Helmut Hausner

Revisiting the Association of Aggression and Suicidal Behavior in Schizophrenic Inpatients

Our study investigated the association of aggression and suicidal behavior in schizophrenic inpatients. Eight thousand nine hundred one admissions for schizophrenia (1998-2007) to a psychiatric university hospital were included. Schizophrenic suicides (n = 7)/suicide attempters (n = 40) were compared to suicides (n = 30)/suicide attempters (n = 186) with other diagnoses and to schizophrenic non-attempters regarding aggression. Logistic regression analysis was performed to explore risk factors for attempted suicide. Schizophrenic suicides/suicide attempters did not differ from other suicides/suicide attempters or from schizophrenic non-attempters with regard to aggression. Risk of inpatient suicide attempt was increased for patients with attempted suicide at admission, high school graduation, and disorganized subtype. Aggression could not be found to be a predictor of attempted suicide. Aggression seems to have a minor role for suicidal behavior in schizophrenia.

Completed Suicides in 47 Psychiatric Hospitals in Germany - Results from the AGATE-Study

INTRODUCTION There is an ongoing debate about a possibly enhanced risk of suicidal behaviour in some psychiatric patients due to psychopharmacotherapy. Our retrospective study aimed at analyzing the psychopharmacotherapy of 133 inpatient suicides and 133 controls by a matched pair design. METHODS We analyzed all suicides (n = 133) reported in the AGATE study from 1991 to 2008. Besides evaluation of sociodemographic variables and suicide methods, we compared psychopharmacotherapy of suicides with schizophrenia (n = 59) and affective disorders (n = 59) to that of a matched control group. RESULTS Most suicides (n = 102, 76.7%) were judged not to be related to psychopharmacotherapy. In general, more psychopharmacological drugs were prescribed for suicides than for controls. Schizophrenic suicides received more low potency FGAs than their controls. More suicides with affective disorders than controls were treated with NASSAs, SNRIs, and high or low potency FGAs. In contrast to their controls, none of the suicides with affective disorders received lithium. NASSAs, SNRIs, and high or low potency FGAs predicted suicide in regression analysis for inpatients with affective disorders. DISCUSSION Differences in psychopharmacotherapy might mainly result from a recognized risk of suicide or a more severe degree of illness. However, the underrepresentation of lithium in the suicide groups is noticeable.

Risk Profiles for Suicide of Schizophrenic and Depressive Inpatients - A Psychological Autopsy Study

OBJECTIVE This psychological autopsy study investigates suicide risk factors of schizophrenic and depressive inpatients. METHODS 67 potential risk factors of inpatient suicide were identified by means of literature research and caregiver interviews of schizophrenic and depressive suicidents (1995-2004). The medical records of the suicidents (n = 20) were analysed in respect to the identified risk factors and compared to their respective control group of non-suicidents (n = 20) which was matched by diagnosis, gender, age, year / month of admission and ward. Univariate and multivariate statistical analyses were performed. RESULTS In comparison to their respective control group schizophrenic (n = 11) and depressive suicidents (n = 9) differed clearly by their risk profile. Suffering from side effects of medication was found to be a predictor of suicide for schizophrenic inpatients. CONCLUSIONS Psychological autopsy studies are indispensable for the construction of diagnosis-specific risk profiles. Reduction of side effects of medication seems to play a larger role in suicide prevention for schizophrenic inpatients than previously assumed.

Media running amok after school shooting in Winnenden, Germany!

According to the The Sun , ‘a TEEN shooter went on a bloody rampage at a German high school today killing 15 people before shooting himself during a gunfight with cops’. ‘Police said the classrooms were “running with blood”.’ ‘Smiling happily for the camera, these are three of the girls shot dead by a crazed gunman at a German school.’ ‘I was shot 3 times … Chantal slumped dead by the door.’ ‘Click here to see the latest pictures from the scene!’1 In the morning of 11 March, a 17-year-old teenager went on a shooting spree at his former secondary school in Winnenden near Stuttgart, southwest Germany. The amok2 resulted in 15 deaths, followed by the suicide of the perpetrator, who had graduated from this school 1 year before. Beneath the speculation that—given the wrong circumstances—any of us is capable of running amok,3 from a psychiatric point of view, it seems that the dynamics of school shooting are similar to the mechanics that govern …

Acute psychiatric inpatient care: a cross-cultural comparison between two hospitals in Germany and Japan.

