic grief and depressive reaction, the diagnostic concepts even overlap (pathologic grief is coded in ICD-10 under F 43.2X) and fluctuating transitions can be detected in the clinical setting too. What is more significant from the therapeutic aspect is ultimately the definition of the borders between normal grief on the one hand and traumatic grief or depressive reaction and other forms of depression on the other, as failure to recognize traumatic grief or a depression generally results in promising and meaningful psychotherapeutic and pharmacotherapeutic interventions not being utilized. Special Features of Depression Diagnosis in Medical Patients Many acute and chronic physical illnesses are accompanied by lethargy, fatigue and increased exhaustion as well as by a lack of appetite and loss of libido. These complaints and symptoms may therefore not be diagnosed a priori in the affected patients as symptoms of a drive disturbance or vital disturbance within the scope of a depressive disorder. The diagnosis of a depressive disorder should be based, at least in severely ill medical patients, not so much on the detection of drive deficits, psychomotor deficits and vital disturbances as on cognitive contents and in particular on the quality and the extent of the depression. This governing principle is manifested in a practicable draft for diagnostic criteria originally designed by Endicott [18] for patients with cancer and meanwhile multiply validated. The DSM-IV criteria of four ‘somatic’ symptoms (loss of appetite/weight, sleeplessness or excessive sleep requirement, loss of energy or increased exhaustion and reduced concentration) are replaced by four ‘nonsomatic’ symptoms (depressive or anxious appearance, reduced speech and social withdrawal, lack of pleasure and reduced ability to be cheered up, and inclination to pessimistic brooding). Although these criteria are not undisputed

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and other approaches have been proposed [19], they have found their way into clinical and research applications. In clinical practice it is advisable to take up these criteria, which were developed for the assessment of severely ill patients, and the underlying fundamental consideration in the context of one’s own clinical experience as a diagnostic guideline, but not to apply them schematically in each suspected case as this may result in depressive morbidity being underestimated, especially in medical patients with less severe illnesses. Prevalence and Course of Depressive Disorders An overview of the prevalence and course of depressive disorders in patients with somatic illnesses can be gained by examining larger samples in general hospitals and general medical practices. The rate (point prevalence) of depressive disorders among patients in general hospitals is about 15%. The empirical studies carried out in this context and based on structured or standardized interviews show a surprising degree of conformity with respect to this prevalence rate [Arolt, pp 31–51]. Differentiating between various forms of depression reveals that about 30–50% of total morbidity falls to severe and about 50–70% to milder forms of depression (major depression vs. minor depression/dysthymia) [20–22]. For instance, differentiation in the Lübeck General Hospital study yielded the following prevalence rates: 3.8% depressive episodes, 4.3% dysthymias, and 7.3% depressive reactions [23], with no differences being found between the samples from internal and surgical wards. Wancata et al. [22] reported a similarly high total morbidity but a slightly lower prevalence of depressive disorders on surgical wards, whereas the severity was shifted towards milder depressions on gynecological and rehabilitation wards. It was also found in these samples that the risk of suffering from a depression is increased by a higher subjective impairment and in particular by a potentially life-threatening somatic disorder [24–26]. A further point to be considered is the substantial comorbidity with other mental disorders, in particular with alcohol dependence/ abuse and anxiety disorders [27, 28]. From the perspective of health care epidemiology the cited studies provide the basis for estimating total mental morbidity in samples from hospital wards; this accounts for the examined samples having been very heterogeneous in terms of the respective somatic disorders. However, if the prevalences of depressive disorder are referred to individual somatic syndromes (i.e. more homogeneous samples), a substantial variation is revealed with the highest morbidity rates (about 30–60%) being recorded for cancer and cerebral insult. Surprisingly few studies are available on the further course of depressive disorders after discharge from hospital; however, a 1-year persistence rate of about 30–40% is likely [29]. This aspect seems all the more problematic, bearing

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in mind that, in a general hospital, a substantial proportion of consultations are requested with reference to problems relating to depressive disorders, while the mean request rate for consultations is, at about 2%, far below the morbidity rates for mental disorders [23, 24]. A substantial psychiatric morbidity rate is recorded among patients of family doctors and internists too. The WHO study, which is characterized by meticulous methodology and was carried out in a number of different countries, suggests a prevalence rate of about 12–13% for depressive disorders [30–32]. However, it has to be borne in mind that this prevalence rate includes not only patients suffering from a comorbid depression in addition to their physical illness but also those attending a medical practice and displaying psychiatric or physical symptoms of non-organic etiology and suffering from a depression without a concomitant physical illness. However, the presence of a physical illness presents a risk of depression in these samples too and forms an unfavorable factor for the further prognosis of the depressive disorder. A 1-year follow-up study of the German subsample of the WHO family doctor study showed in one third of cases a relapsing or chronic course that also led to a high degree of social impairment [33].

Causal Relationships

Classifications for possible relationships between physical and mental illnesses have been proposed by various authors. Basically, the following typology of corresponding relationships (with examples) is currently accepted. (1) Mental and physical illnesses occur independent of each other. This type of relationship is likely to be the most frequent. In a sample from a general hospital, more than half of the depressive episodes and dysthymias were assessed as being independent of the physical illness [24]. (2) The mental illness is caused by the physical illness. Häfner and Bickel [34] pointed out that three mechanisms are essentially recognizable in this type of relationship. (a) Depressive symptoms are induced by a mental (mis-?)processing of a physical illness. This is primarily the case in the depressive reaction. (b) The depressive symptoms are caused by the physical illness itself or by its treatment. This is the case, for instance, in organo-cerebral diseases or in the treatment of hepatitis C with interferon-␣. (c) One common factor is essentially responsible for both the physical and the mental illness. This might, for example, be the case in chronic stress which entails on the one hand an increased risk of depression and, on the other, for example, an increased risk of the development of a metabolic syndrome and thus a cardiovascular risk [35].

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(3) The mental illness is by the physical illness. A preexisting depression may be exacerbated by a concomitant physical illness in terms of both the intensity of its symptoms and its course. Such an exacerbation was registered in approximately 1/3 of depressive patients in general hospitals [24]. (4) The physical illness is caused by the mental illness. This type of relationship might underlie the epidemiologically largely secured finding that severe depressions in particular constitute an independent risk factor in the pathogenesis of cardiovascular diseases. However, in view of the data currently available, other modes of interaction are also conceivable, for example the (co-)inducing by one common factor, e.g. psychosocial stress or even the precipitation of a depression by subtle inflammatory changes to the arterial vascular system. (5) The physical illness is exacerbated by the mental illness. For example, the risk of mortality after surviving a cardiac infarction is 3–5 times higher in patients suffering from severe depression. The prognosis for breast cancer and possibly for other forms of cancer is poorer. (6) The physical symptoms are not of physical but of mental origin (somatization). In practice, however, physical and mental illness may be so inextricably interlinked so as to preclude any differentiation of causal relationships.

Influence of Depressive Disorders on the Course of Physical Illnesses

The presence of a depressive disorder has to be assumed to have a negative impact on the course of a physical illness [for an overview see, 36]. This applies in particular to coronary cardiac disease but is disputed in other diseases such as cancer or terminal renal insufficiency. In a sample of internally ill inpatients not selected on the basis of disease groups, an independent influence of depressivity (dimensional) on total mortality was observed in consecutively examined admissions [37]. The risk of noncompliance during medical treatment is on average about three times higher (!) in depressives, as shown by a meta-analysis of 12 studies carried out by DiMatteo et al. [38]. This may be due to resigned oppression and inhibited drive associated with depressive disorders, but possibly to a more fragile social integration and to cognitive deficits within the framework of the depressive disorder [39]. However, studies published during the past decade show increasingly that severe depression (major depression) in particular influences the course of a physical illness by various biological means, with especially those biological

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changes accompanying severe depressions being regarded as ‘candidates’ for the potential influencing of physical illnesses. These include a changed tonus of the vegetative nervous system, upward regulation of the hypothalamo-pituitaryadrenal axis, increased thrombocyte aggregation, and complex changes in the immunologic subsystems, especially the activation of proinflammatory mechanisms [40, 41].

Depression in Specific Physical Illnesses

Some physical illnesses or groups of illnesses which play a major role in terms of their need for outpatient and inpatient medical care and in which a significantly increased incidence of depression is registered are detailed below. Coronary Heart Disease For the past 10 years or so, intensive research interest has been focused on the relationships between coronary heart disease and depressive disorders. However, the findings are being put into clinical practice only very gradually. A wide range of comprehensive, practice-relevant overviews has been published on this topic [42, 43]. The relationships between susceptibility to depression and coronary heart disease are complex and possibly reciprocal. Special attention has been paid to the influence of depressive disorders on cardiac morbidity and mortality in more recent publications. In subjects with an initially intact heart, the presence of a severe (but also of a milder) depression now has to be seen as an independent risk factor in addition to the known risk factors for the development of coronary heart disease. Severe depressions appear to entail a 3- to 4-fold increase in the risk [44]. Approximately 20% of patients who have coronary heart disease or have survived a myocardial infarction are likely to be suffering from a severe depression [45]. When milder forms of depression (including depressive reactions) are taken into account, the prevalence rate is twice as high at 40% [46]. About 2/3 of both forms of depression appear to persist at least for some months. The presence of a depression is an independent risk factor for postinfarction cardiac mortality and entails an approximately 3 times higher risk of cardiac death. The severity of the depressive symptoms after the infarction appears to correlate with the risk of mortality even 5 years later [47]. A meta-analysis of 29 studies has shown that patients suffering from coronary heart disease benefit from a rehabilitation regime including psychosocial interventions [48]. Various approaches such as stress management or group and individual psychotherapy were found to have a significantly positive impact on

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important course-predictive parameters, e.g. subjective stress, heart rate, systolic blood pressure, and cholesterol level. The occurrence or recurrence of infarctions and the mortality rate in the untreated control group were significantly higher over a 2-year period with a relative risk of 1.8 and 1.7, respectively. Overall, recent findings suggest that rehabilitation programs combining somatic rehabilitation, stress-reducing measures and individual psychotherapy help to prevent further cardiac events. Although studies confirming the effectiveness of psychotherapeutic measures in terms of reduced mortality have yet to be published, no cardiotoxic effects of psychotherapy are known [49]. First results of large-scale intervention studies such as the ‘Enhancing Recovery in Coronary Heart Disease Study’, in which patients suffering from a depression in the wake of a cardiac infarction were treated with behavior therapy show that, while antidepressive interventions did improve the patients’ quality of life, they were unexpectedly incapable of lowering the infarction recurrence rate or the cardiac mortality rate (24.4% death rate in the intervention group, 24.2% in the control group after a mean 41-month follow-up) [50]. By contrast, improved social support appears to have a positive impact on cardiac mortality [51]. However, no definitive conclusions should be drawn until the study data have been analyzed in greater detail and results of other studies have been published. The use of tricyclic antidepressants (TCAs) in antidepressive pharmacotherapy has been disputed. The relatively high rate of cardiovascular side effects, e.g. the precipitation and exacerbation of conductivity disorders especially in patients with a previously damaged heart, an increased pulse rate and orthostatic complaints, or the precipitation of delirious syndrome, has led to very great restraint in the prescribing of these preparations for patients undergoing cardiologic rehabilitation. It has even been shown that patients treated with TCAs had a higher cardiac mortality rate than untreated patients or those treated with serotonin selective reuptake inhibitors (SSRIs) [52]. Corresponding risks have been confirmed in animal experiments. Reluctance towards an adequately dosed and consistent pharmacotherapy has obviously still to be overcome in clinical practice, although treatment with SSRIs has increasingly been shown not only to be effective in treating depression but also to be a low-risk approach. The results of studies carried out in the 1990s as well a those of initial, targeted intervention studies indicate that SSRIs (sertraline, paroxetine) are well tolerated by patients who have suffered a cardiac infarction and that they reduce the depressive symptoms with no additional cardiac risk [50, 53]. One observation of interest in this context is that the risk of infarction in high-risk persons (smokers) who have not yet suffered an infarction is reduced by the intake of SSRIs [54]. However, direct proof that a medication-induced reduction of depressivity lowers the risk of cardiac mortality has yet to be provided.

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The evidence currently available justifies antidepressive, medication-based therapy at least to improve the quality of life of those concerned. However, the not inconsiderable interaction potential of some SSRIs with frequently prescribed cardiac medications has to be borne in mind. For instance, the breakdown of anti-arrhythmics, ␤-blockers and calcium antagonists is delayed by competitive breakdown inhibition mediated by the cytochrome P450 system when SSRIs are taken simultaneously. Preference should therefore be given to SSRIs or antidepressants with a ‘dual’ (serotonergic and noradrenergic) mode of action and with the lowest possible interaction potential (e.g. citalopram, sertraline, mirtazapin, venlafaxin). Negative findings of studies with antidepressive interventions might also imply that the intervention was applied not only too late (incorrect time point) but also perhaps to an incorrect psychosocial or biological mechanism. The fact might be, for example, that psychosocial stress induced the development of both illness units early and persistently and that interventions are already ineffective when the cardiac disorder becomes manifest. It is also conceivable, however, that the depression is precipitated primarily by the underlying physical illness itself, especially in patients with such a predisposition. For instance, the tryptophan/serotonine metabolism and thus the pathogenesis of the depression might be influenced by a chronic inflammatory, vascular process [55]. A multivascular cerebral disorder might result in minor strokes associated with an increased risk of depression. Stroke Strokes have long been known to entail an increased incidence of depressive disorders [56]. From the currently available studies Whyte and Mulsant [57] compiled the point prevalence rates for post-stroke major depression with regard to the time lapse since the event. Within a 2-week period, about 25% of patients develop a major depression, after 3–4 months the mean prevalence rates are still just as high, and after 1 year they are 10–15%. Two studies reported rates of about 20% after 2 years. A systematic review of possible risk factors for post-stroke depression [58] showed that probable risk factors are: history of depression or psychiatric symptoms; dysphasia; post-stroke functional impairments; living alone, and post-stroke social isolation. Factors whose influence is less clear are: age; gender; socioeconomic status; pre-stroke social stress, and post-stroke dependence on the help of others. The mechanisms involved in a post-stroke depression can thus be divided into more psychological and more biological factors. The psychological mechanisms include on the one hand personality-associated problems characterized by a psychiatric anamnesis, which may lead to a post-stroke reduction in coping ability. On the other hand, it is quite plausible that extensive lesions (direct

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relationship with incidence of depression) and the associated functional impairments are difficult to cope with (i.e. overstretch the coping ability). The biological mechanisms can be assumed on the one hand to be genetic factors with a predisposition to depressive disorders that is manifest under specific circumstances of life. On the other hand, however, the sites of infarction may affect those very regions of the brain that are involved in regulating mood and drive, e.g. sinistrocerebral regions and the basal ganglia. The extent to which a depressive disorder is an important predictor of post-stroke mortality is subject to controversial debate on account of the small number of publications [56]. The development of post-stroke depression is a complex process in which the respective pathogenetic factors should be worked out in each individual clinical case. It is the opportunity for differential indication and the prospective success of psychotherapeutic interventions rather than the indication for pharmacotherapy that are decided on this basis. Psychosocial interventions in the patient’s family have so far proved to especially helpful. From the pharmacotherapeutic aspect it is primarily SSRIs that are now to be recommended [for review see, 57]. To date, nortriptyline, trazodone, fluoxetine and citalopram have been successfully tested in randomized, placebo-controlled studies. The effectiveness of electroconvulsive therapy has also been verified. Individual successful trials have also been undertaken with psychoanaleptics (e.g. methylphenidate). Cancer It can be regarded as statistically secured that depressive disorders occur with a markedly increased incidence after the diagnosis of cancer, with a point prevalence of about 20% for both severe and milder depressive disorders [59, 60]. The risk of a cancer patient suffering from depression seems to depend on the presence of a depression in the case history or in the family, alcohol dependence, advanced stage of the disease, inadequate pain therapy, medical complications, and depressiogenic pharmacotherapy [59]. For depressions in cancer patients too, more psychological and more biological mechanisms of development can be differentiated. While an abundance of literature is available on coping mechanisms/adaptation, the possible biological mechanisms underlying the development of the depression remain unclear. On the other hand, the presence of a depression appears to have little effect, if any, on the development of cancer. Although individual studies report a slightly higher risk in this respect, currently available large-scale cohort studies speak against this [61, 62]. However, many studies indicate that the course of certain types of cancer may correlate with coping ability and thus with a predisposition to depressivity. Although account has to be taken both of sample effects and of the heterogeneity

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of the methods used to measure coping, the relationship between active, ‘aggressive’ confrontation with the disease and a higher lack of relapse or a higher survival rate is an impressive finding [63]. By contrast, depressive coping with the disease tends to have a detrimental effect. For example, the presence of a depression leads to an independent (e.g. through suicide), increased risk of mortality in breast cancer patients [64, 65]. In the respective studies, widely differing therapeutic approaches have proved to be beneficial, especially by reducing depressivity and anxiety. Under various therapies both the quality of life and the coping ability increase. However, the 10 randomized studies published to date have produced inconsistent findings, with 5 reporting a significantly positive influence on survival time and 5 no influence. It has to be borne in mind when interpreting these findings that the respective study samples were suffering from different types of cancer and that the samples themselves were strikingly heterogeneous. Furthermore, different kinds of psychotherapeutic interventions were selected: psychodynamicsupportive; cognitive-behavioral; relaxation strategies, and hypnosis. An analysis of the corresponding studies reveals no clear-cut superiority of one or more psychotherapeutic approaches with respect to a specific form of cancer. Spiegel [66] argued that the conspicuous changes in cancer therapy in the 1990s (improved early diagnosis, innovative treatment principles, enhanced social support) might be partially responsible for the observation that more recent studies in particular found no influence on survival time. These changes might well have had such a strong impact as to mask the comparatively weak impact of psychotherapy on survival time. Parkinson’s Disease On average, 40% of all patients with Parkinson’s disease suffer from a depressive disorder [67, 68], with approximately half the prevalence rate falling to severe, and half to milder forms of depression. In a significant number of cases the depressive disorder is manifest before the development of motor symptoms and can be seen as a syndrome within the scope of the initial manifestation. However, an increased risk of depression remains even after the illness has been diagnosed, also in comparison with other chronic diseases such as diabetes type II and osteoporosis [69]. The degree of depressivity is not correlated with the type and extent of motor symptoms. Although the physical impairment and social restrictions for which it is partially responsible may have an influence on the pathogenesis of the depression, independent biological relationships between neurodegenerative mechanisms within the framework of the underlying disease and the occurrence of a depressive disorder also appear to play an important role [70, 71]. The crucial factor here is likely to be the reduction not only in the dopamine metabolism but also in the serotonin metabolism.

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No major, randomized, placebo-controlled studies that might offer good evidence of the successful treatment of depressive syndromes in patients with Parkinson’s disease have been published to date. Open-label studies suggest, however, that antidepressants, primarily selective serotonin or noradrenaline reuptake inhibitors, might be effective. Although sufficient empirical evidence is lacking, the currently available data indicate a good effectiveness of SSRIs [72]. However, some case reports indicate that the administration of SSRIs may have exacerbated the motor symptoms of Parkinson patients [73, 74]. Treatment with levodopa appears to have depression-alleviating effects in some patients. Special interest has been aroused by recent observations that bilateral electrical stimulation of the subthalamic nucleus may lead to a substantial improvement not only in motor functions but also in cognitive deficits and depressive syndromes [75]. The possibility of the basal ganglia being involved in the development of depression is also of some theoretical interest. As electroconvulsive therapy is indicated both for Parkinson’s disease and for severe melancholic depression, the application of this procedure suggests itself in Parkinson-associated depression too. As controlled studies have yet to be published, the decision to apply this therapy remains confined to individual cases [76]. HIV A recently performed meta-analysis of 10 studies showed that the risk of HIV-infected subjects suffering a depression was approximately twice as high as in healthy subjects [77]. This applied both to severe depression and to dysthymia. However, the cross-sectional prevalences among HIV-infected persons were only 9.4% for severe depression and 4.2% for dysthymia. HIV-infected subjects suffering from AIDS were no more susceptible to depression than asymptomatic HIV patients. The meta-analysis covered only those studies in which standardized diagnostic techniques had been used and HIV-negative groups had been examined for comparison purposes. However, individual studies not included in the meta-analysis report higher prevalence rates of ca. 20–30% for severe depression [for overview see, 78]. An extensive comorbidity study reported depressive symptoms (dimensional assessment) in about 35% of HIV-infected subjects without AIDS and in 65% with AIDS [79]. Varyingly composed patient collectives and different methods used for diagnosing depression might account for the discrepant findings. In all events, depressive disorders are undoubtedly a clinically significant problem for HIV-seropositive patients. Depressive symptoms, life events experienced as stressors, and inadequate social support appear to have a negative impact on the progression of HIV, the development of manifest AIDS symptoms, and mortality [79, 80]. It is conceivable that a comorbid depression might contribute towards a poorer

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prognosis by reducing the activity of the natural killer cells, the CD4⫹ lymphocytes, and by increasing the quantity of activated CD8⫹ cells and viruses [79, 80]. From the therapeutic standpoint, TCAs and SSRIs are similarly effective, but preference is generally given to SSRIs on account of their less pronounced side effects [for overview see, 81]. However, the interaction potential of antidepressants has to be borne in mind, as HIV-infected patients are often treated simultaneously with different chemotherapeutic and virostatic agents (metabolism via the cytochrome P450 system).

Depression in Association with Medicotherapeutic Measures

It is not only psychosocial factors and disease-associated biological factors but also various medical treatment measures that may precipitate depressive symptoms. However, it has to be conceded that modern, markedly invasive therapeutic procedures such as bone marrow transplantation (BMT), extracorporeal maintenance of the circulatory system, or defibrillator implantation may have a mentally traumatizing and depression-promoting effect. Surprisingly few studies have investigated this aspect of modern clinical therapy. In a large-scale study of 437 patients, 31% displayed depressive symptoms (dimensional assessment) prior to BMT [82]. In a prospective study in which patients were evaluated before and after BMT, no change over time was recorded in depressive symptoms [83]. During the post-BMT isolation period 47.5% of patients were diagnosed as having an adaptive disorder with depressive mood, and 5% an organically induced affective disorder [84]. Other authors reported that the presence of depressive symptoms had no influence on the prognosis [85]. Colon et al. [86], however, reported a poorer prognosis in patients with depressive symptoms. Owing to the scant data available, no conclusive assessment can be made at present. Individual finds suggest, however, that the confrontation with the diagnosis of cancer might ultimately be more stressful than the actual BMT [87]. Following cardioverter defibrillator implantation in patients with lifethreatening, recurrent ventricular arrhythmia, it was primarily anxiety symptoms as well as depressive disorders that were reported. In a study of 35 patients, 8.6% were diagnosed as suffering from severe depression immediately after implantation. Nine to 18 months after implantation 7.4% of the remaining patients had developed a severe depression [88]. A large number of broadly applied medical preparations may cause depressive symptoms. The mechanisms of action involved vary considerably

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and have still to be definitively clarified in many cases [89, 90]. In recent years, scientific interest has been focused on immunologically based approaches in the treatment of cancer and hepatitis C, i.e. with interleukin-2 or interferon-␣. The incidence of severe depression in hepatitis C patients being treated with interferon-␣ is approximately 25–40%, occurring in 2/3 of all cases within the first 8 weeks of treatment and correlating with the degree of depressivity at the start of treatment [91, 92]. Interferon-␣ treatment leads to complex changes in cellular immune functions and in cytokine release. However, the precipitation of the depression is closely linked with a reduction in tryptophan availability [55], probably through the activation of indoleamine 2,3-dioxygenase, the enzyme that degrades tryptophan into kynurenine. A placebo-controlled intervention study by Capuron et al. [93] shows that the prophylactic administration of paroxetine has a positive impact on depressive symptoms, especially with respect to parathymia and anxiety, but not on vital symptoms such as fatigue and loss of appetite which may rather be associated with the underlying disease. Another aspect of interest in depression research is the observation that even more minor changes in the serum concentration of cytokines may induce CNS-related changes in mood, drive, cognition and sleep pattern [94, 95]. This provides a link with the frequently described induction of proinflammatory cytokines in patients suffering from depressive disorders [96], though rather with depression forms of the non-melancholic subtype [97, 98].

Desire for Death and Suicidal Tendency

Against the background of the current debate on the possibility of ‘euthanasia’ in terminal diseases, the question of the desire for death and the actual risk of suicide has justifiably attracted attention. Somatic disorders have long been known as a risk factor for suicidal tendency; in samples of subjects who have committed suicide, the prevalence of significant physical illnesses is higher at about 35% than in the age-related general population [99]. Certain physical illnesses appear to be accompanied by a clearly increased suicidal tendency. These include neurological diseases such as amyotrophic lateral sclerosis, multiple sclerosis, cancer of the CNS, and in particular HIV/AIDS. A desire for death and suicidal tendencies correlate with the subjectively perceived hopelessness of the perceived burden on the environment and the loss of control over one’s own person as well as with the progression of the physical disease and especially with intolerable pain [100, 101]. It is the first group of factors in particular that reveals how close this is to genuine depressive symptoms

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and illustrates how difficult it can be in individual cases to diagnose a depression where the decision has ultimately to be made on whether stated perceptions comply with the facts or are subject to typical, depression-induced distortion. The presence of a depression does not imply a suicidal tendency per se. For instance, Akechi et al. [102] reported that 51.4% of severely depressed cancer patients thought about suicide. The severity of the depression, poor physical health, and vocational integration were found to be predictive in comparison with non-suicidal depressive patients. This shows that, understandable as the desire for death and active suicidal tendencies may be, the diagnosis and possible treatment of a depressive disorder are absolutely vital especially in the case of terminally ill patients, as are adequate pain therapy and support for the physical functioning. Outlook

From the perspective of patient care, substantial improvements are needed in the early, expert diagnosis and treatment of depressive disorders in medical patients. This can help to improve the patient’s quality of life and to reduce the negative effects on the course of the somatic disorder as well as to relieve the strain on relatives and to avoid social withdrawal. We in Germany are further removed from this perspective than is really necessary in view of the fundamentally available therapeutic options. Stumbling blocks on the part of the patient, ‘somatic’ medicine, and the other structures in psychiatry, psychosomatics, psychotherapy and medical psychology, which are fraught with overlaps, lack of clarity and conflicting interests, are a burden on the patient in the routine clinical setting and push up costs. The influence of the new remuneration system on adequate integrational care can be viewed with skepticism. A decline in the number of psychiatric consultations might be conceivable if the costs of such a service are subject to internal settlement. On the other hand the frequency with which psychiatric-psychotherapeutic experts are consulted might increase as soon as it becomes clear in clinical practice that somatically ill patients with a comorbid psychiatric disorder recover less quickly, so that their hospitalization period is prolonged. In addition, diagnosing a mental comorbidity might increase the severity of the case, resulting in higher flat rates for each case. Perspectives of health care research, which hardly exists in this field in Germany, are the improved diagnosis of depressive disorders in routine clinical practice and the evaluation of treatment programs as well as research into the interactions between coping and psychotherapeutic intervention strategies.

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Tandberg E, Larsen JP, Aarsland D, Laake K, Cummings JL: Risk factors for depression in Parkinson disease. Arch Neurol 1997;54:625–630. Lemke MR, Raethjen J: Depression und Morbus Parkinson. Klinik, Diagnose, Therapie. Bremen, Uni-Med, 2002. Aarsland D, Cummings JL: Depression in Parkinson’s disease. Acta Psychiatr Scand 2002; 106:161–162. Zesiewicz TA, Gold M, Chari G, Hauser RA: Current issues in depression in Parkinson’s disease. Am J Geriatr Psychiatry 1999;7:110–118. Daniele A, Albanese A, Contarino MF, Zinzi P, Barbier A, Gasparini F, Romito LM, Bentivoglio AR, Scerrati M: Cognitive and behavioural effects of chronic stimulation of the subthalamic nucleus in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry 2003;74:175–182. Folkerts H: Elektrokrampftherapie bei neurologischen Erkrankungen. Nervenarzt 1995;66: 241–251. Ciesla JA, Roberts JE: Meta-analysis of the relationship between HIV infection and risk for depressive disorder. Am J Psychiatry 2001;158:725–730. Treisman G, Fishman M, Schwartz J, Hutton H, Lyketsos C: Mood disorders in HIV infection. Depress Anxiety 1998;7:178–187. Page-Schafer K, Delorenze GN, Satariano WA, Winkelstein W: Comorbidity and survival in HIV- infected men in the San Francisco Men’s Health Survey. Ann Epidemiol 1996;6:420–430. Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum EE, Schuman P, Boland RJ, Moore J, HIV Epidemiology Research Study Group: Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: Longitudinal analysis from the HIV Epidemiology Research Study. JAMA 2001;285:1466–1474. Elliott AJ, Roy-Byrne PP: Major depressive disorder and HIV-1 infection: A review of treatment trials. Semin Clin Neuropsychiatry 1998;3:137–150. Baker F, Marcellus D, Zabora J, Polland A, Jodrey D: Psychological distress among adult patients being evaluated for bone marrow transplantation. Psychosomatics 1997;38:10–19. Wettergren L, Languis A, Bjorkholm M, Bjorvell H: Physical and psychosocial functioning in patients undergoing autologous bone marrow transplantation – A prospective study. Bone Marrow Transplant 1997;20:497–502. Schweigkofler H, Sperner-Unterweger B, Kopp M, Trojer-Zeidler M, Holzner B: Psychiatric problems in bone marrow transplantation patients during isolation. Nervenarzt 1996;67:799–804. Jenkins PL, Letser H, Alexander J, Whittaker J: A prospective study of psychosocial morbidity in adult bone marrow transplant recipients. Psychosomatics 1994;35:361–367. Colon EA, Callies AL, Popkin MK, McGlave PB: Depressed mood and other variables related to bone marrow transplantation survival in acute leukemia. Psychosomatics 1991;32:420–425. Mundy EA, Blanchard EB, Cirenza E, Gargiulo J, Maloy B, Blanchard CG: Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments. Behav Res Ther 2000;38:1015–1027. Crow SJ, Collins J, Justic M, Goetz R, Adler S: Psychopathology following cardioverter defibrillator implantation. Psychosomatics 1998;39:305–310. Klimke A, von Wilmsdorff M: Medikamentöse Behandlung – psychotrope Nebenwirkungen von Nichtpsychopharmaka; in Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin. Darmstadt, Steinkopff, 2004, pp 160–172. Kasper S, Jung B: Psychiatrisch relevante Nebenwirkungen der nichtpsychopharmakologischen Pharmakotherapie Nervenarzt 1995;66:649–661. Bonaccorso S, Marino V, Biondi M, Grimaldi F, Ippoliti F, Maes M: Depression induced by treatment with interferon-alpha in patients affected by hepatitis C virus. J Affect Disord 2002;72: 237–241. Horikawa N, Yamazaki T, Izumi N, Uchihara M: Incidence and clinical course of major depression in patients with chronic hepatitis type C undergoing interferon-alpha therapy: A prospective study. Gen Hosp Psychiatry 2003;25:34–38. Capuron L, Gumnick JF, Musselman DL, Lawson DH, Reemsnyder A, Nemeroff CB, Miller AH: Neurobehavioral effects of interferon-alpha in cancer patients: Phenomenology and paroxetine responsiveness of symptom dimensions. Neuropsychopharmacology 2002;26:643–652.

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Prof. Dr. Volker Arolt Department of Psychiatry University of Münster, Albert-Schweitzer-Strasse 11 DE–48129 Münster (Germany) Tel. ⫹49 251 83 56604, Fax ⫹49 251 83 56988, E-Mail [email protected]

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Alcohol-Related Interventions in General Hospitals in Germany: Public Health and Consultation-Liaison Psychiatry Perspectives Georg Kremera, Bernhard Baunea, Martin Driessena, Günther Wienbergb a

Center of Psychiatry and Psychotherapeutic Medicine, Gilead Hospital, Bethel, and bExecutive Board, v. Bodelschwinghsche Anstalten Bethel, Bielefeld, Germany

Alcohol-Related Disorders as a Complex Problem

Recent epidemiological studies on substance use disorders in Germany revealed valid estimates of incidence and prevalence of alcohol related-disorders. Alcohol abuse and alcohol dependence are among the most common and frequent diseases in the general population. They have a significant impact on physical as well as on mental health status in more than 75%, and they are associated with a variety of DSM-IV Axis I and Axis II comorbid mental disorders in more than 60% of alcohol-dependent persons [1]. In Germany, about 42,000 persons/year die due to alcohol-related diseases, another at least 14,000/year are accepted for early retirement, and in about 850,000 persons/year alcohol causes periods of inability to work. At least 570,000 admissions to general hospitals/year are related to alcohol problems with an economic impact of EUR 1.9 billion each year [2]. Alcoholism and its common physical and/or mental comorbidity establish many medical and/or psychiatric treatment needs and leads to much higher prevalence rates in the health care system compared to the general population.

Prevalence of Alcohol Problems in the General Population and in Subpopulations

Because alcohol-related problems vary on a continuum of addictive behaviors, epidemiological investigations and alcohol-related interventions should reflect the different stages of this continuum. For several years, the per capita intake of alcohol in Germany remains on a constant level of about 156 liters/ year corresponding to 10.6 liters pure alcohol [3]. In a ranking of 28 countries in Europe and abroad, Germany ranks 5th. Several representative epidemiological surveys (‘Bundesstudie’, nationwide; Transitions in Alcohol Consumption and Smoking Project, Luebeck, and Early Developmental Stages of Psychopathology Study, Munich) indicate that the intake of alcohol is a major problem in the general German population [4–6]. In a representative general populationbased study conducted by Kraus and Bauernfeind [4] 12,000 subjects (age 18–59) were included and, with an overall response rate of 67%, altogether 8,020 people were investigated for alcohol problems. The authors found a 12-month prevalence of 2.4% (1.6 million inhabitants) for DSM-IV alcohol dependence and of 4.0% (2.7 million) for alcohol abuse. Another representative study (German National Health Survey – Mental Health Supplement; n ⫽ 4,181; response rate 88%) carried out in the general population (age 18–65) in 1998–1999 found similar (partly unpublished) results [7, 8]. According to this study 4.95% of the general population were diagnosed as alcohol abusers and a further 2.43% as alcohol-dependent (1-year prevalence). Although national and international, standardized and validated diagnostic instruments for the investigation of alcohol disorders were implemented in these recent studies, the true prevalence of alcohol disorders in the general population was probably underestimated due to a sample selection bias by excluding highrisk groups for alcohol abuse, such as homeless people and people with language limitations that are common in ethnic minorities (i.e. immigrants from the former Soviet Union), due to response bias because of social awareness, due to recall bias and missing values, e.g. of persons with alcohol-related cognitive deficits. This underestimation of prevalence will have its effects on the quantity of the ‘true’ population in need for alcohol-related interventions. From a need of care perspective, the population in need can be differentiated in at least 4 groups with alcohol problems [9]: group 1, persons with atrisk drinking, i.e. ⬎40 mg pure alcohol in men, ⬎20 mg in women (⬃3.2 million); group 2, persons with alcohol abuse (⬃2.7 million); group 3, persons with alcohol dependence (⬃2.0 million); group 4, persons with chronic alcohol disorder and severe alcohol-related social, mental and physical problems (the prevalence and incidence of this group is included in group 3).

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Each of these 4 subpopulations is in need of specific and appropriate interventions ranging from early recognition and brief intervention, intensive counselling, psychiatric and medical treatment to medical and social rehabilitation and harm reduction. Both the subpopulations in need and the different types of interventions reflect the continuum of alcohol problems and alcoholrelated interventions.

Prevalence of Alcohol-Related Disorders in Primary Health Care

In the last decade methodologically profound epidemiological studies in the German primary health care (PHC) system were completed. In general practices current prevalence rates (point prevalence, 1-year prevalence) of alcohol dependence vary between 4.7 and 7.2% [10–12], and the prevalence rates of all alcohol-related disorders converged in two studies with 10.4 and 10.2%, respectively [12, 13]. These figures indicate an up to three times higher prevalence than in the general population and underline the high general morbidity of addicted persons. Clinical studies on medical or surgical wards of general hospitals revealed prevalence rates between 7.8 and 14.0% for alcohol dependence and between 3.9 and 7.5% for alcohol abuse (clinical diagnoses, ICD 10) [14–16]. The wide range of findings is partly explained by different context variables (type and location of hospitals), but they are comparable to findings in several European studies [for review see, 10]. They underline the substantial impact of the PHC system for the treatment of persons with alcohol problems. The gap between population-based prevalence and PHC-based prevalence demonstrates a more general issue in the field of addiction. The German care system for persons with alcohol problems is roughly separated into three subsystems [17–19]: (1) subsystem 1 provides special services for substance use problems, mainly for the treatment of persons with a manifest dependence syndrome; (2) subsystem 2 provides psychiatric and social services for the mental and social consequences of alcohol problems but is not or only partially specialized, and (3) subsystem 3 is represented by the PHC system with a primary focus on physical aspects of alcohol-related disorders. Using published data from different sources it was possible to calculate rough estimates for the annual institutional prevalence, i.e. the annual contact rate among the ⬃2 million persons with alcohol dependence in Germany, across the three subsystems. These rates were: 7–10% for subsystem 1; 8–10% (psychiatric services) and less than 10% (all other social services) for subsystem 2, and more than 80% for subsystem 3. This comparison indicates that about 4 of 5 persons with a manifest alcohol dependence syndrome have at least

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1 contact/year with the PHC system: 25–35% are treated at least once per year on a surgical or medical ward of a general hospital, and about 70–80% visit their general practitioner at least once per year [9, 10, 19, 20]. Also considering persons at risk of drinking or alcohol abuse would make the gap between institution-based prevalence and population-based prevalence even more striking since these groups nearly exclusively contact the PHC system. The presented epidemiological data prove a high level of contact among people with alcohol abuse or dependence to the PHC system. Other characteristics of PHC such as the immediate responsibility of general hospitals and general practitioners for the health care of the general population and its easy access for patients are preconditions of efficient early recognition of alcohol problems and brief intervention strategies.

Types of Interventions by the Consultation-Liaison Psychiatrist and Psychologist

A variety of alcohol-related activities are applied by consultation-liaison (CL) psychiatrists and psychologists in general hospitals in Germany. Some of the activities are personal interventions in direct contact with the patient, but cooperation with and educational activities for the medical staff are as important and sometimes more efficient (for an overview see table 1). The international literature on early recognition and brief intervention shows a great variety in some important aspects, e.g. length of interventions, organization, staff attendance, etc. (see meta-analyses by Miller and Wilbourne [21] and Moyer et al. [22]). Thus, it is difficult to draw generalized conclusions from scientific findings for the transfer into the routine care of German general hospitals. Diagnosis and Early Recognition Although the results of recent investigations rejected the widespread assumption that physicians do not recognize severe alcohol-related disorders [23], there is a widespread failure of documenting diagnoses and communicating it to the patient in most cases without complications. Nearly all cases with at-risk consumption who do not meet the diagnostic criteria (subthreshold cases) are neglected. From a public health perspective, however, this latter group is the most important one for early recognition and early intervention. Consequently, the implementation of screening instruments (e.g. CAGE [24], LAST [25], AUDIT [26]) into general hospital routine is helpful but needs education and/or instructions by CL services. How should early recognition be organized? If a screening questionnaire is used it should be handed over and received by the

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Table 1. Alcohol-related interventions and cooperation of general hospital staff with consultationliaison psychiatry service (CLPS) Task/type of intervention

Preparation and methods

Responsibility

Screening In all patients or in suspicious cases

Providing instruments and education of staff by CLPS

Nurses and doctors of general hospital ward

Detailed and differential diagnosis

Diagnostic sessions (including psychiatric CLPS comorbidity)

Monitoring withdrawal

Providing instruments and education of staff by CL psychiatrist

Nurses (scoring) and doctors (observation) of general hospital ward

Treating withdrawal syndromes

Recommendation of a score-guided medication scheme by CL psychiatrist

Nurses (drug administration) and doctors (observation) of general hospital ward

Crisis intervention

Education for recognition of psychosocial crises

Nurses and doctors of general hospital ward

Specific psychiatric/psychotherapeutic crisis intervention

CLPS

Establishing single and/or group setting by CLPS

CLPS and/or social worker

Motivational intervention

Planning alcohol-related Education of social workers and the interventions after discharge/ staff by CL psychiatrist contact to the specialized system of care

CLPS and/or social worker together with nurses and doctors of general hospital ward

ward physician or nurses in order to decrease the rate of refusals. If the ward staff is not able to take over this task (this will probably be the case on almost all surgical wards, and also on some medical wards), then the CL psychiatrist or psychologist has to realize screening, diagnoses and counselling. Monitoring Withdrawal Episodes and Score-Guided Treatment Monitoring withdrawal in patients with alcohol dependence using standardized instruments (e.g. the Alcohol Withdrawal Scale [27, 28]) can prevent severe complications, provides the option of rational and standardized treatment strategies, and may reduce the dosages of drugs with sedating side effects. In the face of the patient’s reduced cognitive capacity during withdrawal, this latter factor is important to enable patients to follow psychological interventions as early as possible. The responsibility of the CL psychiatrist is to introduce such instruments, establish treatment schemes, and to educate and motivate ward staff.

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Contents of Brief Psychological Interventions The contents of almost all brief intervention methods are based on three counselling concepts. The first one is the model of Motivational Interviewing developed by Miller and Rollnick [29, 30], and adapted for medical settings by Rollnick et al. [31] as Brief Motivational Interviewing (BMI). This approach strengthens the motivational aspects of behavioral change and covers: (1) lifestyle, stressors and substance use (opening strategy); (2) health and substance use (opening strategy); (3) a typical day/session; (4) the good things and the less good things; (5) providing information; (6) the future and the present; (7) exploring concerns, and (8) help in decision making. The second concept refers to cognitive-behavioral theory, especially the self-control concept developed by Hester and Miller [32]. It was adapted for medical settings by Heather et al. [33] as Skills Based Counselling (SBC). This approach strengthens the practical aspects of behavioral change and covers: (1) investigation of drinking patterns and lifestyle; (2) comparison of consumption and norms; (3) information about recommended limits; (4) instruction in self-monitoring; (5) tips for reducing the rate of drinking; (6) identification of high-risk drinking situations; (7) instruction on how to cope with these situations without drinking, and (8) discussion of alternative activities associated with a changed lifestyle. The third concept refers to self-efficacy aspects and was adapted for brief interventions. Gentilello et al. [34] described 5 steps of intervention: (1) give personalized feedback; (2) help the patient to develop goals for behavioral change; (3) emphasize the patients’ needs to assume personal responsibility for change; (4) provide the patient with choices of alternative strategies for changing behavior, and (5) try to instill a sense of hope that change is possible. Similar key elements of brief interventions were characterized by the acronym FRAMES: give Feedback, emphasize Responsibility, give Advice, discuss the Menu of alternatives, express Empathy, reinforce Self-efficacy [35]. Intensity of Intervention: From Single Advice to Extended Motivational Enhancement Therapy Considering PHC conditions, Babor [36] distinguished between minimal (1 intervention up to 5 min), brief (3 sessions maximum up to 60 min each), moderate (5–7 sessions) and intensive interventions (8 or more sessions). To our knowledge, most of the German workgroups apply 1 to maximum 2 sessions of 30 (to 45) min. The 2nd session is required if a patient is severely dependent and/or additional psychosocial problems exist. In general, however, the correlation between length of counselling and outcome are at most weak.

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Evaluation of Alcohol-Related Interventions in General Hospitals in Germany The above-reported epidemiological figures have stimulated conceptual efforts and research on the feasibility, efficacy and implementation of (early) recognition and brief intervention strategies for patients with alcohol problems in German general hospitals. Two large projects in Luebeck [10] and Bielefeld [16, 37] in the 1990s were funded by the German Ministry of Health. These studies revealed that brief interventions (most often 1–2 sessions) can double the number of patients who utilize the special services for substance use problems during the follow-up period (56.1%) compared to the same time before the index hospitalization (28.9%) [10]. Alcohol-related behaviors were also improved in many patients after intervention. As a consequence, the rates of patients with at-risk alcohol consumption and of those with alcohol abuse each reduced from 25% (of all patients with interventions) to 11%. Vice versa, the rate of patients without alcohol-related diagnoses increased from 0 to 25%. Interestingly, the rates of patients with alcohol dependence did not significantly change (43–38%) [37]. These results underline that brief interventions are a domain for patients with minor to moderate alcohol-related problems while patients with major problems in the general hospital need more intensive treatment and care. This conclusion is in agreement with international experiences [22].

Structural Conditions of Consultation-Liaison Psychiatry of Alcoholism in Germany

Although nowadays the majority of clinical directors and consultants are aware of the impact of alcohol-related disorders in their hospitals and departments, the realization of CL psychiatry most often is reduced to a minor consultation service. One reason for this unsatisfactory state is the restricted funding of general hospitals in which any CL service must be provided by the global budget per patient and day. In addition, psychiatry has no tradition of broad acceptance in the German PHC. Both factors converge to the point that psychiatric consultation services in general cover not much more than the field of emergency psychiatry (e.g. suicidal crises, delirious states, severe behavioral problems). Consequently, the number of all psychiatric consultations for patients with alcohol-related disorders is rather low in German general hospitals [15]. In a Munich general hospital with more than 1,400 beds only 43 of the total 713 consultations (6.0%) were performed due to alcohol problems and additional 82 (11.5%) due to all alcohol- and not alcohol-related delirious states [38]. These figures from 1990 have scarcely changed over time. In 1998 the authors found a

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slight increase in all consultations (n ⫽ 1,025) and in the rates of consultations due to alcoholism (8.2%) and due to delirious states (16.6%). However, this situation may be improved in the coming years by the introduction of the diagnosis-related groups (DRG) system to somatic medicine in 2003. This system allows not only case-related remuneration according to the main diagnostic classes but additional compensation by complications and (psychiatric and other medical) comorbidities.

Demands and Perspectives

To achieve the goals of screening, early recognition and brief effective therapies in PHC, there is a need for further adequate professional qualification and for the integration of inpatient and outpatient PHC into a network of care for persons with alcohol problems in the community. Even inpatient motivational enhancement therapies (for about 3 weeks) can and should be realized in the general hospital [39], as the consensus conferences of psychiatrists, health insurance representatives and health politicians have developed concepts and quality standards (e.g. for North-Rhine Westphalia [40]). In a recent meeting on new therapeutic approaches in Berlin supported by the Drug and Addiction Secretary of the German Federal Ministry of Health, 10 main theses were formulated regarding the improvement of therapy (‘Berliner Eckpunkte zur Verbesserung der Therapie bei Alkoholproblemen’, ‘Berlin milestones for the improvement of the treatment of alcohol problems’) [41]. Among these, early recognition and brief intervention of alcohol problems (point 3), better education in addictive medicine for physicians (point 4), motivational enhancement therapy directly after detoxification (point 5), as well as motivational counselling in general hospitals (point 7) were proclaimed. If these demands of the experts and health policy are recognized and realized by the health insurance companies, an adequate CL service for alcohol-related problems will have a chance to be established in general hospitals in Germany.

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Dr. public health Georg Kremer Gilead Hospital, Bethel, Center of Psychiatry and Psychotherapeutic Medicine Department of Substance Use Disorders, Remterweg 69–71 DE–33617 Bielefeld (Germany) Tel. ⫹49 521 144 3712, Fax ⫹49 521 144 5101, E-Mail [email protected]

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Delirium in General Hospital Inpatients: German Developments F.M. Reischies, A. Diefenbacher Klinik und Poliklinik für Psychiatrie und Psychotherapie, Charité, Universitätsklinikum Berlin, Deutschland

Delirium is common in patients with physical illness treated on somatic wards in general hospitals. It can be diagnosed in 10–15% of those patients, with a even higher prevalence of 14–56% in patients older than 65 years [1–3]. Differences in prevalence are probably due to the different diagnostic criteria used [1, 4], but it is generally agreed that this condition affects a large portion of elderly inpatients on medical or surgical wards, and leads to a more complicated course of illness with a longer duration of stay in the hospital, higher mortality and morbidity after discharge, and with an increased risk of having such patients referred to nursing home care [5–8]. It is estimated that each year delirium accounts for more than USD 4 billion (in 1994) of Medicare expenditures in the USA [9]. Unfortunately, it is often not recognized by medicalsurgical physicians, with especially hypoactive deliria being underdiagnosed or misdiagnosed as depression [10]. Diagnosis and treatment of delirium is a main part of consultation-liaison (CL) psychiatric services [1, 11] with referral rates in the range of 20–30% of CL services as reported in German and international studies [12–14].

Definition of Delirium in the German Tradition

In the 19th century discussions in psychiatry were focussed on taxonomy, and enclosed a syndrome which today we label as delirium. It was difficult to classify confusion (‘Verwirrtheit’) either as a symptom, a core symptom or as syndrome/disease [15, 16]. Furthermore, at that time it was not easy to differentiate the symptoms of delirium from the symptoms of a florid psychosis with predominant symptoms such as hallucinations or delusions which were later

described as schizophrenia. The German psychiatrist Griesinger [17] considered active dreams during the waking state, or sleepiness, as a central symptom of delirium: his contribution can be considered as an emerging concept of a psychopathological syndrome occurring during acute disorders of the brain. Regarding the etiology, febrile and non-febrile forms were differentiated. The term ‘confusion’ was used by Griesinger for acute and non-acute forms of psychopathological brain lesion syndromes, i.e. also for dementia syndromes. Acute confusion (‘Verwirrtheit’) was introduced as syndrome by Wille [18] when he described an acute functional disorder of the brain with confusion, hallucination, delusion, disorder of consciousness, and facultative stupor. In his ‘Presentation of psychiatric cases’, Wernicke [19] defined the syndrome of delirium very precisely, already before his coworker Bonhoeffer’s [20] work on acute exogenous reaction types. Wernicke [19] differentiated delirium, e.g. from acute hallucinosis, as caused by an etiologically unspecific brain impairment (acute hallucinosis was also seen as etiologically unspecific). According to Wernicke not only alcohol but also meningitis and encephalitis as well as intoxications could cause the delirium syndrome. Thus in 1900 he postulated an etiologically unspecific delirium syndrome. He described the complex psychopathological pattern of delirium and especially emphasized disorientation, suggestibility and illusional misperception as its symptoms, and furthermore he mentioned dementia as being difficult at times to differentiate from delirium. The notion of clouding of consciousness (and temporo-spatial disorientation) was established during that time, and Bonhoeffer [20, 21] conceptualized delirium as one of the cardinal manifestations of different kinds of acute brain impairment [15, 22, 23]. The brain could, according to this view, react to any impairment only by a limited range of syndromes, and the clouding of consciousness in the delirium syndrome was seen as one of these reaction types. This influential view is still considered one of the fundamentals of psychiatry. Furthermore Bonhoeffer [20] characterized the disorder of consciousness as the defining symptom of the acute exogenic reaction types [22]. The symptom of an impaired consciousness was seen as a diagnostic criterion in delirium. This was generally accepted in the German tradition [24]. Nonetheless the ‘axis symptom’ of impaired consciousness underwent critical discussion. Wieck [25, 26] defined transitional syndromes (‘Durchgangssyndrome’) which occur without disorder of consciousness. The term ‘Durchgangssyndrom’ was prominent in organic psychiatry after the Second World War. In his textbook, Ewald [27] defined two levels or stages of severity of the acute exogenous reaction type. (1) A dazed state (‘Benommenheit’) was defined as a mild clouding of consciousness with: (a) reduced ability for recollection (‘Schwerbesinnlichkeit’); (b) deficits in word finding; (c) disturbed flow of thinking and comprehension;

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(d) difficulties in higher thinking capacities, e.g. reciting months backwards; (e) diminution of recall from secondary memory (‘Merkfähigkeit’), and (f) enhanced fatigue. This is an equivalent of mild delirium in the new definition of the modern classification systems, e.g. ICD-10. (2) Only more severe symptoms of the acute exogenous reaction type were called a delirium. The symptoms of ‘Benommenheit’ plus disorder of orientation for time and location, misjudgment with respect to situation, illusional misidentification of things and persons, and oneirism with perceptual errors. The thinking was described as fragmented. Within the affective dimension, fluctuations were considered as driven by unpredictable internal experiences. Ewald [27] notes that the patient is only able to focus clear attention on the environment for a short time. This distinction comprises mild cognitive signs in mild clouding of consciousness, which may be a characteristic feature of confusional syndromes without major productive psychotic symptoms like hallucinations or delusions and major loss of orientation. Weitbrecht [28] stressed the difference between somnolence as a change in vigilance and the dazed state (‘Benommenheit’), a mild clouding of consciousness. Again, delirium was seen as a second step in the development of a more severe acute organic brain syndrome. Disorder of consciousness was regarded as critical, together with disorder of orientation. Furthermore he described confused thinking, and actions, as characteristic of the severe acute organic brain syndrome. This view of delirium was accepted until the modern classification systems (ICD-10, DSM-IV) were introduced in Germany. Up to this change, delirium was contrasted with the other acute exogenic reaction types such as the ‘Dämmerzustand’ (twilight state), e.g. ictal or post-ictal states of altered consciousness (especially the narrowing of the focus of consciousness), acute hallucinosis, organic oneiric state with dreamlike experiences, and a confusional state, which did not show hallucinations and delusions like delirium (the term ‘acute organic brain syndrome’ was sometimes preferred for mild delirium or pre-delirium states). Some authors also recognized ‘amentia’ with a predominant disorder in formal thinking and delusions. These multiple types of psychopathological brain impairment syndromes are now subsumed under the term ‘delirium’ according to ICD-10 and DSM-IV. However, the modern classification systems are not consistent with respect to delirium: ICD-10 describes a much more complex type of syndrome, in contrast to ICD-10 Research Diagnostic Criteria and DSM-IV [29–31]: (1) in DSM-IV, disorder of consciousness is operationalized by clouded awareness of the environment with disorders of attention; (2) both DSM-IV and ICD-10 demand cognitive deficits in memory and orientation and also language and

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perception; (3) both DSM-IV and ICD-10 characterize the time course as acute and fluctuating, in ICD-RDC with disorders in the sleep-wake cycle, and (4) ICD-10 mentions disorders in thinking, psychomotor behavior and emotion.

Problems in the Classification of Delirium

The difference between the concept of the DSM-IV definition of delirium and that of ICD-10 resembles the difference between the German concepts of the ‘confusional syndrome’ and ‘delirium’, i.e. a difference in the level of complexity or severity of the acute organic brain syndromes, with ICD-10 resembling the more complex type, or the typical syndrome, whereas DSM-IV represents the neuropsychological core syndrome of delirium. It seems reasonable to classify a ‘mild syndrome of cognitive impairment’ including a disorder of attention or of awareness of the environment, because it signals to the clinician that a potentially life-threatening disease should be ruled out and possibly treated. According to this concept, delirium is more a feverlike ‘alarm syndrome’ of a brain disorder of uncertain etiology. In ICD-10, the mild cognitive disorder F06.7 is in part comparable to the mild unspecific confusional syndrome. The diagnosis of mild cognitive disorder can be most reliably classified in cases with a reversible time course of the syndrome and an association to a temporary disturbance of brain function. Another difference in the concepts of delirium in the international classification systems and the German diagnostic tradition refers to the concept of ‘awareness of the environment’. In Germany the psychopathology of acute organic brain syndromes is anchored in the disorder of consciousness (‘Bewusstseinsstörung’) and this still is mentioned in the German versions of the ICD-10 definitions of delirium, whereas the English versions favor the term ‘disorder of awareness of the environment’, which is better defined as the disorder of consciousness. The neuropsychology of delirium has been addressed by some studies in Germany, e.g. by Wallesch of [32, 33] with analyses of the misnaming by delirious patients, and the time course of memory and fluency disorder in transitional confusional syndromes after, e.g., coronary bypass surgery.

Epidemiological and Clinical Studies of Delirium

Overall, interest in diagnosis and treatment gained new momentum in Germany in the 1990s [34–37]. Epidemiological studies were performed on the importance of delirium in the medical-surgical inpatient as well as geriatric

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inpatient populations. As in other countries, a high percentage of delirium is found on medical-surgical wards [38, 39]. Using the Confusion Assessment Method [40], an acute confusional syndrome was found in 23.8% of hip surgery patients, with the prevalence being highest between postoperative days 2 and 5 [41]. In patients undergoing elective arterial surgery, 38.9% developed delirium, with patients undergoing aortic surgery developing delirium more frequently than those with non-aortic procedures (55.5 vs. 22.2%) [42]. Special attention has been paid to the monitoring of adverse drug reactions leading to and during inpatient psychiatric treatment. A multicenter adverse drug reaction-monitoring program (‘Arzneimittelüberwachung in der Psychiatrie’) found about 1% toxic delirium and 0.8% massive sedation under classic neuroleptics and tricyclic antidepressants [43–45]. Follow-up investigations, taking into account the use of newer psychopharmacological drugs, are now under way (‘Arzneimittelsicherheit in der Psychiatrie’) [46]. With regard to diagnostic issues, the Short Mini-Mental State of Klein et al. [47] has been investigated in a large epidemiological sample of communitydwelling older persons in Berlin [48], and compared with the performance of an inpatient sample of elderly medical-surgical inpatients of a university hospital including many cases of delirium [49]. As for the original Mini-Mental State examination, the score of the Short Mini-Mental State was found to be sensitive in the medical-surgical patient population not only for dementia but for delirium as well. The short version is especially valid for psychiatric CL services [50, 51].

Treatment Issues

Psychopharmacological treatment of delirium is hardly standardized. Treatment recommendations by German psychiatrists are similar to guidelines such as proposed the American Psychiatric Association, recommending, e.g., the intravenous use of haloperidol, adding intravenous lorazepam, if necessary, with a dosage regimen depending on the severity of the clinical picture [1, 11, 13, 52–54]. To measure the severity of delirium, a German version of the Delirium Rating Scale has been proposed [54–56] as well as a scale for assessment of mild impairment of the awareness of the environment [1]. Second-generation antipsychotics (e.g. olanzapine, risperidone, quetiapine) also have been reported to be helpful in the treatment of delirium in case series, but larger trials using such compounds still are lacking [57, 58]. As a special feature, chlormethiazole has been used as a therapeutic approach to delirium tremens – especially preventing the development of a full delirium syndrome – in Germany and many other European countries [52]. This compound is not marketed in the USA where, in such cases, benzodiazepines are prescribed

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[53]. Its introduction led to a decrease in the mortality of delirium tremens from an estimated 15 to 1.7% or less [59]. A comprehensive overview of this compound can be found in Majumdar [60]. Lately, benzodiazepines are being used more often. This seems to hold true for other European countries as well, where the use of chlormethiazole in managing alcohol withdrawal is even discouraged [61, 62].

Future Developments

Given the high costs incurred by delirium in the general hospital [9], a number of studies have addressed the identification of risk factors, and the efficacy of targeted interventions to prevent and/or treat delirium in medicalsurgical inpatients. An array of risk factors has been identified with, e.g. exsiccation, urinary tract infections, and use of anticholinergic medication, to name but a few, most often found as being harmful [1, 41, 63]. While earlier results of interventional trials to prevent delirium have been mixed, recently two large scale trials that used specific intervention protocols for, e.g., cognitive impairment, dehydration, and sleep hygiene showed significant reductions in the number and duration of episodes of delirium in hospitalized older patients [9, 64]. An interesting venue of research to pursue might be the prophylactic administration of, e.g., a once daily fixed dose of 5 mg haloperidol on the first 5 postoperative days which, in a placebo-controlled randomized trial, led to the development of postoperative delirium in 10.5% of the intervention group vs. 32.5% in the control group (p ⬍ 0.05) [65]. These studies have been performed by, e.g., internists and geriatricians, physician specialties with which it is critical for the CL psychiatrist to liaise in the treatment of older patients [66, 67]. Delirium still leaves questions open with regard to the efficacy of treatments available, as well as to their effective implementation in the daily routine of busy medical and surgical wards in general hospitals [68].

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Prof. Dr. F.M. Reischies Arbeitsgruppe Neuropsychiatrie und Psychiatrische Neuropsychologie Klinik und Poliklinik für Psychiatrie und Psychotherapie Charité – Universitätsklinikum Berlin Campus Benjamin Franklin, Eschenallee 3 DE–14050 Berlin (Germany) Tel. ⫹49 30 8445 8780, Fax ⫹49 30 8445 8393, E-Mail [email protected]

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Suicide Attempts: Results and Experiences from the German Competency Network on Depression Hartmut Lehfelda, David Althausb, Ulrich Hegerlb, Anja Ziervogelb, Günter Niklewskia a

Klinik für Psychiatrie und Psychotherapie, Klinikum Nürnberg, und Psychiatrische Klinik der Ludwig-Maximilians-Universität München, Deutschland

b

Introduction

In 1996, a large-scale study carried out by the World Health Organization (WHO) showed that depression impairs patients’ quality of life more than other psychiatric or somatic diseases [1]. It is estimated that 40–70% of suicides are committed by patients suffering from depressive disorders [2]. Despite its severe and potentially lethal consequences, depression is still not adequately diagnosed and treated by general practitioners (GPs) [3]. Furthermore, depression is often not acknowledged as a serious disease by the public and frequently looked upon as a sign of individual failure or weakness. In 1999, the German Ministry of Education and Research initiated an ambitious and unique program called the ‘German Research Network on Depression’. Within the framework of this program, research centers and universities, psychiatric departments of general hospitals, clinics for psychosomatic medicine, physicians in private practice and in practice networks, health insurance organizations and other members of the German health system cooperate under the aegis of the Psychiatric University Hospital in Munich. The program comprises 25 sub-projects dealing with various aspects of depression. As one of the sub-projects of the network, based on the experiences of the Gotland study [4], an extensive awareness program on depression was set up in the city of Nuremberg. This program is run by the ‘Nuremberg Alliance against Depression’ which was established to coordinate the activities throughout the

city. The awareness campaign aims at improving the quality of care for patients suffering from depression. The approach chosen within the campaign can be described as a multilevel action program. Within this program, GPs are considered the most important target group because they usually see patients earlier than specialists, i.e. psychiatrists or psychotherapists. Therefore, it must be assumed that the ability of GPs to recognize depression will determine the quality of treatment in the future. However, improvements in care will not be possible without changing public opinion on depression and its pharmacological treatment. False perceptions are considered obstacles for progress in the care of depressed patients. Therefore, an intense public information campaign about depression was deemed essential for the success of the project. This campaign encompassed, for example, poster advertisements throughout the city, the distribution of 100,000 information leaflets on depression and 25,000 brochures for patients and their relatives, a cinema infomercial, several press conferences and a series of information events. Aside from GPs, other professional groups dealing with depressed patients were also identified as important target groups of the awareness campaign. It was therefore aimed at better informing, for example, geriatric nurses, teachers, the police or priests about depression, thereby enabling them to support their clients in finding qualified treatment and therapy. Finally, specific support was considered essential for patients and their relatives. This includes assistance in the form of self-help activities and support for patients after suicide attempts. For example, an emergency card [5] was offered to patients, which guarantees direct contact to a specialist in case of a future suicidal crisis. In the evaluation of the awareness program, the numbers of suicides and suicide attempts were defined as the primary outcome variables [6]. Additionally, changes in the amount of referrals of depressed patients from GPs to specialists as well as changes in prescription rates of antidepressants are considered to be indicators of diagnostic and therapeutic improvement. Furthermore, the intended change in public opinion on depression and pharmacological treatment will be evaluated within a representative telephone survey which will be repeated in the course the campaign [7]. The total evaluation period will be 5 years. The numbers of suicides and suicide attempts in the year 2000 serve as the baseline [8]. The awareness campaign on depression was launched in January 2001 and faded out by the end of 2002. Subsequently, the effects of the awareness program in Nuremberg will be analyzed until the end of the year 2004. The present article reports preliminary results from the project using available data from the months January to September of the baseline year 2000 and the first year of intervention, i.e. 2001.

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Methods Instruments From the beginning of 2000, suicide attempts in Nuremberg are documented using a standardized protocol sheet based on the monitoring sheet used within the WHO/EURO study on parasuicide [9]. The protocol administered in the present study comprises 20 questions. The items include sociodemographic variables, method and motive of the attempt, previous suicide attempts or self-destructive behaviors, suggested treatment procedures, as well as a preliminary psychiatric diagnosis. Sampling All identifiable suicide attempts were to be recorded which fulfilled the respective WHO criteria and which were carried out by persons older than 18 years residing in Nuremberg for more than 4 weeks prior to the attempt. According to the WHO definition, a suicide attempt or ‘parasuicide’ is ‘an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage …’ [9]. Statistics The statistical results outlined in the present paper focus on the changes in the frequency of parasuicidal episodes in Nuremberg between the first 9 months of the years 2000 and 2001. Differences are analyzed for the variables age, sex, method, and psychiatric diagnosis. For the present analyses 8 age groups were defined: 18–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89, and 90 years or older (originally, age was documented using 5-year intervals). The suicide methods used were rated according to the X-code of the WHO outlined in ICD-10 [10]. For a more global analysis of methods, ICD suicide codes X60–X69 (self-poisoning) and X78 (self-harm by sharp object) were collapsed into a category ‘soft methods’ [11], whereas the remaining codes X70–X82 (e.g., hanging, firearm discharge, jumping) were considered to be ‘hard methods’. Psychiatric diagnoses were made according to ICD-10 and documented to the second decimal place. For the present article, evaluation was carried out for the broad diagnostic categories F0–F6. The frequencies of cases falling into the single categories of the variables under consideration were compared between the 2 years by means of ␹2 statistics. Statistical analyses were carried out using the statistical package SPSS 10.0.5.

Results

Within the first 9 months of 2000 and 2001, there was an overall decrease in the number suicidal episodes from 396 episodes in the year 2000 to 327 episodes in 2001. For this decrease, no gender differences could be observed. Between January and September 2000, 166 men and 230 women tried to commit suicide; in 2001 the respective numbers were 136 men and 191 women.

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140

2000 2001

120 100 80 60 40 20 0 18–29 30–39 40–49 50–59 60–69 70–79 80–89

⬎89

Fig. 1. Number of suicide attempts across age groups for the first 9 months of the years 2000 and 2001.

(Because there were patients with several attempts, the figures for cases were somewhat smaller: 365 patients in 2000, 293 patients in 2001.) Pertaining to parasuicidal episodes, the distribution of age groups is depicted in figure 1 for the 9-month interval of each year. In both years, the highest suicide attempt rates were found for women in the age group 18–29 years (19.7% of all episodes in 2000, 15.0% in 2001). When dividing the sample into groups of younger (age 18–49 years) and older (age 50 and above) subjects, the decrease in the number of suicide attempts was significantly more pronounced in age groups younger than 50 years (p ⬍ 0.05). Furthermore, a statistically significant shift in methods as assessed using the WHO X-code could be demonstrated. A global comparison of the frequency of ‘soft’ and ‘hard’ methods indicated that the usage of ‘hard’ methods significantly (p ⬍ 0.05) dropped from 14.5% (corresponding to an absolute number of 57 episodes) in 2000 to 8.4% (27 episodes) in 2001. Correspondingly, the percentage of ‘soft’ methods increased between 2000 and 2001 from 85.5% (335 episodes) to 91.6% (293 episodes). Moreover, a significant difference could also be found for the psychiatric diagnoses of patients attempting suicide in the first 9 months of the years 2000 and 2001 (p ⬍ 0.001). Figure 2 visualizes the frequency of ICD-10 codes for the 9-month intervals of each year. Most obvious is an increase in 2001 in F3 diagnoses (affective disorders). At the same time, in 2001 the absolute numbers as well as the percentage of F1 and F4 diagnoses decreased compared to 2000.

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160

2000 2001

140 120 100 80 60 40 20 0 F0

F1

F2

F3

F4

F6

others

Fig. 2. Number of suicidal episodes across ICD-10 diagnostic categories for the first 9 months of the years 2000 and 2001.

Discussion

Germany is a country with a higher than average suicide rate. More people lose their lives by suicide than by car accidents. A major portion of the suicides is committed by patients diagnosed as being depressed. However, among GPs, a deficit in the recognition and therapy of depressive syndromes has become evident, which increases the frequency of suicides. Consequently, an inverse relation between the frequency of suicides and the diagnosis of depression could be demonstrated [12]. Moreover, most suicidal patients were in contact with their consultant physician prior to committing suicide. Therefore, the importance of primary care for an efficient suicide prevention program is obvious. In January 2001, a large-scale awareness campaign against depression was started in the city of Nuremberg. Using a multilevel approach, the goal of this campaign is to improve primary care for depressed patients. In the evaluation of this anti-depression program, the changes in numbers of suicides and suicide attempts serve as the main target variables. Preliminary analyses on suicide attempts within the first 9 months of each year reveal a drop from 396 episodes of attempted suicide in 2000 to 327 episodes in 2001, an 18% decrease. A gender effect was not observed in association with this reduction. However, suicide attempts in younger age groups revealed a larger decline than in age groups 50 years and older [11]. From this finding, it may be concluded that elderly patients could not be addressed as

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efficiently as younger persons by the awareness campaign. Further analyses will have to scrutinize this finding more closely. Significant differences between January and September 2000 and 2001 could also be observed for the variables ‘methods’ and ‘psychiatric diagnosis’. A reduction in the percentage of ‘hard’ methods was logically complemented by an increase in ‘soft’ methods. For example, the numbers of episodes using hanging or jumping from a high place as methods dropped by more than 50% between 2000 and 2001 (hanging, 20 episodes between January and September 2000 and 8 episodes in 2001; jumping, 25 episodes in 2000 and 11 episodes in 2001). Furthermore, in 2001 the diagnosis of an affective disorder was made more often than in the preceding year, whereas the numbers of patients with F1 and F4 diagnoses decreased. To further investigate this finding, analyses were made for those patients who were given the F4 diagnosis of an ‘adjustment disorder’ on the occasion of the first contact after the suicide attempt. It could be shown that in 22.8% of the cases this diagnosis had been altered into an F3 diagnosis at the time of discharge [13]. Therefore, the observed diagnostic shift could cautiously be interpreted as reflecting a greater diagnostic competence of the physicians having first contact with the patient after the suicide attempt. It remains speculative to state that this gain in competence was brought about by the manifold lectures and seminars which were part of the education program in the course of the awareness campaign on depression. Altogether, first results from the awareness campaign on depression pertaining to data from the first 9 months of the baseline year 2000 and the following first year of intervention are very promising. However, the final evaluation of the success of the awareness campaign requires the full data set covering a period of 5 consecutive years. For the evaluation, comparisons with the control region (the city of Würzburg) and the overall trend for Germany are of special interest. Furthermore, results obtained for the reduction of suicides and suicide attempts will have to be complemented by the outcome of other variables under consideration, e.g. prescription rates of antidepressant medication, referrals from GPs to specialists and the telephone survey assessing knowledge of depression in the public. Regardless of any improvements shown by ‘hard’ data, it can already be stated that cooperation and communication between professionals and institutions dealing with depressed patients in the city of Nuremberg has significantly benefited from the program.

Acknowledgment The ‘Nuremberg Alliance against Depression’ is part of the ‘German Research Network on Depression’ which is funded by the German Ministry of Education and Research. The

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authors wish to express their gratitude to all cooperation partners within the awareness campaign run in the city of Nuremberg and to all those who contributed in the documentation and evaluation of data. We would also like to thank Paul Cash, psychologist in the Department of Psychiatry and Psychotherapy at the Klinikum Nuremberg, for proof-reading the manuscript.

References 1 2 3

4

5 6 7

8 9

10 11

12 13

Murray CJ, Lopez AD: The global burden of disease in 1990; in Murray CJ, Lopez AD (eds): The Global Burden of Disease. Boston, Harvard University Press, 1997, pp 247–293. Lönnqvist J: Psychiatric aspects of suicidal behaviour: Depression; in Hawton K, von Heeringen K (eds): Suicide and Attempted Suicide. Chichester, Wiley, 2000, pp 107–120. Spitzer RL, Kroenke K, Linzer M, Hahn SR, Williams JB, deGruy FV, Brody D, Davies M: Health-related quality of life in primary care patients with mental disorders. JAMA 1995;274: 1511–1517. Rutz W, von Knorring L, Walinder J: Long-term effects of an educational program for general practitioners given by Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiatr Scand 1992;85:83–88. Morgan HG, Jones EM, Owen JH: Secondary prevention of non fatal deliberate self harm. The green card study. Br J Psychiatry 1993;163:111–112. Althaus D, Hegerl U: Depressionsprävention als Baustein einer erfolgreichen Suizidprävention. Psycho 2002;28:589–591. Althaus D, Stefanek J, Hasford J, Hegerl U: Wissensstand und Einstellungen der Allgemeinbevölkerung zu Symptomen, Ursachen und Behandlungsmöglichkeiten depressiver Erkrankungen. Nervenarzt 2002;73:659–664. Althaus D, Niklewski G, Kunz J, Hegerl U: Suizidversuche in Nürnberg im Jahr 2000: Ergebnisse einer Baselineerfassung. Suizidprophylaxe 2000;29:20–25. Schmidtke A, Bille-Brahe U, DeLeo D, Kerkhof A, Bjerke T, et al: Attempted suicide in Europe: Rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/Euro Multicentre Study on Parasuicide. Acta Psychiatry Scand 1996;93:327–338. WHO: ICD-10. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva, World Health Organization, 1992. Althaus D, Niklewski G, Schmidtke A, Felber W, Kunz J, Lehfeld H, Hegerl U: Veränderungen in der Häufigkeit von Suizidversuchen: Ergebnisse nach 9 Monaten Intervention des “Nürnberger Bündnis gegen Depression”. Psycho 2003;29:28–34. Rihmer Z, Barsi J, Veg K, Katona CL: Suicide rates in Hungary correlate negatively with reported rates of depression. J Affect Disord 1990;20:87–91. Niklewski G, Althaus D, Lehfeld H: Anpassungsstörungen im psychiatrischen Konsiliar- und Liaisondienst; in Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin – Handbuch der Konsiliar-Liaisonpsychiatrie, Darmstadt, Steinkopff, 2004, pp 389–392.

Dr. Hartmut Lehfeld Klinik für Psychiatrie und Psychotherapie Prof.-Ernst-Nathan-Strasse 1 DE–90419 Nürnberg (Germany) Tel. ⫹49 0911 398 3690, Fax ⫹49 0911 398 3224, E-Mail [email protected]

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 144–158

Somatoform Disorders in Primary Care and Inpatient Settings Winfried Rief, Alexandra Nanke Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany

Epidemiology and Health Care Utilization of Patients with Somatoform Symptoms

The major reasons for visits to the doctor are physical complaints. However, in many cases physical symptoms cannot be accounted for by a known disease, and the symptoms have other origin [1]. DSM-III has introduced the term ‘somatoform’ for these kind of symptoms which mimic physical diseases, but do not have a disease-relevant organic pathology. The prototype of somatoform disorders is somatization disorder which describes patients with multiple unexplained physical symptoms. If these criteria are not fulfilled, further diagnoses of DSM-IV can be considered: pain disorder; conversion disorder; hypochondriasis; body dysmorphic disorder, and undifferentiated somatoform disorder. Somatoform symptoms are a frequent phenomenon. An investigation of more than 2,000 Germans revealed that about 24% reported multiple somatic complaints during the previous 2 years which could not be accounted for by a physical condition. Women were more affected by somatoform symptoms than men [2]. In this survey, people only confirmed symptoms if the symptoms caused significant reductions in subjective well-being and/or doctor visits. The most frequent symptoms were back pain (30%), joint pain (25%), pain in the extremities (20%), headache (19%), bloating (13%), food intolerance (12%), palpitation (11%), abdominal pain (11%), stomach discomfort (11%), and sexual indifference (11%). Many of these people had not only one single symptom but multiple symptoms [2]. This is an important point, as Kroenke and Mangelsdorf [1] have pointed out that a history of multiple symptoms is a predictor of poor outcome.

Table 1. Mental disorders in primary care patients with medically unexplained symptoms (n
295)

Disorders

n

%

Somatoform disorder Somatization disorder Undifferentiated somatoform disorder Hypochondriasis Pain disorder Conversion disorder Anxiety disorder Affective disorder

242 53 105

82 18 36

32 81 6 132 105

11 28 2 45 36

Somatoform symptoms are not only associated with reductions in subjective well-being, but also with an enormous economical burden on society. In clinical settings, 15–30% of patients describe ‘unexplained’ physical symptoms [3, 4]. Smith et al. [5] found that the mean treatment costs for patients with somatization disorder are ninefold that of the mean per capita expenditure of health care insurance. The burden on society is even higher due to workers’ disabilities. In Germany, workers’ disability days are compensated by health care insurance and these costs override direct treatment costs. In another representative survey, the German National Health Interview and Examination Survey – Mental Health Supplement (GHS-MS), a total of 4,181 participants were interviewed using the Composite International Diagnostic Interview (DIA-X-M-CIDI). The 12-month prevalence of somatoform disorder in the German population was estimated to be 7.5% [6]. On a nationwide level it was confirmed that women were significantly more affected than men. Data form the Early Developmental Stages of Psychopathology Study (EDSP) even showed that somatoform disorders and syndromes (as defined by the Somatic Symptom Index SSI 4/6) are highly prevalent in German adolescents and young adults [7]. Additionally it was found that somatoform conditions are often comorbid with other mental disorders and associated with remarkable impairments and disabilities. Analyses of the temporal relationship between the onset of pain disorder or SSI 4/6 and comorbid mental disorders (often depressive disorder or substance dependence) suggest the somatoform condition to have the earlier onset [8]. In a recently finished study, we investigated the diagnoses of patients of primary care offices using a structured clinical interview. General practitioners (GPs) referred patients to our study if the patient described medically unexplained symptoms. As can be seen in table 1, most of these patients fulfilled the criteria of one of the somatoform disorders. Somatization disorder was found in 18% of

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all cases, whereas undifferentiated somatoform disorder was even more prevalent (36% of all cases). In some cases, however, symptoms were better accounted for by diagnoses of anxiety disorders or affective disorders. Like other studies [9] these results suggest that somatoform disorders are much more prevalent in medical treatment settings than in the general population. The highest rate of patients with unexplained physical symptoms in Germany can be found in the so-called ‘psychosomatic hospitals’. These treatment units are characterized by an intensive psychotherapeutic approach combining psychological interventions with medical, physiotherapeutic and social treatments. These inpatient settings are considered if patients have a long history of symptom persistence, comorbidity with psychiatric and organic disorders, or if the local situation does not allow adequate outpatient treatment. In these hospitals, pain symptoms, cardiovascular symptoms and gastrointestinal symptoms have base rates of above 50%. It has been demonstrated that this costly treatment approach is even cost-effective for patients with somatoform symptoms, as the reduction in direct and indirect treatment costs after discharge compensates for the costs for the inpatient treatment within a few months [10].

Psychological Assessment of Patients with Unexplained Physical Symptoms

Screener to Identify High-Risk Groups for Somatoform Disorders The typical time frame for doctor visits in most countries is between 5 and 15 min. If patients suffer from multiple complaints, this brief time period does not allow a full exploration of long symptom lists. Therefore, self-rating scales screening for unexplained physical symptoms can be helpful. Moreover, such screeners can also be valuable for other purposes such as identifying high-risk groups in settings with many people, e.g. hospitals or companies. In the following, we present screening methods which have been evaluated for use with somatoform disorders. Screening for Somatoform Symptoms Multiple reliability and validity studies have supported the use of the Screening of Somatoform Symptoms (SOMS) [11] (an English-language version can be ordered from the authors). This self-rating scale includes all somatoform symptoms mentioned in DSM-IV somatization disorder, ICD-10 somatization disorder and ICD-10 somatoform autonomic dysfunction. Patients are instructed to confirm the complaints if they have been present during the previous 2 years and have been reducing quality of life or leading

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to doctor visits. After checking the 53 physical symptoms, 12 items ask for information that is used for inclusion and exclusion criteria. While this version is useful to assess trait variables, another version of the SOMS (SOMS-7) asks for the intensity of physical complaints during the last 7 days and is more suitable to assess change (e.g. during treatment). The number of somatoform symptoms assessed with the SOMS is highly associated with the number of somatoform symptoms assessed by a time-consuming interview. The retest reliability is in a reasonable range (rtt
0.89). Patients with different somatoform syndromes (somatization syndrome according to SSI 4/6; somatization syndrome according to SSI 8; full criteria of somatization disorder) also differ in their SOMS results. Patients’ Health Questionnaire Spitzer et al. [12] also tried to improve the detection of patients with somatoform syndromes and those with anxiety or depressive syndromes in primary care. They developed a self-rating instrument which includes 13 somatoform symptoms, as well as sections on depressive and anxiety symptoms and other disorders. This instrument has been used in some thousands of patients in GPs’ offices. In comparison with the SOMS, this instrument has the advantage of also screening for other frequent psychiatric syndromes, but has disadvantages of less comprehensive consideration of somatoform symptoms and missing validation of this section using structured classification interviews. The Subscale ‘Somatization’ of the Symptom Check List SCL-90R One of the most frequently used instruments to assess psychopathological symptoms is the Symptom Check List SCL-90R by Derogatis [13]. This selfrating scale asks for 90 symptoms of which 12 are used to assess ‘somatization’. However, the symptom selection and the validation studies did not address the relevance to somatoform disorders. The symptom list seems to be sensitive for changes in anxiety and depressive syndromes; therefore the specificity for somatization is questionable.

Further Instruments Hypochondriasis is also a subgroup of somatoform disorders. In hypochondriasis, heath anxiety and health concern are the major features. To assess health anxiety, the most frequently used instrument is the Whiteley Index [14]. This economic instrument comprises 14 items which can be summarized to three factors: disease phobia, somatic complaints, and disease conviction. In several studies it has been confirmed that the internal consistency, stability, and

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validity of this questionnaire are satisfactory. An overall sum score of 8 (of the maximum 14) seems to be an indicator for the diagnosis of hypochondriasis [15]. More comprehensive approaches to assess aspects of health anxiety and illness behavior are the Illness Behavior Questionnaire [16] and the Illness Attitude Scales [17]. In both instruments internal consistency is good and stability is excellent. Another approach comes from Barsky et al. [18] and is named the ‘Somatosensory Amplification Scale’. Barsky et al. [18] postulate that patients with somatoform symptoms tend to focus their attention on physical sensations leading to an amplification of sensory input. They developed this 10-item selfrating scale to assess the tendency to focus attention on physical complaints. The Cognitions About Body and Health Questionnaire (CABAH) [19] was developed to assess typical cognitions of patients with somatoform syndromes as well as hypochondriasis. The 31 items of this scale can be summed to the following 5 factors: catastrophizing interpretation of bodily complaints; autonomic sensations; bodily weakness; intolerance of bodily complaints, and health habits. The cognitive features of somatoform disorders are frequently combined with behavioral features. Pilowsky [20, 21] defined the concept of ‘abnormal illness behavior’ and emphasized how behavioral aspects contribute to the course, disability levels and outcome of unexplained physical symptoms. To measure this construct, an instrument to assess illness behavior is necessary. As illness behavior includes multiple facets, we tried to develop an instrument to assess illness behavior multi-dimensionally. The ‘Scale for the Assessment of Illness Behavior’ [22] comprises different aspects such as use of medication, verification of diagnosis, disability, body scanning and others.

Primary Care-Oriented Interventions

Consultation and Training of General Practitioners Patients with unexplained physical symptoms have a bad reputation in the offices of GPs. Many physicians feel they are poorly prepared for the management of patients who complain a lot, but who do not have organic disorders. Therefore, education and training of GPs could be a useful approach to improve the diagnostic detection, treatment and clinical outcome of somatoform disorders in primary care. Smith et al. [23] reported a successful attempt to assist GPs when they treat patients fulfilling the complete criteria of somatization disorder. Using a phone call and a consultation letter, they instructed the GPs to avoid unnecessary investigations, to avoid unnecessary referrals, to make regular appointments with the patient (e.g. every 4–6 weeks) and to take the symptom reports of the patients

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seriously. This very economic intervention led to significant reductions in treatment costs, but did not improve the patients’ functional status. A second investigation using the same intervention found that it not only reduced the health care costs of patients with abridged somatization disorder, but it also improved physical functioning [24]. A recent critical review of interventions to improve provider diagnosis and treatment of mental disorders in primary care by Kroenke et al. [25] found 48 usable controlled studies (published from 1966 through 1998), but only 3 of them focused on somatoform disorders. While there is enough evidence that these interventions improved the primary care provider’s diagnosis and onset of treatment of mental disorders in general, controlled studies assessing the effect on clinical outcome are still needed. At present, a couple of international attempts are in progress to train GPs how to treat ‘difficult’ patients with somatoform symptoms effectively. A study by our own group included 23 GPs who were trained how to manage patients with somatoform symptoms in their offices. We assessed the scores of 300 patients with unexplained physical symptoms presenting to these GPs. Half of the patients (n
150) were treated by untrained GPs, the other half by GPs who had received a 1-day training and education session. This training session included how to decide whether a patient had an anxiety disorder, depressive disorder or somatoform disorder. Moreover, a number of management guidelines were presented and GPs were trained in their use (table 2). A detailed evaluation and analysis of this GP training will be presented in other articles (e.g. effects on clinical outcome of patients, health care utilization and patients’ satisfaction with treatment). In this article, we focus on whether GPs find such training helpful or not. After the training, the participating GPs were given a rating scale and answered items about the usefulness of the training, the relevance for their everyday practice and whether they would recommend this training to colleagues or not, as well as other items. Figure 1 presents some of GPs’ ratings. The majority of participating physicians were satisfied or very satisfied (89%) with the training, rated it to be recommendable or very recommendable to colleagues (83%), and considered it highly relevant to primary care (87%). These results demonstrate good acceptance of such a provider-based intervention.

Minimal Interventions Feasible with the Needs of Primary Care Offices In our work with primary care physicians, GPs frequently argued that they felt they hadn’t the time and competence to manage these patients psychologically.

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Low relevance Very low 4% relevance Partial 0% relevance 9%

Less recommendable 4% Not at all 0% Partially 13% Highly recommendable 57% Recommendable 26%

Very high relevance 48% High relevance 39%

a

b

Fig. 1. Physicians’ ratings. a Degree of recommendation to other physicians. b ‘How relevant is the subject of training to primary care?’

Table 2. Treatment guidelines for GPs to improve care of patients with somatoform symptoms General aspects

Show empathy and understanding for the complaints and frustrating experiences the patient has had so far (e.g. explain that medically unexplained symptoms are common) Get a good patient–physician relationship to be the ‘coodinator’ of diagnostic procedures and care

Diagnosis

Explore not only their history of complaints and former treatments, but impairment, (health) anxiety, psychosocial issues Take screeners and self-report questionnaires as economic instruments, symptom diaries to assess course and influencing factors of symptoms When the patient presents with a new symptom, examine the relevant organ system Show the results of investigations to explain the absence of pathology and to give clear reassurance that there is no serious physical disease Avoid unnecessary diagnostic tests or surgical procedures

Treatment

Provide regularly scheduled visits (e.g. every 4–6 weeks), especially in the cases of very frequent health care utilization Explain that treatment is coping not curing (when pathology cannot be found/does not explain degree of complaints) Suggest coping strategies like regular physical activation, relaxation, distraction

Referral

If referral is necessary to start psychotherapy or psychopharmacotherapy, prepare the patient to the treatment and show him/her that you will continue to be ‘his/her doctor’

Rief/Nanke

150

60

70

% of patients

51.5 45.6

50

50 (%)

30

40 28.4

30 20

20

10

2.9

0

0

0

4.5

4.5

10

0

gr ee di sa lly ta

To

Pa rti a

lly

bi

di sa

va l

gr ee

en t

re e

Am

Pa rti a

lly ta To

lly

ag

ag

re e

gr ee ta

To

lly

lly

di sa

di sa

gr ee

en t va l bi Pa rti a

Am

lly Pa rti a

ta

lly

ag

ag

re e

re e

0

To

a

% of patients

60

40 (%)

62.7

Fig. 2. Ratings of patients in the intervention study. a ‘I would recommend this intervention to others’ (n
71). b ‘The recommended treatment strategies are promising’ (n
71).

On the other hand, most patients refuse to start long-lasting psychotherapy, particularly those who are convinced they have an organic disorder. Therefore there is a strong need for very brief interventions which can be combined with GP management of somatoform disordered patients. We decided to evaluate a one-session treatment which was not named ‘psychological’ or ‘psychotherapeutic’, but ‘information session for patients with unexplained physical symptoms’. About 200 patients with somatoform symptoms presenting to GP offices were randomized either to this one session treatment or to standard medical care. Again, a major question was whether a psychologically oriented one session intervention such as this could be helpful and whether it would be accepted by patients. The contents of the intervention were as follows: information on the nature and origin of physical complaints; distress as a cause of physical symptoms; relaxation training as a possible coping strategy; ‘de-catastrophizing’ and cognitive restructuring; adequate physical activation, and recommendation of evidencebased interventions (e.g. for comorbid disorders). This group intervention was assisted by CDs with relaxation instructions and written information forms. If patients accept this treatment, we expect that a short intervention such as this may lead to an optimization of treatment methods and to a reduction in inefficient and unnecessary treatments. Again, we were able to demonstrate that this short intervention was highly accepted by patients (fig. 2). They found this intervention helpful, adequate and they would recommend it to friends with comparable problems. Their willingness to use psychologically oriented approaches to cope with their problems was

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b

substantially increased. At the end of the half-day program they were asked which strategy they would use to cope with their bodily complaints. The majority of the patients chose relaxation techniques as their preferred coping strategy (79%), 43% of the patients decided to use strategies involving cognitive restructuring, and 41% decided to improve their level of physical activity. As the study is ongoing, further results will be presented later.

Further Treatment Options

Fifteen years ago, many textbooks on psychiatry and medicine emphasized that the primary goal in the treatment of patients with somatoform disorders was the prevention of iatrogenic harm. Fortunately, treatment approaches have since been developed and evaluated which have lead to more optimistic ratings about the possibilities of intervention. Some of these approaches are outlined below.

Cognitive Behavioral Therapy Kroenke and Swindle [26] summarized existing studies on the efficacy of cognitive behavioral interventions in somatoform disorders and associated problems [27]. They concluded that cognitive behavioral approaches are well founded and have scientifically based success. The major contents of cognitive behavioral therapy (CBT) are: the exploration of patients’ maladaptive health beliefs, patients’ illness behavior, affects and motivational aspects; cognitive techniques to reattribute patients’ illness beliefs, to de-catastrophize illness perceptions and to develop more normalizing cognitive strategies; reduction of illness behavior such as body scanning, body checking, and avoidance of physical tasks, enhancement of physical fitness, exposure to symptom-provoking situations. Most cognitive behavioral treatment packages also include relaxation training, the improvement of communication techniques and further strategies to improve quality of life. Speckens et al. [28, 29] have evaluated an individual treatment approach for patients with medically unexplained physical complaints. One of the most exciting results of that study was the high acceptability of the treatment. After a full explanation was given to patients, more than 80% agreed to participate. The treatment was introduced by their physician and it took place in the general medical outpatient clinic itself, which may have facilitated acceptance of the treatment. One can assume that for many patients this was the first introduction to the possibility of psychotherapy. Patients who rejected psychological treatment

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had lower levels of physical symptoms and functional impairment. It therefore appears that it was those patients with less severe problems who did not accept the treatment. Other studies have also demonstrated that CBT is not only effective, but also acceptable to patients. Sharpe et al. [30] conducted a randomized clinical trial evaluating CBT for patients with chronic fatigue syndrome. Of 60 referred patients, only 2 patients refused to participate, and all patients offered CBT completed treatment. The cognitive behavioral approach has also been used in patients suffering from hypochondriasis. One of the most successful trials in this area was presented by Clark et al. [31]. They found not only substantial treatment effects, but also effect sizes of 2 and above for some variables. These examples demonstrate that CBT is effective for the treatment of patients with unexplained physical symptoms/somatoform disorders. However, we have to acknowledge that treatment effects are typically lower than those for the treatment of anxiety disorders. Therefore there is still a need to continue and improve intervention research. One goal is to identify specific interventions that are to be effective, and another is to identify specific factors associated with treatment success. For example it has been suggested that pretreatment anxiety is a predictor of symptom improvement through treatment [32].

Biofeedback A powerful alternative showing the ‘body-mind connection’ can be done using the technique of biofeedback. Psychophysiological demonstrations can be used to assist the process of symptom reattribution and to change organic health beliefs. While physiological processes are continuously registered, reactions to ‘stress provocation tests’ (e.g. time-limited mental arithmetics, the mere expectation of an event, imagining a distressing event, or focusing on disease-related stressors such as body sensations or complaints) can be shown. These vivid demonstrations of an individual’s reactions have high ‘face validity’ for patients and offer the opportunity to introduce alternative (benign) explanations of their symptoms. Because the existence of physiological changes plays a major part in this approach, patients can accept it more easily than a purely psychological approach. In a controlled treatment study we evaluated the effects of a 6-session biofeedback intervention for somatoform disorders [33]. The intervention included the demonstration of psychophysiological mechanisms and the control of physiological processes to improve self-control strategies in the management of symptoms. Fifty inpatients with somatization syndrome were randomized to 1 of 2 treatment

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Biofeedback

Range (5–25)

25

Relaxation

20

15

10 1

2

3

4 Session

5

6

Fig. 3. Credibility ratings of a six-session treatment based on biofeedback or relaxation (n
50 patients with somatoform disorder).

groups, either biofeedback or control. The patients of the control group received a relaxation-based treatment. After treatment the biofeedback group showed a reduction in catastrophizing cognitions (in the CABAH), whereas patients in the control group did not. At each therapy session the patients in the biofeedback group rated the ‘credibility’ of the intervention significantly higher than the control group did (fig. 3). Although these results are yet to be confirmed, there is some evidence that biofeedback may be a useful additional tool in psychotherapy. It may be of special interest to introduce the intervention in the medical health care system, where patients with unexplained symptoms seek help to find the ‘pathological origin’ of their symptoms. Instead of telling patients ‘that there is nothing abnormal’, it would be possible to show them alternative factors associated with symptom perception. Inpatient Treatment Consultation-Liaison Services in the General Hospital In patients with nonspecific physical symptoms, Ehlert et al. [34] evaluated CBT offered by a psychological consultation-liaison service in a general hospital in Germany. Usually patients are referred to a general hospital by their primary or secondary physician. At admission they are screened for signs of psychiatric disorder or psychosocial problems, and patients scoring positively are referred to a clinical psychologist for consultation. In this study, nearly 15% of the patients met the DSM criteria for somatoform disorder or showed psychological factors affecting physical conditions, suggesting again the high prevalence in medical settings.

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The treatment group of 21 patients with physical symptoms that could not be sufficiently explained by a medical condition received short-term CBT in addition to standard hospital treatment. A comparison group, receiving only standard hospital treatment, was gathered in another general hospital. The CBT group showed significantly decreased bodily complaints and negative mood, better insight into psychosomatic causes and high motivation for subsequent psychotherapy. No such changes were found in the control group. Although this study has some methodological shortcomings (e.g. no randomization), the results of a treatment embedded in routine clinical practice are very promising. There are two advantages of the direct referral to CBT in a general hospital: time between identification of the problem and referral is very short, and the collaboration between the hospital’s medical staff and the consultation-liaison therapists is optimized. Psychosomatic Hospitals As we have already mentioned, inpatient treatment in specialized psychosomatic hospitals is quite common in Germany. Despite the high costs of treatment, it may be cost effective in very severe cases with persistent symptomatology. Bleichhardt et al. [35] have developed a specialized intervention program that is based on group therapy [36]. They treated 200 patients with somatization syndrome (at least 8 somatoform symptoms during the last 2 years) and compared them with a wait-list group. The treatment was highly effective in terms of reduced number of somatoform symptoms, reduced depressive and anxiety symptoms, increased subjective quality of life and improvements in other outcomes. Those patients getting the highly structured group therapy for somatoform symptoms did better in terms of reduced outpatient doctor visits and reduced catastrophizing cognitions. As this study was performed in a standard medical care unit, it not only confirms the efficacy, but also the efficiency of this approach. In table 3, we present a brief outline of the contents of the specialized and standardized group intervention program for patients with somatoform disorders.

Some Final Remarks

Unexplained physical symptoms are a major challenge in all areas of medicine and psychiatry. Symptoms are so common that there is a major need to develop approaches that are feasible in primary care and general medical settings. Currently there are multiple studies in different countries in progress and over the next few years, the results of those empirically based approaches will be presented.

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Start

General practitioner After years, patient selection

Medical investigations Feedback to GP ???

Psychiatric care psychotherapy After years, further selection Inpatient treatment in psychosomatic hospitals

Fig. 4. Steps of managed care for somatoform disorders in the German health care system. Table 3. Contents of an eight session cognitive-behavioral group therapy for somatoform disorders Session

Content

1

Introduction and defining treatment goals Exchange of former experiences, introduction to a symptom diary, and defining subjective treatment goals (realistic short, medium and long term)

23

A stress model and relaxation as coping strategy Biofeedback-assisted demonstration of the individual stress reaction to underline explanations of the body-mind connections, introduction to progressive muscle relaxation

4

Selective focus of attention The role of attention intensifying the perception of symptoms is shown in behavioral experiments, methods of distraction and positive activities serve as coping strategies

56

The role of cognitions and reattribution of dysfunctional beliefs Identifying, testing and changing dysfunctional automatic thoughts, the role of catastrophizing is outlined, patients are encouraged to find alternative (benign) explanations of their symptoms

7

Behavioral aspects, change illness behavior Changing dysfunctional avoidance and checking behavior; encouraging regular physical activity

8

Medical health care utilization and coping with reassurance seeking The dysfunctional role of very frequent doctor visits to reduce anxiety is elaborated, coping strategies are outlined (regular dates despite current intensity of symptoms)

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Different psychological and behavioral approaches have proved to be very useful in the management and treatment of somatoform disorders. First, the use of screening methods for symptomatology as well as psychometric assessments of the features associated with somatoform symptoms can improve the detection rate of affected patients as well as the treatment and outcome quality. Second, more sophisticated psychological intervention programs have been developed and evaluated; these may particularly help patients for whom medical management has failed. Such patients may include those with persisting symptoms, comorbidity with depression and other mental disorders, or chronically disabled patients. Therefore our plea is for a step-wise approach starting with general medical care, and continuing with minimal outpatient interventions, CBT and finally inpatient treatment if the other approaches fail (fig. 4). It is evident that this step-wise approach will be helpful for most patients with somatoform disorders.

References 1 2 3

4

5 6

7

8 9 10 11 12

13 14

Kroenke K, Mangelsdorff D: Common symptoms in ambulatory care: Incidence, evaluation, therapy and outcome. Am J Med 1989;86:262–266. Rief W, Hessel A, Braehler E: Somatization symptoms and hypochondriacal features in the general population. Psychosom Med 2001;63:595–602. Peveler R, Kilkenny L, Kinmonth AL: Medically unexplained physical symptoms in primary care: A comparison of self-report screening questionnaires and clinical opinion. J Psychosom Res 1997;42:245–252. Kroenke K, Spitzer RL, deGruy FV, et al: Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997;54:352–358. Smith GR, Monson RA, Ray DC: Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization. Arch Intern Med 1986;146:69–72. Wittchen H-U, Müller N, Pfister H, Winter S, Schmidtkunz B: Affektive, somatoforme und Angststörungen in Deutschland – Erste Ergebnisse des Bundesweiten Zusatzsurveys «Psychische Störungen». Gesundheitswesen 1999;61:216–222. Lieb R, Pfister H, Mastaler M, Wittchen H-U: Somatoform syndromes and disorders in a representative population sample of adolescents and young adults: Prevalence, comorbidity and impairments. Acta Psychiatr Scand 2000;101:194–208. Rief W, Schaefer S, Hiller W, Fichter MM: Lifetime diagnoses in patients with somatoform disorders: Which came first? Eur Arch Psychiatry Clin Neurosci 1992;241:236–240. Gureje O, Simon GE, Ustun TB, Goldberg DP: Somatization in cross-cultural perspective: A World Health Organization study in primary care. Am J Psychiatry 1997;154:989–995. Hiller W, Fichter MM, Rief W: A controlled treatment study of somatoform disorders including analysis of health care utilization and cost-effectiveness. J Psychosom Res 2003;54:369–380. Rief W, Hiller W, Heuser J: SOMS – Das Screening für Somatoforme Störungen. Manual zum Fragebogen (SOMS – The Screening for Somatoform Symptoms). Bern, Huber, 1997. Spitzer RL, Kroenke K, Williams JB: Patient health questionnaire primary care study group. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. JAMA 1999;282:1734–1744. Derogatis LR: SCL-90. Administration, Scoring and Procedures. Massachussetts, Author, 1994. Pilowsky I: Dimensions of hypochondriasis. Br J Psychiatry 1967;113:89–93.

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26 27 28

29

30 31 32

33 34

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Rief W, Hiller W, Geissner E, Fichter MM: Hypochondrie: Erfassung und erste klinische Ergebnisse. Z klin Psychol 1994;23:34–42. Pilowsky I, Spence ND: Manual for the Illness Behaviour Questionnaire (IBQ), ed 2. Adelaide, Author, 1983. Kellner R: Somatization and Hypochondriasis. New York, Praeger, 1986. Barsky AJ, Wyshak G, Klerman GL: The somatosensory amplification scale and its relationship to hypochondriasis. J Psychiatr Res 1990;24:323–334. Rief W, Hiller W, Margraf J: Cognitive aspects in hypochondriasis and the somatization syndrome. J Abnorm Psychol 1998;107:587–595. Pilowsky I: Aspects of abnormal illness behaviour. Psychother Psychosom 1993;60:62–74. Pilowsky I: Abnormal Illness Behaviour. Chichester, Wiley, 1997. Rief W, Ihle D, Pilger F: A new approach to assess illness behaviour. J Psychosom Res 2003;54: 405–414. Smith GR, Monson RA, Ray DC: Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med 1986;314:1407–1413. Smith GR, Rost K, Kashner M: A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52:238–243. Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE: Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature. Psychosomatics 2000;41:39–52. Kroenke K, Swindle R: Cognitive-behavioral therapy for somatization and symptom syndromes: A critical review of controlled clinical trials. Psychother Psychosom 2000;69:205–215. Looper KJ, Kirmayer LJ: Behavioral medicine approaches to somatoform disorders. J Consult Clin Psychol 2002;70:810–827. Speckens AEM, van Hemert AM, Bolk JH, Hawton KE, Rooijmans HGM: The acceptability of psychological treatment in patients with medically unexplained symptoms. J Psychosom Res 1995;39:855–863. Speckens AEM, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooijmans HGM: Cognitive behavioural therapy for medically unexplained physical symptoms: A randomised controlled trial. BMJ 1995;311:1328–1332. Sharpe M, Hawton K, Simkin S, et al: Cognitive behaviour therapy for the chronic fatigue syndrome: A randomised controlled trial. BMJ 1996;312:22–26. Clark DM, Salkovskis PM, Hackman A, et al: Two psychological treatments for hypochondriasis. Br J Psychiatry 1998;173:218–225. Nakao M, Fricchione G, Myers P, et al: Anxiety is a good indicator for somatic symptom reduction through behavioral medicine intervention in a mind/body medicine clinic. Psychother Psychosom 2001;70:50–57. Nanke A, Rief W: Biofeedback-Therapie bei somatoformen Störungen. Verhaltenstherapie 2000; 10:238–248. Ehlert U, Wagner D, Lupke U: Consultation-liaison service in the general hospital: Effects of cognitive-behavioral therapy in patients with physical nonspecific symptoms. J Psychosom Res 1999;47:411–417. Bleichhardt G, Timmer B, Rief W: Efficacy of an inpatient treatment programme for patients with chronic and multiple somatoform symptoms. J Psychosom Res, in press. Rief W, Bleichhardt G, Timmer B: Gruppentherapie für somatoforme Störungen – Behandlungsleitfaden, Akzeptanz und Prozessqualität. Verhaltenstherapie 2002;12:183–191.

Prof. Winfried Rief Department of Clinical Psychology and Psychotherapy Philipps University of Marburg Gutenbergstrasse 18 DE–35032 Marburg (Germany) Tel. 49 6421 282 3657, Fax 49 6421 282 8904, E-Mail [email protected]

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 159–170

Therapeutic Approaches to Chronic Pain and the Role of the Consultation-Liaison Psychiatrist Bogdan P. Radanov Klinik W. Schulthess, Zürich, Schweiz

Introduction

Therapy-resistant pain is one of the most important problems in medicine today. A study commissioned by the World Health Organization in various countries showed that in general practice approximately 22% of patients suffer from chronic pain [1]. It is not surprising, therefore, that the care of these patients is associated with considerable costs in relation to medical examinations, treatment and indirect costs. The direct costs for therapy-resistant pain in the USA alone run at an estimated USD 40 billion/year and indirect costs due, for example, to sick days and longer periods of incapacity are growing beyond measure [2]. It is presumed that patients suffering from chronic pain spend a substantial amount of their income on alternative therapies and unfortunately also quackery in the hope of alleviating their suffering. Therapy-resistant pain leads to a considerable impairment in quality of life, from physical, psychological and social points of view, both for the patients themselves and for those in their immediate family/social circle [3]. Every year in Germany around 3,000 people suffering from therapy-resistant pain commit suicide [3]. In view of the complex nature of therapy of resistant pain, it is hardly surprising that today’s research on the mechanisms of pain and the subsequent initial treatment is of great importance. Our research group was especially interested in the integration of neurobiological and psychosocial aspects in relation to therapeutic procedures. Concerning the presentation of the realizations of these works, this chapter will summarize an introduction of the following aspects: (1) a short summary of the

Cerebral cortex

Cerebral cortex

Thalamus Midbrain NE 5HT

Spinothalamic tract

Thalamus Peripheral lesion Prostaglandins Substance P Bradykinin Cholecystokinin Bombesin

Dorsal horn

WDR neuron

C fiber

A
fiber

GABA neuron

Opioid neuron

Fig. 1. Schematic drawing of the nociceptive impulse transmission.

latest scientific findings on chronic pain based on the gate-control theory of pain; (2) the results of our own studies on the possible influence of psychosocial burdens on therapy-resistant pain; (3) data from our own study on the possible neurobiological mechanisms of therapy-resistant pain, and (4) an introduction of therapeutic intervention based on our own research results so far, and taking into account the role of the consulting psychiatrist.

The Development of Theories on Pain

Melzack and Wall [4] set a milestone in the understanding of the ‘pain’ phenomenon in 1965 with their gate-control theory. This theory speaks of a so-called Gate System in the dorsal horn of the spinal cord, in which a modulation of the nociceptive impulse takes place. This modified input passes up the spinal cord and through the thalamus to the cerebral cortex where it is sensed as pain. A short summary of these phenomena can be seen on the simplified diagram (fig. 1): the nociceptive impulse originates from an arbitrary peripheral lesion, followed by a production of polypeptides. The nociceptive impulse reaches the dorsal horn of the spinal cord through so-called C and A
fibers where they are switched onto the second neuron (in the diagram labelled ‘wide

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dynamic range neuron’ or ‘WDR neuron’ as it receives afferent input from different fibers). The C and A
fibers simultaneously receive impulses from GABA and opioidergic neurons of the spinal cord. The GABA and opioidergic neurons reduce the influence on the WDR neuron, causing its stimulus threshold to drop. Simultaneously, the descending tracts from the mid-brain also act on WDR, GABA and opioidergic neurons via noradrenergic (NE) and serotoninergic (5HT) pathways, thereby contributing additionally to the inhibition of the WDR neuron. The centripetal nociceptive impulses are repeatedly inhibited by modulation in the dorsal horn of the spinal cord. Hence the following conclusions may be drawn: (a) the insufficient inhibitory modulation of the centripetal nociceptive impulses is central to the development of chronic pain, and (b) both physiological and psychological influences execute an inhibitory modulation on the nociceptive impulses by the appropriate pathways. To test these theories in practice, it is essential that these influences are empirically evaluated, so that their possible consideration in the therapeutic concept of chronic pain can receive due attention.

Consequences of Inadequate Inhibitory Modulation

Experimental investigations have shown that, with therapy-resistant and/or chronic pain, inhibitory modulation is insufficient [5]. Research has also shown that, because of the inadequate inhibitory modulation of the nociceptive impulse, neurobiological changes of the WDR neuron take place [5, 6]. These can be described briefly as follows. The nociceptive impulses (e.g. through an inflammation or a peripheral lesion) arise as a result of a peripheral lesion in which polypeptides, also described as the so-called ‘inflammation soup’ play a role (fig. 1). These polypeptides generate the nociceptive impulses (C and A
fibers), which stimulate the WDR neuron. The nociceptive stimulation of the WDR neuron (mainly by the glutamatergic C fibers) leads to a more or less constant depolarization of this neuron. The effect of the glutamate on the N-methyl-D-aspartate (NMDA) receptor is crucial, as the receptor is responsible for controlling calcium ion channels. The opening of these channels leads, among other things, to the influx of the calcium ions into the neuron, which plays a biologically central role. This influx in particular sets the second-messenger system in motion, followed by the transcription of the genetic information and an increased gene expression (by the so-called immediate early gene). This leads to a reproduction of NMDA receptors on the WDR neuron. This is, biologically speaking, a protective mechanism which protects the WDR neuron from excessive stimuli. However, the WDR neuron receives other biological characteristics from the aforementioned procedures, which can have two effects. (1) Since there is now a higher density of

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the NMDA receptors on the WDR neuron, all presynaptic impulses can lead to the depolarization of this neuron. The neurobiological changes in the dorsal horn are more comprehensive than can be described here and at times can take place very rapidly, sometimes within hours [6]. In relation to chronic pain, the most important finding is the fact that the aforementioned changes can cause nociceptive impulses to excite the WDR neuron, which can also be felt as pain. (2) As a result of the biological changes that have taken place, the WDR neuron shows an unusually high spontaneous discharge. These biological changes are also known as the ‘wind-up’ phenomenon (the neuron is ‘wound up’ and thereby becomes more excitable) and represent the basis of central sensitization [5, 7]. The process of sensitization is currently attributed considerable importance in the development of chronic pain. Based on these findings, and in particular the fact that the described changes can take place rapidly [6], an important aspect of pain treatment is the prevention of central sensitization. As such, the initial treatment phase, in which attempts are made to protect the WDR neuron, is of particular importance.

Psychosocial Factors and Chronic Pain

As explained above (fig. 1), the transmitters from the mid-brain (NE and 5HT tracts) play an important role in the inhibitory modulation of the nociceptive impulses that flow into the WDR neuron [8]. These tracts exert their influence through the use of the same neurotransmitters as those that are of substantial importance in various psychological processes (e.g. fear and depression). The controversy regarding the role of psychological changes in relation to chronic pain has a long history [9]. Many earlier studies addressed the question of whether the psychological changes were a consequence or cause of the pain [10, 11]. Current views, based on empirical studies of outstanding quality, suggest that a reciprocal interaction of somatic and psychological factors early on in the process is responsible for the chronification of pain [9]. Chronic pain is nearly always accompanied by psychological changes. It must be assumed that these changes are based on a dysbalance of the neurotransmitters (e.g. mainly NE and 5HT). This dysbalance can involve, among other things, an inadequate inhibitory modulation of the nociceptive influences of the WDR neuron. On the basis of this, it can be assumed that, in the case of psychological changes involving the aforementioned neurotransmitters (i.e. affective disturbances like fear or depression), an insufficient inhibitory modulation of the WDR neuron is involved. Accordingly, psychological changes will always play an important role in chronic pain, and the question of whether or not they are the cause or consequence of the pain, per se, is immaterial. Nevertheless a

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decisive question in this context is: which psychosocial factors play an important role in the experience of pain and how specific are these in relation to the development of therapy-resistant pain? Numerous previous studies have postulated that life stressors, particularly in the early phase, can lead to emotional problems and affective disturbances and thus to chronic pain [10, 11]. In a retrospective study, we analyzed the modulating influence of the acquired psychosocial disturbances on pain in rheumatoid arthritis [12]. 66 patients with rheumatoid arthritis (table 1), being seen in a private practice, were examined. As somatic parameters, the radiological stage of the illness and also the duration of the disease were considered. 40% of those examined were actually in an advanced stage of the illness according to established criteria (stages III and IV) [13, 14]. In this study, we assumed that the pain intensity, as measured on a 0- to 10-point visual analog scale, would be influenced primarily by somatic factors, such as radiologically verified joint destruction. An alternative possibility, to be expressly examined here, was that the pain intensity was explained by psychosocial factors. Psychosocial disturbance was evaluated and documented in a structured fashion [15]. Both previous and current psychosocial stresses were evaluated (table 1) [for the whole methodology see, 12]. This kind of evaluation allows an operationalized analysis of the different stress factors (e.g. by the formation of scores) for use in further statistical analysis [12]. The patients also completed self-rating questionnaires (table 1), consisting of visual analog scales to rate the pain as well as various aspects of current and acquired stress. In addition, the patients filled out the Zurich version of the Health Assessment Questionnaire (HAQ) [16] and State Trait Anxiety Inventory [17]. Only the main results will be outlined here. By means of a regression analysis, it was shown that the factors that had a statistically significant relationship with pain intensity were the HAQ score and the fear score from the State Trait Anxiety Inventory [12]. The various previous psychosocial stresses, recorded during a structured history-taking, did not correlate significantly with pain intensity. It is also important to stress that the HAQ score did not correlate significantly with any objective determinants of the illness (e.g. radiological stage or duration of the disease). It can therefore be concluded that the HAQ score essentially reflects subjective attitudes (and thus, in the broadest sense, the cognitive evaluation of one’s own illness, its consequences and possible strategies for coping with it). In summary, on the basis of these data, we can emphasize two aspects that play an important role in the experience of pain, namely mental thought processes (i.e. cognition) and emotional changes (i.e. increasing fear impairing affectivity). This fact, and in particular the mental adjustment to the illness and the development of coping strategies, is currently gaining increasing recognition [18].

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Table 1. Summary of the important basic data in the study of rheumatoid arthritis [for details see, 12] Admission criteria Rheumatoid arthritis (ARA criteria) [14] German mother tongue Younger than 70 years of age Recruitment Private rheumatologic practice Patient data n  66 74% women Age 50.8  12.6 years Disease duration  13.4  10.5 (1–54) years

Radiological stage I 3 (4%) II 36 (55%) III 20 (30%) IV 7 (11%)

Methodology Structured biographical history for pain patients [15] Acquired aspect Functional disturbances ‘Pain memory’ Family burdens Developmental burdens

Factors (examples) Relapsing stomach pains, anorexia/ bulimia, psychological problems Illnesses in childhood and adolescence Model of important guardians Psychopathology/addiction Death of parents, separation/divorce Quality of emotional attachments Emotional safety Physical/sexual abuse

Self-ratings [15] Pain intensity (visual-analog scale, VAS) Relationships (time of development, VAS) Safety during time of development (VAS) Partner relationship (VAS) Partner understanding of pain (VAS) The State Trait Anxiety Inventory [17] and the Health Assessment Questionnaire were used [16].

Retrospective vs. Prospective Investigations of the Influence of Psychosocial Factors on Chronic Pain

A further problem in the evaluation of the influence of psychosocial variables on therapy-resistant pain arises from the fact that many of the earlier

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Table 2. Methodology in the prospective study on whiplash patients [19] Acquired aspect

Factors (examples)

Emotional deprivation (time of development) Underachieving (in school) Dysfunctional family

Fears, bed wetting, social withdrawal, authoritarian problems Partial performance deficit Death, separation/divorce, psychopathology/addiction, physical/sexual abuse Pain of the guardian Substance abuse, suicidal tendencies, anorexia/bulimia Family, job, finances

‘Models’ Psychological/behavioral problems Current trauma Expectations of health development Pre-traumatic headaches

All factors were gathered on the occasion of the baseline examination, at a time when the future health status could not have been predicted. Stress/disturbances were established during the baseline examination (structured interview). The Freiburg Personality Inventory [20] and the Well-Being Scale [21] were used.

studies merely examined a selection of patients from outpatient pain clinics. The data collected from such studies can lead to an unfavorable interpretation bias when considering therapy concepts. An important conclusion of such studies could be that psychological factors are related to the experience of pain in a causal way, in all patients, and should therefore represent the focus of therapy. In a 2-year long, prospective study, we examined the predictive power of psychosocial factors (table 2) in relation to their influence on therapy-resistant pain in patients with whiplash injury of the cervical spine [19]. 117 primary care patients suffering from cervical spine distortion were examined approximately 7 days after the trauma. After 2 years, 21 patients complained of therapy-resistant head and neck pain that could not be explained objectively by radiological or neurological findings. Psychosocial factors were assessed in all 117 patients during the initial consultation by means of a structured history-taking. In a similar manner to that described earlier for the study on rheumatoid arthritis patients, stress scores were formed from these psychosocial stress factors [19]. In addition, the patients’ expectations in relation to anticipated changes in their health after the trauma were documented. Psychological variables such as the

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Freiburg Personality Inventory [20] and the Well-Being Scale [21] (table 2) were also assessed. The results of the whole study cannot be presented here; the interested reader is instead referred to the full article [19]. Analysis of variance showed that, of all the factors examined, only patients’ expectations regarding their likely recovery, as assessed on average 7 days after the trauma, showed a statistically significant correlation with pain intensity at the 2-year follow-up. An interpretation of this result is that, even early on in the process, the anticipation of subsequent poor health and persistent pain seems to play an important role in the whole pain experience. As mentioned above, this result is consistent with the results of other recent investigations [18]. The psychosocial and psychological factors, assessed at a point immediately after the trauma, in which the likelihood of recovery could not be foreseen, were not able to significantly predict pain intensity. Furthermore, it was shown that the psychological changes could be interpreted as being a consequence of the somatic symptoms [22].

Possible Role of Central Sensitization in Chronic Pain: An Empirical Investigation

In relation to the therapeutic interventions of therapy-resistant pain, it is worth mentioning the results of our cervical spine distortion study in which possible neurobiological changes were examined as being the basis of chronic pain [23]. In this study, 14 patients who had had a cervical spine injury and were suffering from therapy-resistant pain were compared with 14 agematched, pain-free volunteers without a history of trauma. Pain thresholds were determined with electrical stimulation of the neck and leg area (i.e., outside the range in which the injury took place; fig. 2a). The electrical stimulation was carried out intramuscularly and transcutaneously and using isolated and repeated stimulation modes. Pain tolerance in relation to a heat stimulus was also established (fig. 2b). The psychosocial aspects of the patients and volunteers were evaluated with the NEO-FFI (fig. 2c), a trait inventory [24], and with the Symptom Check List-90-R (fig. 2d) [25]. It is clear from the graphically displayed results (fig. 2) that the patients with therapy-resistant pain after cervical spine distortion showed lower pain thresholds in all investigation paradigms. However, the differences between the patients and volunteers in their pain tolerance in relation to the application of heat were not significant. There were also no significant differences between the patients and volunteers in their personality profiles as measured by the NEO-FFI trait inventory. In addition, the results for the individual scales fell within the normal range for

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Single stimuli

Repetitive stimuli

55

Neck

Leg

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Transcutaneous stimulation

a

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Pain tolerance threshold, C

Pain threshold, mA

Repetitive stimuli 10 9 8 7 6 5 4 3 2 1

50

b

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40 Neck

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Neuroticism

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Obsession- Depression comp

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60 55 t value

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Openess Conscientiousness

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50 45 45 40

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c

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d

n.s. n.s. Patients

Fig. 2. a Evaluation of pain threshold: electrical stimulation. b Evaluation of pain tolerance: heat stimulation. c NEO-FFI. d Symptom Check List 90-R.

both the patients and the volunteers (fig. 2). However, highly significant differences were found on various scales of the Symptom Check List, with the patients scoring higher values and sometimes reaching pathological or borderline pathological levels. The electrophysiological results from this study confirm the results of investigations from other research [26, 27] and lead to the assertion that therapy-resistant pain after a whiplash type of trauma may be understood as a sign of central sensitization. Based on the foregoing discussion, it may also be assumed that the pain is attributable to neurobiological changes. In turn, this can be interpreted as being the consequence of an inadequate initial pain modulation, i.e. suboptimal analgesia, during the early stages after injury. In this respect, the importance of an initially adequate analgesia must be borne in mind.

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n.s. Volunteers

Summary and Implications

The results of both our retrospective study on patients suffering from rheumatoid arthritis and our prospective study of whiplash patients suggest that neither previous nor current psychosocial stress can be considered to be significant determinants of therapy-resistant pain. In contrast, in both studies, cognitive attitudes concerning the patients’ perceptions of their own illness and/or health development (essentially assumed negative outcome and expectations) were significant predictors. Furthermore, and in accordance with earlier studies [9], it was shown that certain psychological changes accompany chronic pain, but in a correlational rather than a causal manner. In agreement with numerous previous studies, the results of our studies, presented briefly here, show that chronic pain patients can suffer from considerable psychological dysbalance, and in particular from affective disturbances. These results imply that psychological factors must be considered in the treatment concept. Finally, the results of the 3rd study clearly support the importance of central sensitization. It is suggested that the whole process represents a vicious circle in which chronic pain arises as a result of central sensitization after which, in turn, psychological disturbance develops. This assumption is supported by the results of other studies which have shown that the continuous elimination of pain leads to an improvement of psychological and cognitive functional capacity [28]. The selected results presented here suggest that therapy-resistant pain is a complex phenomenon which demands an integrated therapeutic approach. This integration should consider all aspects that were mentioned earlier in the theoretical part of this article. There are sufficient rigorously collected research data [7] to suggest that neurobiological changes hinder the patient’s ability to achieve a pain-free status. Patients need to be informed of this in order to increase their understanding of the possible need for a longer period of therapy for their chronic pain. In connection with this, one of the most important therapeutic goals should not be the achievement of a pain-free status but, rather, an adaptation to the pain and/or elimination of factors that can have a negative affect on the pain. Psychosocial stress was not shown to be a predictor of the future pain experience, either in our studies or in those of others. The relationship between various psychosocial aspects and chronic pain may essentially be recognized as correlational and not as causal. The relationship between psychosocial factors and pain does exist and requires appropriate consideration in the framework of all therapeutic interventions. In agreement with many earlier studies, patients’ cognitive attitudes towards their own illness and/or to their ability to cope seem to play a decisive role, and it is important that these are pointed out to the patient and modified accordingly. In conclusion, therapy of

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chronic pain must be interdisciplinary, integrative and short, and structured primarily around the concept of adaptation.

Role of the Consultant Psychiatrist in the Treatment of Chronic Pain

The aforementioned findings indicate that the primary task of the consultation-liaison psychiatrist, in dealing with the chronic pain patient, is to carry out a systematic evaluation of the relevant psychosocial factors so that these can be integrated into a multidisciplinary therapy concept. The consultation-liaison psychiatrist has the necessary knowledge of these aspects (e.g. fears, expectations, and apprehensions) and also the ability to adequately expose them. He is familiar with the various evaluation tools and instruments that can be used to accomplish these aims. He can thereby implement the information gained in the therapeutic intervention. As a result of his professional training in the assessment of psychosocial factors, and in psychotherapy, behavioral medicine and psychopharmacology, the consulting psychiatrist is particularly suitable as the coordinator of, and responsible person for, the therapy of chronic pain patients. At the same time, the consulting psychiatrist must know the important principles of analgesic therapy, including the effectiveness of combined treatments and the problems that can arise with interactions between treatments. In relation to this concept, the consulting psychiatrist is dependent on cooperation with other disciplines (e.g. anesthesiology, neurology, orthopedics, physiotherapy, and rheumatology). Such a cooperation prevents pain treatment from being one-sided, either from a psychotherapeutic or from a somatic perspective.

References 1 2 3 4 5 6 7 8 9 10

Gureje O, Von Korff M, Simon G, Gater R: Persistent pain and well-being: A World Health Organization study in primary care. JAMA 1998;280:147–151. Taylor H, Curran NM: The Nuprin Pain Report. New York, Harris, 1985. Rouss M: Psychologie des Schmerzes. Göttingen, Hogrefe, 1998. Melzack R, Wall PD: Pain mechanisms: A new theory. Science 1965;150:971–979. Besson JM: The neurobiology of pain. Lancet 1999;353:1610–1615. Hoheisel U, Koch K, Mense S: Functional reorganisation in the rat dorsal horn during an experimental myositis. Pain 1994;59:111–118. Dickenson AH: Spinal cord pharmacology of pain. Br J Anaesth 1995;75:193–200. Linton SJ: A review of psychological risk factors in back and neck pain. Spine 2000;25: 1148–1156. Ren K, Dubner R: Enhanced descending modulation of nociception in rats with persistent hindpaw inflammation. J Neurophysiol 1996;76:3025–3037. Engel GL: Psychogenic pain and the pain-prone patient. Am J Med 1959;26:899–918.

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11 12

13 14

15 16

17 18 19

20 21 22 23 24 25 26 27 28

Blumer D, Heilbronn M: Chronic pain as a variant of depressive disease. The pain-prone disorder. J Nerv Ment Dis 1982;170:381–406. Radanov BP, Frost S-A, Schwarz HA, Augustiny KF: Experience of pain in rheumatoid arthritis – An empirical evaluation of the contribution of developmental psychosocial stress. Acta Psychiatr Scand 1996;93:482–484. Steinbrocker O, Traeger CH, Battman RC: Therapeutic criteria in rheumatoid arthritis. JAMA 1949;140:659. Hochberg MC, Chang RW, Dworsh I, Lindsey S, Pincus T, Wolfe F: The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis. Arthrit Rheum 1992;35:498–502. Egle UT, Hoffmann SO: Der Schmerzkranke. Stuttgart, Schattauer, 1993. Brühlmann P, Stucki G, Michel BA: Evaluation of a German version of the physical dimensions of the health assessment questionnaire in patients with rheumatoid arthritis. J Rheumatol 1994;21: 1245–1249. Laux L, Glanzmann P, Schaffner P, Spielberger CD: State-Trait Angstinventar. Weinheim, Beltz 1981. Crombez G, Vlaeyen JW, Heuts PH, Lysens R: Pain related fear is more disabling than pain itself. Pain 1999;80:329–339. Radanov BP, Sturzenegger M, Di Stefano G: Long-term outcome after whiplash injury. A two year follow-up considering features of accident mechanism, somatic, radiological and psychosocial findings. Medicine (Baltimore) 1995;74:281–297. Fahrenberg J, Hampel R, Selg H: Das Freiburger Persönlichkeitsinventar (FPI) 4. Auflage. Göttingen, Hogrefe, 1984. Von Zerssen D, Koeller D-M: Die Befindlichkeits-Skala. Weinheim, Beltz, 1976. Radanov BP, Di Stefano G, Schnidrig A, Sturzenegger M: Common whiplash: Psychosomatic or somatopsychic? J Neurol Neurosurg Psychiatry 1994;57:486–490. Curatolo M, Petersen-Felix S, Arendt-Nielsen L, Giani C, Zbinden AM, Radanov BP: Central hypersensitivity in chronic pain after whiplash injury. Clin J Pain 2001;17:306–315. Borkenau P, Ostendorf F: NEO-Fünf-Faktoren Inventar (NEO-FFI) nach Costa und McCrae. Göttingen, Hogrefe, 1993. Franke G: Die Symptom-Checkliste von Derogatis. Deutsche Version. Göttingen, Beltz, 1995. Sheather-Reid RB, Cohen ML: Psychophysical evidence for a neuropathic component of chronic neck pain. Pain 1998;75:341–347. Koelbaek Johansen M, Graven-Nielsen T, Schou Olesen A, Arendt-Nielsen L: Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain 1999;83:229–234. Wallis BJ, Lord SM, Bogduk N: Resolution of psychological distress of whiplash patients following treatment by radiofrequency neurotomy: A randomised, double-blind, placebo-controlled trial. Pain 1997;73;15–22.

Prof. Dr. med. Bogdan Radanov Klinik Wilhelm Schulthess, Lengghalde 2 CH–8008 Zürich (Switzerland) Tel. 41 1 385 74 31, Fax 41 1 385 75 78, E-Mail [email protected]

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Are Sleep and Its Disorders of Interest for Psychiatric and Psychosomatic Medicine? Jürgen Staedta,b, Gabriela Stoppeb a b

Department of Psychiatry, Vivantes Klinikum, Berlin-Spandau, Germany, and Department of Psychiatry, University of Basel, Switzerland

Introduction

From the early beginnings of human interest in the mind, dreams and sleep have been of major interest. In 1899, De Manacéine [1] referred to the beneficial aspects of sleep for the neuronal nets; he stated that dreams ‘… have direct salutary influence insofar as they serve to exercise regions of the brain which in the waking state remain unemployed’. A milestone in sleep research was done in 1953 by Aserinsky and Kleitman [2] who introduced a comparative study on the so-called rapid eye movement (REM) sleep, characterized by fast horizontal eye movements in relation to non-REM sleep with slow rolling eye movements. Four years later in 1957, Dement and Kleitman [3] were the first to report on dreams after waking from REM sleep. By continuously accomplishing electroencephalograms (EEGs), electrooculograms and electromyograms during the night, five different recurring patterns of biosignals were classified [4]. In such records we can find cyclic ‘ultradiane’ sleep cycles of about 90 min in length as a standard for nocturnal sleeping periods of 6–8 h (fig. 1). For a succinct text on sleep disorders and their direct relation to consultation-liaison psychiatry proper, the interested reader should refer to Weilburg and Winkelman [5]. We will draw the reader’s attention to the interesting field of the function of sleep in general, as well as to some issues of sleep medicine and medical service delivery in Germany.

Sleep stages Wake REM Non-REM I Non-REM II Non-REM III Non-REM IV 22:00

0:00

2:00

4:00

6:00

8:00

Time, h

Fig. 1. Polysomnogram with four sleep cycles. REM ⫽ Rapid eye movement sleep; non-REM I–IV ⫽ non-rapid eye movement sleep stages I–IV.

Function of Sleep

Most obviously, rest and activity cycles have generated in order to adapt to fluctuating temperature and light intensity to render efficient metabolic activity [for review see, 6]. By this means, electrophysiologically measurable sleep could have developed by the coincidence of the generation of complex neuronal structures with a rest period. This means that non-REM sleep is, from a physiological point of view, an energy-saving rest period, i.e. a decrease in temperature, palpitation, respiration, metabolism, and muscle tonus, as well as a slowing and synchronization in EEG signals. Correspondingly, we can find an adverse effect for REM sleep with an acceleration in temperature, metabolism, and blood flow, as well as in neuronal activity which is similar to the waking EEG. In addition, a lot of species show a decrease in temperature for non-REM sleep and an increase for REM sleep. However, this effect cannot unequivocally be transferred to man, i.e. on the one hand it was shown that physiological activity (increase in temperature) leads to an increase in slow wave non-REM sleep, whereas on the other hand the occurrence of REM sleep increases with a decline in body core temperature. Subsequently, an increase in the ‘working temperature’ of the central nervous system (CNS) caused by REM sleep phases could have meant an important advantage by much faster processing and responsiveness on external stimulations (arousal). We can find an increase in responsiveness on external stimulations for REM sleep. So the presentation of an acoustic signal during the rapid eye movements of REM sleep for example, which was already applied before during the learning period, improved the results compared to controls.

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Non-REM, REM Sleep and Neuronal Nets

When a more complex CNS developed during human evolution, more complex neocortical nets could be specified. Not only was the regulation of energy release important, but also the storage and maintenance of information. Memories can be stored by reinforcement of synaptic transmission processes in neuronal nets. As can be observed in hibernating mammals, the information thus stored has to be stabilized dynamically by neuronal transmission. When for instance the Arctic ground squirrel is hibernating, its temperature will drop to a range of 2–5⬚C where no neuronal activity (EEG) can be found [7]. But every 1–3 weeks, the squirrel’s temperature increases up to 32–36⬚C so that the animal is able to sleep for 12–18 h. This means that after some time unnecessary synaptic transmission capacity will loose its typical potentials which were established before by synaptic reinforcement. If we suppose now that the processing of sensory inputs, especially the visual system and the maintenance of sensomotoric functions, results in overlapping activity of neuronal circuits, the importance of intermittent ‘non-use-dependent’ activation of neuronal circuits becomes obvious, because this is the only possibility to keep plasticity as well as to store or recall new/old information. By reducing the sensomotoric input, sleep phases provide the potential to process and reactivate new memory as well as old memory stored by dynamic interactive states of neurons in order to keep them at disposal and not ‘forget’ them. This means that sleep could be seen as a decoupling of neuronal networks, if compared to waking. In this line cortical slow wave activity, which is characteristic for non-REM sleep, can still be found after thalamectomy. During slow wave oscillations, a rhythmic spike-train activity of cortical neurons can be observed, which can be compared to a degree of activation of the neurons in the waking phase. The high percentage of REM sleep in mammals, which decreases during maturation from 8 h in newborn children to 1.5 h in adults, indicates that REM sleep is of importance in the development and maturing process of neuronal networks. Chaotic activation in REM sleep phases supports synaptic and axonal growth. As observed in rats, in which REM sleep was pharmacologically suppressed in the postnatal phase, a reduction in cerebral weight as well as behavioral disturbances were found, a fact that underlines the beneficial aspects of REM sleep for neuronal development. The multiple neuronal activations in REM sleep may also be advantageous for the maturing process of the ‘phylogenetic neuronal memory’ as well as for fine-tuning and for the development of complex associative neuronal connections. As REM sleep is of major importance for the consolidation of nondeclarative memories, associative sensomotoric representations can be reinforced.

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Exercising complex sensorial and motoric associations in REM sleep is of great importance for further more complex requirements; for example, the requirements when playing an instrument, i.e. melodic lines will be stored twice. On the one hand this is done sensomotorically (e.g. the play pattern of the fingers), on the other hand this happens auditorily. When playing music again, these two channels will be recombined. The associative potentials of dreaming have to be developed, this means that forms of adult dreaming cannot be observed before the age of 7–8 years. In contrast to the general assumption that REM sleep is equivalent to dreaming, this is not true. According to Cavallero et al. [8] and Occhionero et al. [9] up to 60% dream reports were reported for the first and second non-REM phase, the only difference in relation to REM sleep persisted in the period’s length. An increase in the regional cerebral blood flow in the visual cortex of non-REM sleep was determined by positron emission tomography. In contrast to REM sleep, non-REM sleep first appears to a larger extent at the end of pregnancy and increases significantly along with cortical differentiation within the first 8 months. In non-REM sleep, the cortex will be sensorially decoupled and driven by the rhythmic spike-train activity of the cortical neurons. These rhythmic activations occurring in phases of depolarization may affect responsiveness and the dendritic growth of cortical neurons, and most probably represent consolidation procedures of ‘revised’ sensorial events. Another hint that declarative memories are consolidated is found in the increased activity of hippocampal CA3/CA1 neurons for non-REM sleep, whose partially synchronized irregularly occurring bursts of discharge may significantly affect the long-term consolidation of memories by a playback to neocortical structures during ‘offline’ non-REM sleep. Furthermore, the first neuropsychological deficits recorded after deprivation of sleep could be traced back to prefrontal cortical structures, i.e. the region where the most significant synchronizations for non-REM sleep can be recorded. For psychiatrists, significant disorders of the prefrontal cortex are of great interest. As working memory, i.e. the ability to store important signals in awareness for some seconds and to process them, is located in the dorsolateral prefrontal cortex, disorders may promote misperceptions of objects, situations and the development of targets. So we may find an incomplete dynamic nonuse-dependent stabilization of neuronal networks as a functional correlate of non-REM sleep disorders as well as an incomplete/deficient stabilization of memories for longer persisting sleep disorders. So incomplete/deficient dynamic stabilization may promote deficient and easy to interfere connections, which may result in delusional behavior, hallucinations, memory disorders or emotional disturbance. Correspondingly, we can find sleep disorders for most forms of psychiatric diseases as well in the beginning as during their course.

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A reduction in slow wave sleep is reported especially for schizophrenia, affective disorders, and dementia, where these symptoms may appear. It can be stated that slow wave sleep synchronizations seemed to be essential for the neuronal regeneration process. For this reason, reducing arousals from non-REM sleep is an important tool in the treatment of patients suffering from major depression, where a quick response can be obtained, whereas less frequent slow wave sleep increases the risk of relapse for depressive patients and deteriorates the prognosis for patients suffering from schizophrenia. A reduction in REM sleep, on the contrary, seems not to implicitly affect cortical functions, at least after having reached cerebral maturity. So significant long-term reductions in REM sleep occurring without any meaning for the state of health or learning/memory can be observed for patients being treated with antidepressant drugs.

Psychiatry and Sleep Disorders in Germany

These evaluations show the impact of sleep disorders in our field of activity, the more so as sleep disorders have become a well-known social phenomenon. As stated in a German representative study, sleep disorders were recorded to be the third most important reason for consulting practitioners. For 26% of these patients the criteria for suffering from sleep disorders (inability to fall asleep and/or to maintain sleep) could be stated [10]. According to their high degree of prevalence, sleep disorders should be taken into account in the treatment of psychiatric disorders, all the more so as they mostly appear in the beginning of psychiatric disorders and may strongly affect their course. For this reason, it is interesting to know how far German psychiatric and psychosomatic treatment is concerned with the diagnosis and treatment of sleep disorders. Retrospectively, in 1975, one year after the foundation of the American Association of Sleep Disorders Center, the first psychiatric sleep laboratory was founded at the psychiatric section of Ludwig Maximilian University in Munich. In 1992 the German Sleep Society (DGSM) was founded, which has increased to an association of more than 1,600 members to date. Today, we can find 232 sleep laboratories certified by the DGSM in Germany (reference date May 2002). Most of these centers are located in sections of internal medicine, only 20 sleep laboratories are located in psychiatric clinics. There is only one foundation which is specified as a psychosomatic sleep laboratory. For this reason, we conclude that differential medical sleep therapeutic approaches are still not sufficiently provided in German consultation-liaison psychiatry. This deficit is surprising, the more so as sleep disorders are even coded by the 10th Revision of the International Classification of Diseases, Chapter V(F) [11] as well as in DSM-IV [12].

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One reason for this deficit may be because polygraph recording was relatively sensitive to interference and work intensive in former times. Nowadays, relatively qualified and easy-to-use computer-supported sleep evaluation programs are available so that the influence of sleep disorders on mental health will most hopefully not be neglected in future therapy. Furthermore, the actual International Classification of Sleep Disorders [13] is most probably irritating its readers with a total of 84(!) diagnoses. It must be stated that, for practitioners, the use of the DSM-IV [12] classification for dyssomnia, parasomnia, and other sleep disorders is sufficient. We hope that this article will enable the reader to get in touch with this interesting field. Finally, we refer to Hobson [14], who stated: ‘Sleep is of the brain, by the brain, and for the brain’.

References 1 2 3 4

5 6 7 8 9 10

11

12 13 14

De Manacéine M: Sleep: Its Physiology, Pathology, Hygiene and Psychology. London, Scott, 1899. Aserinsky E, Kleitman N: Regularly occurring periods of eye motility and concomitant phenomena during sleep. Science 1953;118:273–274. Dement WC, Kleitman N: Cyclic variations in EEG during sleep and their relation to eye movements, body motility, and dreaming. Electroencephalogr Clin Neurophysiol 1957;9:673–690. Rechtschaffen A, Kales A: A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. Los Angeles, Brain Information Service/Brain Research Institute, UCLA, 1968. Weilburg JB, Winkelman JW: Sleep disorders; in Rundell JR, Wise MG (eds): Textbook of Consultation-Liaison Psychiatry. Washington, American Psychiatric Press, 1996, pp 507–531. Staedt J, Stoppe G: Evolution and function of sleep. Fortschr Neurol Psychiatr 2001;69:51–57. Daan S, Barnes BM, Strijkstra AM: Ground squirrels sleep during arousals from hibernation. Neurosci Lett 1991;128:265–268. Cavallero C, Cicogna P, Natale V, Occhionero M, Zito A: Slow wave sleep dreaming: Dream research. Sleep 1992;15:562–566. Occhionero M, Cicogna P, Natale V, Esposito MJ, Bosinelli M: A comparison of mental activity during slow wave sleep and REM sleep. 14th ESRS Congress, Madrid. J Sleep Res 1998;7:190. Wittchen H-U, Krause P, Höfler M, Pittrow D, Winter S, Spiegel B, Hajak G, Riemann D, Steiger A, Pfister H: NISAS-2000: Die ‘Nationwide Insomnia Screening and Awareness Study’. Prävalenz und Verschreibungsverhalten in der allgemeinärztlichen Versorgung. Fortschr Med 2001;119:9–19. World Health Organization: International Classification of Diseases. Chapter V (F): Mental and Behavioral Disorders. Clinical Descriptions and Diagnostic Guidelines, 10th revision. Geneva, WHO, 1991. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, American Psychiatric Association, 1994. American Sleep Disorders Association: International Classification of Sleep Disorders: ICSD Diagnostic and Coding Manual. Rochester, American Sleep Disorders Association, 1990. Hobson JA: Sleep. New York, Scientific American Library, 1989.

Prof. Dr. Jürgen Staedt Department of Psychiatry, Vivantes Klinikum Berlin-Spandau Griesingerstrasse 27–30 DE–13589 Berlin (Germany) Tel. ⫹49 30 37014054, Fax ⫹49 30 37013427, E-Mail [email protected]

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Debate Section Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 177–180

Consultation-Liaison Psychiatry and Psychosomatics in Germany: Futile Dispute or Lesson to Be Learned? Introductory Comment

Albert Diefenbacher Abteilung für Psychiatrie und Psychotherapie, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Deutschland

Following a decision by the Deutsche Ärztetag (German Medical Council) in 1992, there are two distinct physician specialities caring for patients with psychiatric disorders: one is called ‘physician for psychiatry and psychotherapy’ (Facharzt für Psychiatrie und Psychotherapie), and the other ‘physician for psychotherapeutic medicine’ (Facharzt für psychotherapeutische Medizin, also called ‘psychosomaticist’). In Germany before 1992, physicians working with psychiatric patients were mostly trained in psychiatry and neurology (Facharzt für Nervenheilkunde), the majority of whom were working in office-based private practices for patients presenting with neurological and/or psychiatric symptoms. About 15 years ago, due to the growing complexity of both psychiatry and neurology, several transitional rules were put forth and the German Medical Board (Bundesärztekammer) separated this physician specialty into neurology and psychiatry. Psychiatrists now have to specialize in a specific psychotherapeutic technique, either behavior therapy or psychodynamically oriented psychotherapy; hence their designation is ‘physician for psychiatry and psychotherapy’. During a limited time period after its inauguration in 1992, the additionally coined title of ‘physician for psychotherapeutic medicine’ was conferred to those physicians who had worked for a certain amount of time with psychotherapeutic techniques. Thus, both psychiatrists, as well as family practitioners, internists or gynecologists, to name but a few, who had earlier acquired the added qualification of ‘psychotherapy’

Table 1. Physicians according to specialities (as of December 31, 2002) Physician specialties

Officebased

Hospitalbased

Neurology & Psychiatry (certified in both neurology and psychiatry) Psychiatry Psychiatry and psychotherapy Psychotherapeutic medicine

2,874

1,519

1,203 733 2,828

1,883 1,328 746

were allowed to have this title too. In 2003, the German Medical Council decided to rename this specialty in ‘physician for psychosomatic medicine and psychotherapy’. Table 1 gives some figures on the number of physicians working with psychiatric patients in Germany. It shows that the majority of ‘psychotherapists/psychosomaticists’ work in private practice, and not in the general hospital. The training in both physician specialties takes 5 years each, with a compulsory year of neurology for ‘psychiatry and psychotherapy’, and one compulsory year of internal medicine and psychiatry and psychotherapy each for ‘psychosomatic medicine and psychotherapy’. Due to a 90% overlap of both specialties, this has been criticized as confusing to both patients and fellow physicians [1; Schmauss, pp 190–191]. In 2000, residents in training for ‘psychiatry and psychotherapy’ (n ⫽ 3,796) by far outnumbered those for ‘psychotherapeutic medicine’ (n ⫽ 153) [1]. Due to the establishment of both separate physician specialties, there has been a slight increase in psychotherapeutic-psychosomatic departments in general hospitals in some of the German states since, but plans to increase their number in addition to psychiatric departments are controversial. Both specialties care for psychiatrically ill patients, with psychiatrists, due to their numerical superiority, delivering most of the consultation-liaison (C-L) services in general hospitals and running the whole gamut of the diagnostic spectrum, while psychosomaticists in Germany focus more, but not exclusively, on referrals for unexplained physical symptoms. For this group of patients, however, as well as for patients suffering from depression, there is a large overlap with psychiatric C-L services [Diefenbacher, pp 1–19]. Algorithms for differential referrals do not exist, with an ensuing uncertainty whether, e.g., patients with depression receive comprehensive treatment combining psychotherapy and antidepressant medication, as pertinent for psychiatric C-L services, or psychotherapy alone, as is true for psychosomaticists [2, 3]. Comparative studies of the outcomes

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of either service delivery for special diagnostic categories would be interesting but, to the best of this author’s knowledge, have not been carried out yet. Thus, the following commentaries provide the reader with rather different viewpoints than with a final conclusion based upon methodologically sound empirical evidence. He or she will learn a lot about the eminent role that historical developments still play in the shaping of the present situation of care for psychiatrically ill patients in Germany. In the first commentary of this debate section, Deter represents the German psychosomatic self-understanding. He emphasizes the historical roots of German psychosomatic medicine, and discusses the influence of the Nazi period on the development of psychiatry and psychotherapy in Germany [for a complimentary German psychiatric analysis of that period see, 4]. Next is Schmauss, immediate-past-president of the German Psychiatric Association (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde), who strongly rejects the necessity of two distinct ‘psycho-physician’ specialties in Germany. Niklewski, head of a department of psychiatry and psychotherapy in one of the largest municipal general hospitals in Nuremberg, Germany, also taps on historical developments and alludes to the everyday clinical practice of a psychiatric C-L service that works alongside a psychosomatic service at the same hospital. Finally, Malt’s view on this genuinely German debate is especially helpful, firstly as he touches upon some often forgotten historical roots of German psychosomatic thinking, and as he tries to distinguish possible strengths and weaknesses of each of the two approaches, reflecting the German peculiarity in an international mirror – with strong emphasis on unraveling the different concurrent meanings of the term ‘psychosomatic medicine’, as they exist in Germany. As mentioned in the preface to this volume, medical psychology emerges as a new player in the field of care for patients with psychiatric and somatic comorbidity, as represented with the example of somatoform disorders [Rief and Nanke, pp 144–158]. Their voices will get stronger in the future [5, 6]. It is this author’s hope that further developments will see integration, or at least better cooperation, of the different forms of care for patients with psychiatric and somatic comorbidity in German-speaking countries [7].

References 1 2

Callies IT, Treichel KC: Quo vadis Psychiatrie und Psychotherapie ? – Sorgen der Weiterbildungsassistenen nach dem Deutschen Ärztetag 2003. Nervenarzt 2003;74:1160–1162. Knorr C, Diefenbacher A, Paetzmann S, ECLW: Vergleich eines psychosomatischen und eines psychiatrischen Konsiliardienstes zweier Universitätsklinika; in Peters UH, Schifferdecker M, Krahl A (eds): 150 Jahre Psychiatrie. Cologne, Martini, 1996, vol 1, pp 634–638.

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3

4

5

6

7

Herzog T, Creed F, Huyse FJ, Malt UF, Lobo A, Stein B, the European Consultation-Liaison Workgroup: ‘Psychosomatic medicine’ in the general hospital; in Sensky T, Katona C, Montgomery S (eds): Psychiatry in Europe – Directions and Developments. London, Gaskell, 1994, pp 143–151. Meyer JE, Seidel R: Die psychiatrischen Patienten im Nationalsozialismus; in Kisker KP, Lauter H, Meyer JE, Müller C, Strömgren E (eds): Brennpunkte der Psychiatrie. Psychiatrie der Gegenwart. Heidelberg, Springer, 1989, vol 9, pp 369–400. Bullinger M, Schmidt S, Morfeld M: Lebensqualität bei körperlichen Erkrankungen; in Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin. Darmstadt, Steinkopff, 2004, pp 86–99. Muthny FA: Krankheitsverarbeitung bei körperlichen Erkrankungen und Erfordernisse des psychosozialen Konsiliardienstes; in Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin. Darmstadt, Steinkopff, 2004, pp 100–121. Diefenbacher A: Psychiatry, psychosomatic medicine and the general hospital in Germany. World Psychiatry 2003;2(2):95–97.

Prof. Dr. Albert Diefenbacher Abteilung für Psychiatrie und Psychotherapie Evangelisches Krankenhaus Königin Elisabeth Herzberge, Herzbergstrasse 79 DE–10365 Berlin (Germany) Tel. ⫹49 30 5472 4802, Fax ⫹49 30 5472 2913, E-Mail [email protected]

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Diefenbacher A (ed): Consultation-Liaison Psychiatry in Germany, Austria and Switzerland. Adv Psychosom Med. Basel, Karger, 2004, vol 26, pp 181–189

Psychosomatic Medicine and Psychotherapy: On the Historical Development of a Special Field in Germany Hans-Christian Deter Department of Psychosomatic Medicine and Psychotherapy, Berlin, Germany

It is an astonishing phenomenon that psychosomatic and psychotherapeutic medicine has become so strong in Germany, the only country in the Western world to have established a specialty for psychotherapeutic medicine in 1993 (which had already existed in the former German Democratic Republic) with more than 100 special hospitals and 10,000 psychosomatic hospital beds. This is the largest number of beds in the Western world. Hübschmann [1] also called psychosomatic medicine ‘memory medicine’ because all its functions can be understood as an attempt to remember, to reflect, to find out where one stands internally and externally and how one feels. He meant this in relation to individuals, but it can also be applied to the experiences of a nation or a discipline like psychosomatic medicine. ‘History’ and ‘experience’ have always had a special meaning in Germany. Dutch television recently confirmed a suspicion that had been repeatedly voiced in recent years: Hans Schwerte, the left-liberal and now retired rector and honorary senator of the Technical University of Aachen, highly esteemed by students and colleagues, was SS-Officer Hans Ernst Schneider before May 8, 1945, and head of the Germanic Scientific Mission of Heinrich Himmler’s ‘Ancestral Heritage’. He had lived in the Federal Republic of Germany under his assumed identity for 50 years. This case, which was reported in the newspapers in May 1995, is not entirely untypical, and the question of continuity and identity in reunified Germany is still of topical interest. This development in Germany generated great interest in a discussion with colleagues in the Department of Social and Environmental Medicine at the Karolinska Institute in Stockholm, but it was received with a mixture of

incomprehension, admiration and concern on the other side of the Baltic Sea. It seemed that this new special German course (how many have there been already?) required some explanation and discussion. This is the reason for expressing a few thoughts that may provide a model for explaining this special German course in psychosomatic medicine which has captured the interest of a number of different authors [2–9]. There are four important movements in the history of medicine and the humanities that had a decisive influence on the development of psychosomatic medicine and its position among the different medical specialties.

Roots of Psychosomatic Thought in the 19th Century

There has been a tradition of holistic thinking in Germany since the time of W. Goethe and H. Heinroth. The epoch of so-called romantic medicine at the beginning of the 19th century was in large parts speculative and mystical because it was felt that the unity of body and soul could only be experienced in this way (instead of through thinking or believing), and there was thus an interest in the dark side of the soul, the unconscious and dreams. From the middle of the last century, a strongly scientifically influenced medicine developed which is tied to the names of W. Griesinger, R. Virchow and R. Koch. However, the first two were very interested in the social and general aspects of medicine. Thus, the holistic discourse never entirely stopped in Germany. Despite the rapid development of scientific medicine, a philosophically influenced debate took place in the 19th century which centered on questions about the relation between body and soul and matter and spirit and extended from Romanticism (e.g. Görres, 1776–1848) to the end of the 19th Century (e.g. W. Brücke in Vienna, who had S. Freud as a student) [10]. The transfer from philosophy to medicine was very closely and predominantly based on individuals because physicians frequently became philosophers: for example, the psychiatrist Jaspers [11] or the internist von Weizsäcker [12], who continued to work in that area despite his great interest in philosophy and theology, and who had a very decisive influence on psychosomatic medicine. This close relationship between philosophy and medicine, especially in Heidelberg, was the climate in which a typical German situation developed [10]: (1) a basic anthropological orientation in medicine (i.e. medicine centered on the individual as a whole and his ‘being’ in a philosophical sense); (2) an interdisciplinary scientific approach to the study of man with room for different theoretical aspects in natural science and the humanities, and (3) a stronger reflection on the applied methods for describing and studying an object, which also implies reflecting on their limitations.

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Development of Psychosomatic Medicine in Internal Medicine at the Beginning of the 20th Century

‘At the end of the last century, physicians observed an increase in neurotically nervous diseases’, according to the words of the director of the medical clinic in Heidelberg, Erb (1840–1921) [13], a neurologist, who called hysteria the curse of the times. War neuroses and afterwards functional disorders without organic findings were increasingly observed during the World War I. The failure of scientific medicine in this area corresponded to the lack of therapeutic possibilities in the entire field of internal and psychiatric medicine.

Medicine and Subspecialties

Medicine underwent stronger development in different special disciplines which led to the explicit desire to reintegrate these ‘separate’ partial areas into a complete medical discipline. It seems helpful here to think back to the ‘the individual as a complete human being’, so that Krehl [14] was able to say: ‘We do not treat diseases but sick people’. Psychosomatic medicine appeared to promote this integration at that time. These first approaches were further pursued between the two world wars by leading German internists, such as V. von Weizsäcker, R. Siebeck, K. Hansen, G. von Bergmann, and others [15]. Moreover, the experience of the national socialist regime and World War II enabled physicians like A. Jores [16] or F. Curtius to become more familiar with psychosomatic viewpoints which they had partially experienced themselves or intensively observed in others during that time. Especially at the internal medicine congress in Wiesbaden in 1949, the further development of psychosomatic medicine at universities and in the German health care system was revolutionized by four very influential internists: T. von Uexküll (Giessen, Ulm), A. Jores (Hamburg), L. Heilmeyer (Freiburg), and W. Seitz (Munich), who supported the newly developed psychosomatic/ psychotherapeutic institutions against various counter-movements particularly from the psychiatric specialist associations. The rapid advancement of psychosomatic medicine before and after World War II was also seen in other countries: in the United States of America, it is associated with the names of S.O. English and E. Weiss, F. Dunbar, F. Alexander (an emigrant from Berlin and a student of G. von Bergmann) and later George Engel; in the Netherlands with J. Groen and H. Pelser, and in England with H. and S. Wolf and J. Paulley. In Germany, psychosomatic medicine made its breakthrough in the academic world and in the area of public health care, but not before two other developments had taken place which will be discussed below.

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Psychoanalytical Roots

After Vienna, Zurich and Budapest, psychoanalysis established another important center in Berlin before and after the First World War, and assembled several representatives of the inner circle around Freud in Germany such as K. Abraham, M. Eitington, F. Boehm, and others. An institute for advanced psychoanalytical training was founded there as well as a clinic in Tegel castle by E. Simmel in the 1920s and by G. Groddeck in Baden-Baden in 1927. After corresponding with Freud, von Weizsäcker set up the first clinic for neurotic patients in the Medical Department at the University of Heidelberg, caring particularly for neurotic retirees. This was in 1930. After the national socialists came to power, psychoanalysis was suppressed, and its first attempts to enter the universities were impeded. Most of the German psychoanalysts went into exile in England, the United States or South America, and did not regain any influence on psychoanalysis in Germany until after World War II. A small group of analysts, in an institute headed by H. Göhring (a cousin of Field Marshal Göhring), managed to continue their psychoanalytical work and thus survived World War II in Germany. A broad range of methods were applied (for example, autogenic training was developed by I.H. Schulz, a member of the group) and psychoanalysis was critically reassessed by H. Schulz-Hencke whose name is associated with neopsychoanalysis. The individual members of this group [8] always denied the accusation that they could not develop new ideas free from any ideological influence under the pressure of the Nazi regime, as voiced, for example, by Brecht [4] in 1985. Thus, it was probably a specifically German situation that the two groups of psychoanalysts met after World War II and formed two separate schools of thought: the psychoanalysts who had stayed in Germany during the dictatorship (German Psychoanalytic Society) and the emigrants who formed the new generation of psychoanalysts in Germany (German Psychoanalytic Association) and introduced the former to the international community of psychoanalysts. The discussions between the two groups continue to this day, although some rapprochement can be seen in the fact that the German Psychoanalytic Society has recently applied for membership in the International Psychoanalytic Association. Important in this context is Alexander Mitscherlich, who underwent psychoanalytical training in London. He was persecuted and imprisoned by the Nazis and became later (1941) Viktor von Weizsäcker’s assistant in Heidelberg. After obtaining his professorship in 1946, and with von Weizsäcker’s support, he launched his first attempt to set up an independent department of psychotherapy at the university medical center. This was unsuccessful, for one

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thing because of the objections of the head of the psychiatric clinic and other members of the faculty. The special dynamics of this case result from the fact that Mitscherlich, who had documented and observed the Nuremberg Trials to the extent that they concerned Nazi physicians, had personalized this attitude: he was refused his own department because the professors from the Nazi era cooperated in the old spirit and refused what was medically called for. He wrote about this to the Secretary of State, Carlo Schmidt, in Stuttgart, after a decision had been delayed for 3 years and the project threatened to fail. After the intervention of this left-liberal politician together with the dean of the University of Heidelberg, it was possible for the first time to establish a department in Germany in 1950 which later became an independent psychosomatic section and was given a chair in 1966. This development only occurred because of the special situation after World War II, the political liability of university professors from the Nazi era and the political pressure from the outside (together with additional funds from the Rockefeller Foundation). A similar course took place until 1965 under the protection of heads of internal medicine department at various universities, including those at Freiburg, Munich, Hamburg and Giessen. This resulted in a number of other outpatient and inpatient clinics that were set up outside universities, for example in Berlin and Göttingen. These facilities became the nucleus of a development which meanwhile includes all university departments, in other words, essentially independent psychosomatic-psychotherapeutic departments outside psychiatric and psychological institutions. The important step toward this goal was a social compromise and social acceptance for such a development at various levels. (a) A first step toward social acceptance of psychotherapy was its inclusion in the German health insurance system (1967). This was preceded not only by important work on the effectiveness of psychotherapeutic treatment, for example by von Dührssen [17], but also by the concerted efforts of the two psychoanalyst associations (which agreed for the first time on this issue and cooperated quite skillfully), the General Physicians’ Society for Psychotherapy as well as various internists and psychiatrists. (b) A further step toward social acceptance was its integration into medical training at the universities (1970). This development was supported by internists (T. von Uexküll) and psychotherapists (H.E. Richter). (c) The final and probably most important step was reached with the introduction of a specialist for psychotherapeutic medicine at the Physicians’ Congress in Germany in 1992. The professional occupation of specialist for psychotherapy, which had already been established in the former German Democratic Republic, served as a model. However, the motivating factor for the

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congress’ decision was the psychological associations’ desire for a legal regulation of their psychotherapeutic activities and the physicians’ concern about losing the entire field of psychotherapeutic care to the psychologists. Despite this widely accepted chronology of important policymaking steps for integrating psychosomatic medicine and psychotherapy into the general field of medicine, the outlined development also has a deeper health policymaking, medical, socio-historical and sociological background which, compared to other countries, allowed this development and influences it to this day.

Reasons for Health Policymaking

The general prosperity in Germany certainly played a role, as well as the relatively fair distribution of financial resources throughout the German social security system for now more than 100 years. Moreover, in 1975, a very competent parliamentary enquiry commission on psychiatric-psychotherapeutic care in Germany made practicable suggestions for improvement and pointed out care deficits [18]. Important pioneering studies were performed that reflected the research efforts to evaluate psychotherapy [17]. Also, a number of very active psychotherapeutic associations (the German Psychoanalytic Society and the General Physicians Society for Psychotherapy) and outstanding personalities (H.-E. Richter, H. Enke, A. Heigl-Evers, A. Dührssen, T. von Uexküll) had a decisive influence on social politics, alternating between strong competition among all parties involved and partial cooperation on questions of practical importance.

Field-Related Reasons

Psychiatry in Germany after World War II was essentially directed at organic conditions or psychoses, and was not familiar with the psychoanalytical or other psychotherapeutic treatment methods of ‘small psychiatry’. It had strongly identified itself with the racial laws and ideology of national socialism and had thus lost its credibility with the post-war generation. Considering the relatively strong integration of psychosomatic medicine in internal medicine, these were reasons which made it rather difficult to integrate psychotherapy/psychosomatic medicine into psychiatry, but could not prevent its independent development in contrast to most other countries (Sweden, Switzerland, Great Britain or the USA). However, the situation has undergone a marked change since the introduction of a specialty in psychiatry and psychotherapy (1992). (In Germany we know both psychosomatic and psychiatric

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consultation-liaison services, e.g., at a university hospital, both care for 3–4% of all inpatients [19].)

A Socio-Historical Effect of Psychoanalysis

There are additional reasons for the independent development in Germany; a topic which already came up in describing Alexander Mitscherlich’s fate (see above). To what extent should psychoanalytically oriented therapy make it possible to individually deal with the deeds and experiences of society in the Third Reich or prevent this by rejecting the psychoanalytical theory? The tendency to forget recent history was particularly strong among physicians and university staff. Now it almost seemed as if the societal consensus had created an instrument against the collective desire to forget (by preserving analytical therapeutic procedures). It may be important in this context to realize that psychoanalysis was reintroduced in Germany after World War II by those Jews who had emigrated, and that the feelings of guilt about forgetting were therefore strongly activated in the population. This may be the reason for the strong inhibition to suppress this discussion in this situation (at least among progressive politicians). The other group of psychoanalysts, who had stayed in Germany during the Nazi regime, were equipped with different but also essential tools: they had learned to survive and prevail under difficult social conditions. They had the social competence to correctly appraise actual power structures and deal with them prospectively. This repertoire was of decisive importance for sociopolitical discussions on the independent development of the field in the 1960s and 1970s. At the same time, this group seemed to have a particularly strong desire to join the universities and the scientific community, which led to a partial reduction in the strictly psychoanalytical methodological orientation under pragmatic aspects and clinical requirements.

Sociological Development in the Federal Republic of Germany

During the student revolt of 1968, medicine showed a new open-mindedness toward social and psychological problems. The book ‘The Group’ by H.E. Richter [20], for example, was a milestone in that it took a different view on specific aspects of homeless people and their special life conditions. This development was very helpful to psychosomatic medicine, which was institutionally more firmly embedded here than in other countries.

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Conclusion

Considering these very successful organizational and institutional developments in the 1960s, 1970s and 1980s, it is astonishing that psychotherapy made it possible for German psychosomatic medicine to take a leading role in the actual medical care of patients. All Germans are insured by the public health system (after an application and expert evaluation) and are entitled to more than 50 h/year of outpatient psychotherapy or inpatient psychotherapeutic care without having to pay for it themselves (1% of all medical care is spent on outpatient psychotherapy in Germany). In international comparison, German researchers played in part a leading role in applied psychotherapeutic research but fell back in the basic psychosomatic sciences like psychophysiology, psychoendocrinology, psychoimmunology and neurosciences. Here we can see a splintering into hospital- and practice-related diagnosis and therapy research in psychosomatic institutions and basic research in psychiatric- and behavioral therapy-oriented departments. This is also to some extent due to the development in the individual specialties, which are extremely oriented towards basic science. Thus it is difficult for psychosomatic specialists who are ‘oriented toward the whole individual’ to compete for research funds. Especially in Germany but also in other countries, this raises questions as to the view of man held by medicine and research, and forms the basis for topics relating to the fundamentals of care research, diagnostics and therapy as well as to the way in which patients are dealt with on the whole. The limited resources and the complex experiences discussed above have led to the conclusion in Germany that such an endeavor can only be organized on an interdisciplinary basis and by sharing the tasks. This can only be achieved by international cooperation [21].

References 1 2 3 4 5 6 7 8

Hübschmann H: Psyche und Tuberkulose. Stuttgart, Enke, 1952. Thomä H: Von der Psychosomatischen Medizin zur Psychoanalyse. Heidelberg 1949–1967. Psyche 1983;38:577–591. von Uexküll T: History of German psychosomatic medicine – Philosophical and medical roots (in German). Psychother Psychosom Med Psychol 1986;36:18–24. Brecht K: Zur Geschichte der Psychoanalyse in Deutschland. Reinbek, Rowohlt, 1985. Meyer AE (ed): The Hamburg short psychotherapy comparison experiment. Psychother Psychosom 1981;35:77–220. Henkelmann T: The history of psychosomatics in Heidelberg (in German). Psychother Psychosom Med Psychol 1992;42:175–186. Schepank H (ed): Verläufe, seelische Gesundheit und psychogene Erkrankungen heute. Berlin, Springer, 1990. Dührssen A: Ein Jahrhundert psychoanalytische Bewegung in Deutschland. Göttingen, Vandenhoeck & Ruprecht, 1994.

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Deter H-C (ed): Psychosomatic Medicine at the Beginning of the 21st Century – The Chance for Biopsychosocial Medicine (in German). Bern, Huber, 2001. Henkelmann T, Hahn P: Historical insights of psychosomatic medicine in Heidelberg. Proc 16th Eur Conf on Psychosomatic Research, New York, 1987, pp 47–52. Jaspers K: Allgmeine Psychophathologie, ed 7. Heidelberg, Springer, 1959. von Weizsäcker V: Gesammelte Schriften, vol I. Frankfurt, Suhrkamp, 1986. Erb W: Über die wachsende Nervosität unserer Zeit. Heidelberg, Wintersche Universitätsbuchhandlung, 1893. von Krehl L: Entstehung, Erkennung und Behandlung innerer Krankheiten. Leipzig, Thieme, vol 2, 1932. von Bergmann G: Funktionelle Pathologie. Berlin, Springer, 1932. Jores A: Selbstdarstellung; in Pongratz L (ed): Psychotherapie in Selbstdarstellungen. Bern, Huber, 1973, pp 228–258. Dührssen A: Katamnestische Ergebnisse bei 1004 Patienten nach analytischer Psychotherapie. Z Psychosom Med 1962;8:94–113. Deutscher Bundestag: Bericht über die Lage der Psychiatrie in der Bundesrepublik Deutschland – Zur psychiatrischen und psychotherapeutisch-psychosomatischen Versorgung der Bevölkerung. Drucksache 7/4200, Bonn 1975. Deter HC: The integration of psychosomatics into clinical medicine; in Seva A (ed): The Handbook of Psychiatry and Mental Health. Barcelona, Anthropos, 1991. Richter HE: Die Gruppe. Hamburg, Rowolt, 1972, p 150. Deter HC: Psychotherapy and psychosomatic: A unitary field (in German). Psychother Psychosom Med Psychol 2002;52:45–46.

Prof. Hans-Christian Deter, MD Department of Psychosomatic Medicine and Psychotherapy Hindenburgdamm 30 DE–12200 Berlin (Germany) Tel. ⫹49 30 8445 3996, Fax ⫹49 30 8445 4590, E-Mail [email protected]

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‘Psychiatry and Psychotherapy’ and ‘Psychotherapeutic Medicine’ A Unique Situation in Germany

Max Schmauss Bezirkskrankenhaus Augsburg, Augsburg, Deutschland

In 1992 the German Physicians Association (Bundesärztekammer) amended its law governing postgraduate medical education (Weiterbildungsordnung). For the first time in Europe a brand new medical discipline, ‘psychotherapeutic medicine’, emerged alongside the established field of ‘psychiatry and psychotherapy’. For many good reasons, the diagnosis and treatment of mental disorders have been unified into one medical discipline in the rest of the world, this split into two different medical disciplines in Germany still remains misunderstood by the medical profession as well as the cost payers, politicians and the whole population in Germany. These new rules of postgraduate medical education in Germany do not simply equate with the established discipline of ‘psychotherapeutic medicine’, but include diagnostic procedures as well as psychotherapeutic treatment for many mental illnesses, such as depression and personality disorders. The law governing postgraduate medical education previously in force already condoned that broad areas of ‘psychosomatic’ as well as ‘psychiatric and psychotherapeutic’ care of the German population were within the responsibility of different medical disciplines and that there existed a massive overlap between these two disciplines in providing the psychiatric and psychotherapeutic care of the population. The new rules of postgraduate medical education therefore disregard instructions by the legislative branch of Germany for clearly defining medical disciplines and separating them in a manner that they can be understood by the citizens of this country. This development results in an increasing number of fatal consequences for the care of the mentally ill. In my opinion, from a scientific point of view, it is not acceptable to establish two parallel structures of health delivery for the

same mental disorders. The consequence also will be a ‘first and second class’ infrastructure for the treatment of our mentally ill patients. Patients with severe mental disorders are being treated within the structures of psychiatry and psychotherapy, whereas patients with less severe mental disorders are treated within the structures of psychotherapeutic medicine. This hierarchy dramatically fosters stigmatization of severe forms of mental illness. This cannot be in the interest of political decision makers in Germany. The area of responsibility of psychotherapeutic/psychosomatic medicine does include diseases with primarily somatic symptoms combined with psychological factors. However, the responsibility definitely does not include primarily mental disorders. If one were to conclude that there is inadequate care for the mentally ill in Germany, one would see the need to increase psychiatric and psychotherapeutic capacities for both inpatients as well as outpatients. Community-based psychiatric and psychotherapeutic treatment facilities need to be optimized as there are still striking deficits in the treatment of elderly patients and patients with alcohol or drug abuse. Psychotherapeutic/psychosomatic medicine is not able to remedy these deficits. Prof. Dr. M. Schmauss Bezirkskrankenhaus Augsburg, Dr. Mack-Strasse 1 DE–85156 Augsburg (Germany) Tel. ⫹49 821 4803101, Fax: ⫹49 821 4803109, E-Mail [email protected]

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Psychosomatic Medicine and Psychiatry: The German Situation Günter Niklewski Klinikum für Psychiatrie, Klinkum Nürnberg, Nürnberg, Deutschland

The relationship between psychosomatic medicine as an autonomous clinical discipline and psychiatry in Germany cannot be sufficiently understood without a historical review. Originating with the planning of psychiatric care in Prussia during the second half of the 19th century, psychiatric specialty hospitals (i.e. state mental hospitals) were established in Germany almost border to border, and were not integrated with the remainder of medical care for the general population [1]. This development eventually caused a continuation of stigmatization by casting out people with mental disorders. After World War II, and after the culpable entanglement of psychiatry in the era of National Socialism through participation in the murder of psychiatric patients [Malt, pp 196–202], the health care structures in Germany were first reformed and reestablished in areas of somatic medicine. As a result, this again led to a neglect of the mentally ill. The stigmatization continued. Institutional neglect and continuing stigmatization led to the circumstance that the mentally ill were still not put on equal terms with the somatically ill with regard to their care systems. This was recognized by an investigation into the situation of psychiatry in West Germany (Federal Republic of Germany) in 1972 which was ordered by the federal government (‘Psychiatrie-Enquête’) [2; Diefenbacher, pp 1–19]. The ensuing report delineated significant deficiencies in the inpatient as well as outpatient care of the mentally ill: large deficiencies in the established institutions were observed, and qualitative and quantitative insufficiencies in the care of the mentally ill were pinpointed. The essential consequences of these recommendations were a decentralization of inpatient psychiatric care and the

creation of departments of psychiatry at general hospitals as a new form of care that would serve as a beacon for the future [3]. Parallel to this, the system of psychosomatic medicine evolved after World War II in Germany. Primarily, it originated as ambulatory psychotherapeutic care which evolved out of psychoanalytically oriented therapeutic institutes. Later, this was followed by the establishment of inpatient psychosomatic institutions which were not located close to the community as was proposed by the ‘Psychiatrie-Enquête’ for psychiatric departments in the general hospital, but followed the pattern of the widely distributed ‘Kurklinik’ which was modeled after German inpatient hospitals for rehabilitative medicine. Acute psychosomatic care is undertaken either by departments of psychiatry or psychiatric specialty hospitals or by the heretofore very few psychosomatic specialty departments at general hospitals. In this regard there is no binding distribution or referral of patients, e.g., according to different nosological groupings of the chapters of the F catalogue of the ICD-10. Generally, one can observe that psychosomatic specialty departments tend to treat patients predominantly according to the section F4 of ICD-10. However, a large overlap between psychosomatic and general psychiatric care exists especially for patients with affective disorders. Over many years in the area of inpatient care in the general hospital, the emphasis of psychosomatic care was placed on offering special treatment settings for patients with precisely defined disorders, e.g. eating disorders or severe personality disorders. In the last few years, however, one can observe a trend towards patient groups with primarily somatic disorders and their resulting problems of coping, disorders of somatization, pain patients and others. As in consultation-liaison (C-L) service delivery proper, there is virtually no empirical research on the allocation of psychiatrically ill patients to either type of service. One notable exception is the Zentralinstitut für Seelische Gesundheit in Mannheim in the state of Baden-Württemberg which is provided with both a psychiatric and a psychosomatic department. In looking at psychosomatic consults ordered by psychiatry, it was found that the need for care of the referred patients lay between that usually found with the respective inpatient populations: younger, better educated, and with fewer previous hospitalizations, they were healthier than the average psychiatric inpatient, yet, on the other hand, represented a risk group within the psychosomatic department, with more intense care needs than the average psychosomatic inpatient, and even the possibility of being transferred back to psychiatry [4]. While the staffing key in psychiatry is regulated by law, such rules do not exist for psychosomatic medicine [5]. On the side of psychiatry this repeatedly leads to the argument that only patients with less severe illnesses can be treated within the realm of inpatient psychosomatic medicine because the necessary

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resources are lacking. A further argument emanating from the internal squabble of the two specialties is that because of this psychosomatic medicine objects to the uniformly one-level approach of psychiatric care, i.e. to care for all mental patients regardless of what psychiatric diagnosis they have and how severely ill they are, and therefore implicitly contributes to the continued stigmatization of severely mentally ill individuals. Currently, a suggestion from the psychiatric camp is being intensely debated, that is to limit psychosomatic treatment offers exclusively to the field of rehabilitation while acute treatments are performed in psychiatry [6]. With regard to the guidelines for training the residents, psychosomaticists offer training towards the board certification of ‘psychosomatic medicine and psychotherapy’, while in psychiatry usually a physician obtains board certification in ‘psychiatry and psychotherapy’. Unfortunately, the law governing specialty training provides only a few offers for combined training for residents of both specialties so that their progressive separation may ensue in the context of medical specialty board training; e.g. an obligatory rotation between the two specialties in the context of medical specialty training is not contemplated. Furthermore, in the psychotherapeutic training of both fields there are only few commonalties, e.g. in the form of a basic training module. So far relatively few young physicians obtain a specialty degree as a physician for ‘psychosomatic medicine and psychotherapy’. In the area of outpatient care these physicians usually work in the context of ambulatory psychotherapy [Diefenbacher, pp 177–180]. The introduction of new forms of cost-accounting in inpatient somatic medicine in conjunction with the equalization of costs within the institutions will cause a dynamic future for the relationship of both specialties. It might be the case that the psychosocial C-L services will no longer be part of the basic offer of care at general hospitals that are financed according to their expenses. Both specialties will have to document their capacity to perform with regard to their consultative care of primarily somatically ill patients in the general hospital. Again, they will also have to prove the economical advantage of their services. It is to be expected that new forms of cost-accounting will become a reality for psychosomatic and psychiatric inpatients in the foreseeable future. It could be a wish for the future that the professional societies of these medical specialties put themselves in the position to conduct negotiations with cost-carriers in the interest of their patients and to activate synergies in continuous education towards specialty boards as well as in ambulatory and inpatient care. An example could be the situation in Nuremberg: here a department of psychiatry and psychotherapy, established in 1897, and a department for psychosomatic medicine, established in 1980, exist next to each other, both within the same general hospital. Both maintain their own C-L services; these work together in a mutually complementary fashion [7]. The inpatient services enhance each

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other as well: the hospital for psychosomatic medicine offers specialized settings, e.g. for traumatized patients or patients with somatoform disorders and coping problems in the presence of primary somatic illness [8]. Principally the relationship of these two specialty groups is in need of improvement. A clear delineation of responsibilities and forms of cooperation are necessary. Psychosomatic medicine as an autonomous care system is firmly established in Germany.

References 1 2

3

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5 6 7

8

Laehr H: Fortschritt – Rückschritt? Reform Ideen des Herrn Geh. Rates Prof. Griesinger in Berlin auf dem Gebiet der Irrenheilkunde. Berlin, Oemigke, 1868. Deutscher Bundestag: Bericht über die Lage der Psychiatrie in der Bundesrepublik Deutschland – Zur psychiatrischen und psychotherapeutisch/psychosomatischen Versorgung der Bevölkerung (Psychiatrie-Enquête). Drucksache 7/4200. Bonn, Heger, 1975. Bauer M: Perspektiven der Krankenhauspsychiatrie – Positionspapier Arbeitskreis der Chefärzte und Chefärztinnen von Kliniken für Psychiatrie und Psychotherapie an Allgemeinkrankenhäusern in der Bundesrepublik Deutschland. Psychiatr Praxis 2001;27:1–12. Häfner St, Riecher-Rössler A, Lotz M, Häfner-Ranabauer W: Das psychosomatische Konsil in der Psychiatrischen Klinik – Vergleichende Untersuchung zur Indikationsstellung und zum Erfolg verschiedener Behandlungsmassnahmen. Z Psychosom Med 1998;44:354–369. Kunze H, Kaltenbach L (eds): Psychiatrie – Personalverordnung (PsychPV), ed 4. Stuttgart, Kohlhammer, 2003. Fritze J, Berger M: Weitere vollstationäre Kapazitäten für Psychosomatik? Bundesländer bringen sich in Widerspruch zu den eigenen Experten. Nervenarzt 2003;74:387–388. Niklewski G, Lehfeld H, Pelzl S, et al: Are elderly patients neglected by psychiatric consultations services? A comparison of psychiatric consultations by age group. Eur J Gerontol 2001;3: 122–130. Burian R, Diefenbacher A: Konsiliar-Liaison-Psychiatrie in Europa. Nervenarzt 2002;73: 1128–1129.

Dr. med. Dr. phil. Günter Niklewski Klinikum Nürnberg Klinik für Psychiatrie und Psychotherapie, Professor-Ernst-Nathan Strasse 1 DE–90419 Nürnberg (Germany) Tel. ⫹49 911 398 2829, Fax ⫹49 911 398 3965, E-Mail [email protected]

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German Psychosomatic Medicine: An International Perspective Ulrik Fredrik Malt Department of Psychosomatic Medicine, Rikshospitalet, University of Oslo, Oslo, Norway

There is neither international nor German agreement on how to define the concept of ‘psychosomatic medicine’. At present, in Germany there are at least three different definitions of ‘psychosomatic medicine’ in use.

Psychosomatic Medicine Defined as ‘Biopsychosocial or Holistic Medicine’

The German physician and researcher, Johann Christian August Heinroth (1773–1843), was most likely the first to use the word ‘psychosomatic’. He argued that it was necessary to incorporate not only a biological perspective in medicine, but also to consider psychological, environmental and cultural issues. Some German reviews of psychosomatic medicine are exactly that [1]. Some Germans consider the so-called ‘basic psychosomatic care’ curriculum (Psychosomatische Grundversorgung) to be a unique German phenomenon. A closer look at the content, however, reveals traditional biopsychosocial medicine [2, 3]. Similar curricula are found in most modern schools of medicine outside Germany, but under different ‘labels’. Sometimes they are part of medical psychology curricula and sometimes part of the psychiatric curriculum. The reason behind the German curriculum of ‘basic psychosomatic care’ seems to be due to the late inclusion of psychotherapy in German academic psychiatry.

Psychosomatic Medicine Defined as ‘Psychological Conflicts Causing Physical Dysfunction and Disease’

When German psychoanalysis adopted the concept ‘psychosomatic medicine’ during the first 30 years of the 20th century, the focus was on medical diseases. The concept of ‘psychosomatic medicine’ was used to describe how psychological factors lead to tissue damage and thus ‘objective’ disease. This definition is still used by some German psychoanalysts today. It corresponds to the earlier efforts by German psychoanalysts to identify true ‘psychosomatic disorders’ such as bronchial asthma, hyperthyreosis, essential hypertension, neurodermatitis, rheumatoid arthritis, colitis and peptic ulcer [4], or to study the association between body and personality or character [5].

‘Psychosomatic Medicine Defined Simply as Psychotherapy’

This is perhaps the most confusing definition of psychosomatic medicine in current Germany for a foreigner not acquainted with German terminology. In fact, many German textbooks of ‘psychosomatic medicine’ are simply regular psychiatric textbooks of non-psychotic (‘neurotic’) disorders, with a strong emphasis on psychological and psychotherapeutic issues [6–10]. This particular German definition of psychosomatic medicine has historical roots. The psychiatrists and physicians who were interested in psychoanalysis did not only address psychosomatic disorders. Correspondingly, the first ‘psychosomatic congress’ in 1926 in Baden-Baden in Germany was called the first General Medical Congress for Psychotherapy (Allgemeiner ärztlicher Kongress für Psychotherapie). The participants discussed the relationship between psychotherapy and psychiatry, psychology, internal medicine, gynecology, and pediatrics. Accordingly, their organization was named ‘Allgemeine Ärztliche Gesellschaft für Psychotherapie’ (General Medical Society for Psychotherapy) and was founded in Berlin in 1927 [11]. The introduction of the word ‘psychosomatic’ as a synonym for psychotherapy seems to have been adopted from the German psychoanalysts who had moved to the United States prior to World War II, and was introduced in Germany after the war by Alexander Mitscherlich and others. For historical reasons during that period, German psychotherapy was more closely related to internal medicine than was the case in other European countries. It is also worth mentioning that the first clinic for psychotherapy in Heidelberg, Germany, integrating psychoanalytical theory into general medicine, was made possible by generous financial support from the Rockefeller Foundation.

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Under the leadership of Ernst Kretschmer, the psychotherapists reorganized their psychotherapeutic society after the World War II and initiated the annual ‘Lindauer Psychotherapy Weeks’ in 1948; an ongoing institution. The journal ‘Zeitschrift für Psychotherapie und Medizinische Psychologie’ (Journal for Psychotherapy and Medical Psychology) was founded in 1951. A few years later, Alexander Mitscherlich renamed the ‘German Society for Psychotherapy and In-depth Psychology’ (Deutschen Gesellschaft für Psychotherapie und Tiefenpsychologie) into the ‘German Society for Psychotherapy, Psychosomatics and In-depth Psychology’ (Deutschen Gesellschaft für Psychotherapie, -Psychosomatik und Tiefenpsychologie). In the coming years, a closer cooperation between the different non-psychiatric psychotherapeutic organizations occurred. There are still strong feelings about this issue in Germany. Some psychotherapists (‘psychosomaticists’) sincerely have the opinion that psychiatry is – and always will be – a biological discipline solely using biological treatment methods. Some even purport the view that current German psychiatry is only a continuation of the Eugenics of the Nazi period with its emphasis on biological deviance and ‘unworthy life’. This is of course not true. However, in the view of those persons, psychosomatic medicine is the humanistic (or psychotherapeutic) alternative to psychiatry. The fact that those opinions are purported even at the beginning of the 21st century tells us something about the strong tensions that still exist in psychological medicine in Germany. It is true, however, that while psychodynamic theory gradually became adopted by clinical psychiatry outside Germany, the Nazi takeover in 1933 prohibited this evolution in Germany. The majority of psychoanalytically oriented psychiatrists working with patients with somatic disorders and issues left office in protest (like Ernst Kretschmer) or flew abroad. However, the psychiatrists more often worked in governmentally run institutions, and perhaps less likely wanted to refrain from power. Is it also possible that their biological orientation made them as a group less resistant to the Nazi ideology? It is well known that Nazi euthanasia programs inflicted on the mentally and physically disabled between 1939 and 1945 were made possible by active participation of many psychiatrists. However, less well known is the closing down of several state mental hospitals (Heil- und Pflegeanstalten) between 1933 and 1945. Psychiatric patients were left on their own in order to use these places for ‘worthier’ purposes [12]. For many patients this lead to personal destruction and some were even subsequently referred to euthanasia programs. In total 70,000 psychiatric patients or more were killed during the Nazi period. It should be added, however, that some psychiatrists, as well as others in key social positions, did protest. Best known is perhaps the bishop (later Cardinal) of the German city of Münster, Clemens August Graf von Galen (1878–1946),

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who in 1941 openly opposed the Nazi killings and the crimes against people of other races. In the struggle for power in post-World War II Germany, some psychotherapists blamed the whole profession of psychiatrists for collaboration with the Nazis. However, some psychotherapists also remained in Nazi Germany. Although some were involved in resistance (e.g. Mitscherlich), some were not and even saluted Hitler and suggested that his ideas would inspire German psychotherapy! In his welcome speech at the 7th Congress of Psychotherapy in 1934, the chairman of the German Psychotherapist Organization, Prof. Dr. med. M.H. Göring, even said it was every psychotherapist’s duty to read Hitler’s biography ‘Mein Kampf’ (the book in which Hitler prophecies the Holocaust and the annihilation of the Russian people). Others just passively adjusted to the new era without active resistance. Thus from a foreigner’s point of view, the statement the psychotherapists were ‘white’ and psychiatrists ‘black’ seems to be an oversimplification.

Psychosomatic Medicine Meaning Consultation-Liaison Psychiatry

Recently the confusion about the meaning of psychosomatic medicine is being (further) messed up by the American Medical Association’s decision to call the new sub-specialty of ‘psychiatry in the medically ill’ not consultationliaison psychiatry but ‘psychosomatic medicine’. However, the new US ‘definition’ of ‘psychosomatic medicine’ has not been adopted in Germany. But the increased use of the phrase ‘consultation-liaison psychiatry’ worldwide has also influenced German terminology. Due to the fact that also psychologists and psychotherapeutically educated physicians perform assessments of and administer treatments to medically ill patients with psychiatric problems and disorders, the Germans have introduced concepts such as ‘consultation- and liaison psychosomatics and psychiatry’ [13], or added the word ‘psychotherapy’ to consultation-liaison psychiatry and psychotherapy [14,15].

Psychosomatic Medicine and Psychiatry in Current Germany: An Evaluation

During the last 30 years most German university hospitals, but not the general hospitals, have had two parallel departments dealing with mental disorders, a department of psychiatry and a department of psychosomatic medicine. At least until recently, departments of psychiatry have mostly been staffed with

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psychiatrists, while the departments of psychosomatic medicine have mostly been staffed with clinical psychologists and internists who have additional psychotherapeutic training. Although psychiatry may see more patients with psychotic disorders and psychosomaticists may see more patients with medical unexplained illness, psychiatry and psychosomatic medicine nevertheless to a large extent see similar types of patients. This leads to rather strange situations. Data from the European Consultation-Liaison Psychiatry and Psychosomatics Workgroup study suggest that the psychological treatments offered to medically ill patients in Germany is often not determined by their needs, but by the kind of department asked to look after the patient. If the somatic department calls the psychiatric consultation service, it is more likely that the patient will receive a drug as part of the treatment. If the somatic department calls the psychosomatic department, it is more likely that the patient will be offered psychotherapy [Diefenbacher, pp 1–19]. The difference between psychiatry and psychosomatic medicine in Germany is also evident when looking at their main psychosomatic society: the German College of Psychosomatic Medicine (Deutsches Kollegium für Psychosomatische Medizin, DKPM). The DKPM defines the scope of its activities as research, treatment, prevention and coping with diseases, in particular the interplay between mental, bodily and social factors in relation to the occurrence and course of diseases. However, established in 1974, the DKPM focuses on psychotherapy and psychological issues in general and not exclusively on issues related to somatic disease. Accordingly, the membership includes many psychologists and internal medical doctors with psychotherapeutic training. The college’s journal is named ‘Psychotherapie, Psychosomatik, Medizinische Psychologie’ (Psychotherapy, Psychosomatics, Medical Psychology). This is in sharp contrast to its American counterpart, the American Academy of Psychosomatic Medicine that mainly consists of psychiatrists offering traditional psychiatric consultations to patients treated on medical-surgical wards in general hospitals. In order to include all Germans doing consultation on somatic wards, the European counterpart organization is called the European Association of Consultation Liaison Psychiatry and Psychosomatics. The organization of psychotherapy separate from psychiatry has some advantages, however. Despite a strong biological movement in current psychiatry worldwide, German psychotherapy is not threatened to the same degree that has been the case in other European countries and the United States. The strong influence on psychiatry exerted by pharmaceutical companies, to a large degree determining the research agenda, will also have less impact on psychotherapy when it is organized independent of psychiatry. The independence of one specialty (e.g. psychiatry, psychology, internal medicine) is also a clear advantage in reducing the risk of being hijacked by one

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theory or professional organization. This may also represent a greater scientific freedom and reduce the risk for being forced into scientific or political correctness. Also from a C-L point of view, a separate organization may have advantages. In times where the resources are scarce, most psychiatric departments may first cut down on the service offered to other departments compared to reducing the level of service offered to traditional psychiatric patients. There are also some disadvantages, however. A separate organization may lead to an artificial and unproductive ‘war’ between ideologies. Instead of integrating neurobiological and psychological perspectives, the German organization may – perhaps paradoxically – reinforce a split between mind and body (neurobiology). There is the impression that German psychosomatic departments sometimes clearly underestimate the role of neurobiological disorders in psychosomatic symptoms (e.g. psychosomatic symptoms as the main manifestation of bipolar II disorder). It is also not very ensuring when patients are not treated based on their needs, but based on ideology. Currently, German psychosomatic medicine is being forced into the evidencebased string. The potential implicit in the unique German integration of internal medicine and psychological theory seems not to be used. Research building on the impressive work of German thinkers and philosophers like Karl Jaspers, and efforts to develop new theories of psychosomatic medicine are absent. Also the uncritically adoption of the system of impact factor and citation indexes represents a risk not only to psychiatry, but also to German psychosomatic medicine. It may loose its potentials as a renewer of psychobiology and end up being just another copy of Anglo-Saxon empirical research. This is perhaps the greatest danger. In a time when there are tendencies to political interference with the freedom of to what to fund and how to present scientific results, and a tolerance of violating human rights for subjects who themselves have violated human rights; we need an ethical and independent psychosomatic medicine.

References 1 2 3 4 5 6 7

Deter HC (ed): Psychosomatik am Beginn des 21. Jahrhunderts – Chancen einer biopsychosozialen Medizin. Bern, Huber, 2001. Fritschke K, Geigges W, Richter D: Psychosomatische Grundversorgung. Berlin, Springer, 2003. Neises M, Ditz S: Psychosomatische Grundversorgung in der Frauenheilkunde. Stuttgart, Thieme, 1999. Alexander F: Psychosomatic Medicine. New York, Norton, 1950. Kretschmer E: Körperbau und Charakter. Berlin, Springer, 1921 (English translation: ‘Physique and Character’, 1925). Freyberger HJ, Schneider W, Stieglitz RD (eds): Kompendium Psychiatrie, Psychotherapie, Psychosomatische Medizin. Basel, Karger, 2002. Hoffmann SO, Hochapfel G: Neurosenlehre, Psychotherapeutische und Psychosomatische Medizin. Compact Lehrbuch, 1995.

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8

9 10 11 12

13 14 15

Meyer A-E, Freyberger H, von Kerekjarto M, Liedtke R, Speidel H (eds): Jores – Praktische Psychosomatik – Einführung in die Psychosomatische und Psychotherapeutische Medizin, ed 3. Bern, Huber, 1996. Plassmann R, Schütz M, von Uexküll T (eds): Integrierte Medizin: Neue Modelle für Psychosomatik und Psychiatrie. Giessen, Psychosozial-Verlag, 2002. Studt HH, Petzold ER (eds): Psychotherapeutische Medizin. Psychoanalyse – Psychosomatik – Psychotherapie. Ein Leitfaden für Klinik und Praxis. Berlin, de Gruyter, 1999. Eliasberg W (ed): Bericht über den I. Allgemeinen Ärztlichen Kongress für Psychotherapie in Baden-Baden, 17.–19. April 1926. Halle, Marhold, 1927. Schmelter T: Nationalsozialistische Psychiatrie in Bayern. Die Räumung der Heil- und Pflegeanstalten (The Practice of Psychiatry during the Nationalsocialist Era in Bavaria: The Eviction of the State Mental Hospitals). Bergtheim b. Würzburg, Deutscher Wissenschafts-Verlag, 1999. Rudolf G, Eich W (eds): Konsiliar- und Liaisonpsychosomatik und -psychiatrie. Stuttgart, Schattauer, 2003. Arolt V, Diefenbacher A (eds): Psychiatrie in der klinischen Medizin. Konsiliarpsychiatrie, – psychosomatik und -psychotherapie. Darmstadt, Steinkopff 2004. Diefenbacher A (ed): Aktuelle Konsiliarpsychiatrie und -psychotherapie. Stuttgart, Thieme, 1999.

Ulrik F. Malt, MD, PhD Department of Psychosomatic Medicine Rikshospitalet, University of Oslo, Sognsvannsveien 20 NO–0027 Oslo (Norway) Tel. ⫹47 23074920, Fax ⫹47 23074930, E-Mail [email protected]

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Author Index

Alexandrowicz, R. 74 Althaus, D. 137 Arolt, V. 31, 98 Baune, B. 118 Caduff, F. 25 Deter, H.-C. 181 Diefenbacher, A. 1, 128, 177 Driessen, M. 118 Georgescu, D. 25 Hegerl, U. 137

Kremer, G. 118 Lehfeld, H. 137 Linden, M. 52 Malt, U.F. 196 Marquart, B. 74 Nanke, A. 144 Niklewski, G. 137, 192

Riessland-Seifert, A. 20 Rothermundt, M. 98 Schmauss, M. 190 Staedt, J. 66, 171 Stoppe, G. 66, 171 Wancata, J. 74 Weiss, M. 74 Wienberg, G. 118 Ziervogel, A. 137

Radanov, B.P. 159 Reischies, F.M. 128 Rief, W. 144

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Subject Index

AIDS, see Human immunodeficiency virus Alcohol abuse comorbidity, physical illness 38–41 consultation-liaison psychiatrist/ psychologist interventions brief psychological interventions 123 diagnosis 121 early intervention 121, 122 intervention evaluation, Germany 124 intervention intensity 123 score-guided treatment 122 withdrawal monitoring 122 consultation-liaison psychiatry, Germany prospects 125 structural conditions 124, 125 German epidemiology classification, alcohol problem groups 119, 120 health impact 118 mortality 118 per capita intake 119 prevalence, primary health care patients 120, 121 Austria, consultation-liaison psychiatry associations and meetings 22, 23 funding 23 goal establishment 23, 24 growth of services 21, 22 historical perspective 20 legal issues 21 referral studies 8, 9 training 23

Benzodiazepine dependence, comorbidity, physical illness 41, 42 Biofeedback, somatoform disorder management 153, 154 Bone marrow transplantation (BMT), depression comorbidity 110 Cancer, depression comorbidity 107, 108 Chlormethiazole, delirium management 132, 133 Chronic pain central sensitization role 166, 167 consultant psychiatrist, role in treatment 169 economic impact 159 gate control theory, pain 160, 161 inhibitory modulation inadequacy consequences 161, 162 nociceptive impulse transmission 160 prevalence 159 prospects, treatment 168, 169 psychosocial factors overview 162–164 rheumatoid arthritis 163, 164 whiplash injury, prospective study 165, 166 suicide risks 159 Cognitions about Body and Health Questionnaire (CABAH), somatoform disorder screening 148

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Cognitive behavioral therapy (CBT), somatoform disorder management 152, 153, 155, 156 Consultation-liaison psychiatry, definition 1 Coronary heart disease, depression comorbidity 104–106 Delirium classification systems 130, 131 economic impact 128 Germany definition 128–130 epidemiology 131, 132 postoperative prevention 133 prevalence and risk factors with physical illness 128, 133 treatment 132, 133 Dementia, comorbidity, physical illness 44 Depression, see also Suicide classification 100 comorbidity, medical therapies bone marrow transplantation 110 implantable cardiac defibrillator 110 interferon alpha treatment 111 comorbidity, physical illness cancer 107, 108 causal relationships 102, 103 coronary heart disease 104–106 course 101, 102 diagnosis 100, 101 human immunodeficiency virus 109, 110 influence on physical illness course 103, 104 internal medicine wards 36, 37 neurological wards 36, 37 Parkinson’s disease 108, 109 prevalence 98, 99, 101 prospects for study 112 stroke 106, 107 suicide risks 111, 112 surgical wards 37, 38 German Research Network on Depression 137 Nuremberg Alliance against Depression 137, 138

Subject Index

screening instruments, see General Health Questionnaire; Geriatric Depression Scale routine screening benefits 91, 93 treatment, primary care setting 57, 58 Elderly patients, see Geriatric consultationliaison psychiatry, Germany General Health Questionnaire (GHQ) depression routine screening benefits 91, 93 false positives 82 Geriatric Depression Scale comparison 93 primary health screening 78 scoring 77, 82 validity studies 78–81 versions 77, 78 General practioners, see Primary care, psychiatric disorders; Somatoform disorders Geriatric consultation-liaison psychiatry, Germany demographics 67 importance 71 indications and outcome studies 69–71 psychiatric disorder prevalence, hospitals 68, 70 training 66, 67 Geriatric Depression Scale (GDS) depression routine screening benefits 91, 93 General Health Questionnaire comparison 93 limitations 82 validity studies GDS-15 87 GDS-30 85, 86 German-speaking countries 83, 89–91 overview 83, 84 predictive value 88 versions 82 Germany, consultation-liaison psychiatry alcohol-related interventions, see Alcohol abuse delirium interventions, see Delirium

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Germany, consultation-liaison psychiatry (continued) diagnosis-related group reimbursement system 12 geriatric consultation-liaison psychiatry, see Geriatric consultation-liaison psychiatry, Germany historical perspective German Democratic Republic 6 inquiries and improvements 3–5 origins 2, 3 psychiatric department growth, hospitals 6, 7 psychosomatic medicine and psychotherapy 181–188, 192–195 surveys 5 medical-psychiatric units, service delivery 13 medical psychological service delivery 12 physician specialties working with psychiatric patients 177, 178 psychosomatic medicine, see Psychosomatic medicine referral studies 8, 9 training 13, 14 Grief definition 99 traumatic grief 99, 100 Health Assessment Questionnaire (HAQ), analysis of rheumatoid arthritis psychosocial factors, pain 163, 164 Human immunodeficiency virus (HIV), depression comorbidity 109, 110 Illness Attitude Scales, somatoform disorder screening 148 Illness Behavior Questionnaire, somatoform disorder screening 148 Implantable cardiac defibrillator, depression comorbidity 110 Interferon alpha treatment, depression comorbidity 111 Medical care systems, see Physical illness, psychiatric comorbidity

Subject Index

Negative predictive value (NPV), screening instruments 76 Pain, see Chronic pain Parkinson’s disease, depression comorbidity 108, 109 Patients’ Health Questionnaire, somatoform disorder screening 147 Physical illness, psychiatric comorbidity case detection rate 33 depression, see Depression epidemiology 31–33 prevalence rates alcohol abuse and dependence 38–41 benzodiazepine dependence 41, 42 data collection problems 34, 35 delirium, see Delirium dementia 44 depression, see also Depression internal medicine wards 36, 37 neurological wards 36, 37 surgical wards 37, 38 elderly prevalence rates, German hospitals 68 physical disease severity correlation 52 psycho-organic syndromes 42–44 relative risk assessment 45, 46 treatment need assessment 35, 36 primary care and psychiatric disorders, see Primary care, psychiatric disorders prospects for study 47, 48 screening instruments, see Screening instruments theories 45–47 Positive predictive value (PPV), screening instruments 76 Primary care, psychiatric disorders diagnosis 53–55 epidemiology 52, 53 general practioner cooperation with mental health specialists 58–61 physical and psychologic topics, physician-patient encounters 58 prevalence, general population 52 research prospects 61

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screening instruments, see Screening instruments treatment 55–58 Psycho-organic syndromes, comorbidity, physical illness 42–44 Psychosomatic hospitals, somatoform disorder management 146, 155 Psychosomatic medicine definitions, Germany holistic medicine 196 psychological conflicts causing physical dysfunction and disease 197 psychotherapy 197–199 United States definition 199 evaluation, Germany 199–201 historical perspective, Germany 181–183, 192, 193 psychiatry relationship, Germany 194, 195, 199, 200 regulation, Germany 193, 194 service delivery, Germany 7, 10, 11 Psychotherapeutic medicine, historical perspective, Germany 190, 191 Psychotherapy, historical perspective, Germany 184–188 Rheumatoid arthritis, psychosocial factors, pain 163, 164 Screening instruments, see also General Health Questionnaire; Geriatric Depression Scale considerations for use 75, 76 criterion validity 76, 77 epidemiology studies 75 general characteristics 74, 75 somatoform disorders, see Somatoform disorders Screening of Somatoform Symptoms (SOMS), somatoform disorder screening 146, 147 Sleep deprivation effects 174, 175 disorders, psychiatric comorbidity 175, 176 dreaming 174

Subject Index

functions 172 hibernation studies 173 history of study 171 non-rapid eye movement sleep features 172, 174, 175 phases 172 rapid eye movement sleep features 172–174 Somatoform disorders classification 144 definition 144 primary-care-oriented interventions general practitioner consultation and training 148, 149 minimal interventions 149, 151, 152 screening high-risk group identification 146 hypochondriasis 147, 148 instruments Cognitions about Body and Health Questionnaire 148 Illness Attitude Scales 148 Illness Behavior Questionnaire 148 Patients’ Health Questionnaire 147 Screening of Somatoform Symptoms 146, 147 Somatosensory Amplification Scale 148 Symptom Check List SCL-90R 147 somatization disorder 144, 145 symptom epidemiology, Germany 144–146 treatment biofeedback 153, 154 cognitive behavioral therapy 152, 153, 155, 156 consultation-liaison inpatient services 154, 155 psychosomatic hospitals 146, 155 steps 156, 157 Somatosensory Amplification Scale, somatoform disorder screening 148 Stroke, depression comorbidity 106, 107 Suicide chronic pain association 159

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Suicide (continued) depression association 137, 141 German awareness programs, prevention evaluation impact on suicide rates 139–142 instruments 139 sampling 139 statistical analysis 139 overview 137, 138 historical perspective 25–27 risks, depression in physical illness 111, 112 Swiss Society of Consultation-Liaison Psychiatry 29 Switzerland, consultation-liaison psychiatry 25–29

Subject Index

Symptom Check List-90R, pain threshold evaluation 166, 167 Training Austria, consultation-liaison psychiatry 23 general practitioner consultation and training for somatoform disorders 148, 149 geriatric consultation-liaison psychiatry, Germany 66, 67 Germany, consultation-liaison psychiatry 13, 14 Traumatic grief, features 99, 100 Whiplash injury, prospective study of psychosocial factors, pain 165, 166

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