Background: Intercultural differences influence acute inpatient psychiatric care systems. Aims: To evaluate characteristics of acute inpatient care in a German and a Japanese hospital. Method: Based on a sample of 465 admissions to the Psychiatric State Hospital Regensburg (BKR) and 91 admissions to the Hirakawa Hospital (HH) over a six-month period in 2008, data from the psychiatric basic documentation system (BADO) were analysed with regard to socio-demographic characteristics, treatment processes and outcome indicators. Results: Schizophrenia and related psychosis was the most common diagnosis in both hospitals. Cases at the BKR were admitted more quickly after onset of the present episode. Global Assessment of Psychosocial Functioning (GAF) ratings at admission were lower at the HH. Most admissions to both hospitals received psychopharmacological treatment, but more at the HH received psychotherapy. Length of stay was significantly longer at the HH (75 days) than at the BKR (28 days). Admissions to the HH were more improved with regard to GAF and clinical global impression (CGI). Conclusions: Acute admissions in Germany provide intensive care with short hospitalization as crisis intervention. For acute admissions in Japan, comprehensive care for severe mental illness precedes emergency admissions and achieves greater improvement with longer hospitalization.

Folgen neu erkannter Arzneimittelrisiken auf die Antipsychotikaverordnung bei Demenzerkrankten

OBJECTIVE We investigated the change of antipsychotic treatment of elderly persons with dementia after several publications indicated an association between use of antipsychotics and cerebrovascular events in this population. METHODS Twice a year, the complete medication, age, diagnosis and gender of all inpatients in 30 German psychiatric sites is collected anonymously in a data base for statistical analysis. RESULTS The treatment changed for the benefit of Quetiapine and Haloperidol. The use of both Risperidone and Olanzapine decreased markedly. CONCLUSION The antipsychotic treatment changed due to critical publication. But, the evidence for the risk profile is still a matter of debate.

„Reden ist Silber, Schweigen ist Gold”: Der Fall Kinski und die ärztliche Schweigepflicht

1War Klaus Kinski ein gefährlicher Psychopath?“ Mit dieser reißerischen Fragestellung trug BILD im Juli 2008 Auszüge aus der psychiatrischen Krankenakte des Patienten Kinski in die Öffent− lichkeit. Aber auch seriöse überregionale Tages− zeitungen ließen sich die Gelegenheit nicht ent− gehen, die psychiatrische Krankengeschichte ei− nes Prominenten zu sezieren. So berichtete bei− spielsweise die Frankfurter Allgemeine Zeitung unter der Überschrift 1Behandelt in Berlin. Klaus Kinski war kein Psychopath“ interessiert über die psychiatrische Behandlung Kinskis in der Witte− nauer Heilstätte, der späteren Karl−Bonhoeffer− Nervenklinik in Reinickendorf (Berlin), die heute vom Vivantes−Konzern betrieben wird. Die Berli− ner Morgenpost sah sich obendrein am 22. Juli 2008 auch zu dem Hinweis veranlasst, dass sich hinter dem jetzt zeitgemäßen Namen der Klinik die frühere 1Städtische Irren− und Idioten−Anstalt zu Baldorff“ verbirgt. Diese umfangreiche Me− dienberichterstattung war möglich geworden, nachdem vom Vivantes−Konzern ± sicherlich in redlicher wissenschaftlicher Absicht ± über 100 000 zeithistorische Krankenakten der Karl− Bonhoeffer−Nervenklinik an das Berliner Landes− archiv übergeben worden waren. Der anfängliche öffentliche Jubel des Landesarchives über den be− deutenden Zuwachs wertvoller historischer Ak− ten verstummte jedoch rasch, als sich zuvorderst nicht die erwarteten Medizinhistoriker, sondern findige Journalisten über den jetzt öffentlich zu− gänglichen Aktenschatz hermachten und gezielt nach prominenten Einzelschicksalen zu fahnden begannen. Für diese öffentliche Neugier an frem− den Krankengeschichten gibt es zahlreiche histo− rische Präzedenzfälle. So werden in der medizin− rechtlichen Fachliteratur als Beispiele für post− mortale Verletzungen der ärztlichen Schweige− pflicht die Veröffentlichung der Krankenakte Bis− marcks durch seinen Leibarzt Schwenninger und die Publikation von Bildern des verstorbenen Papstes Pius XII. durch dessen Leibarzt Galeazzi− Lisi angeführt [1]. Die Hinterbliebenen Klaus Kin− skis haben bereits kurz nach der Veröffentli− chung seiner Krankengeschichte die Legitimität dieses Vorgehens bezweifelt und wehren sich mit rechtlichen Mitteln gegen den Eingriff in die Persönlichkeitsrechte des Verstorbenen. Unabhängig davon wie dieser individuelle Rechtsstreit letztlich ausgeht und ob die Sperr− fristen des Berliner Landesarchivgesetzes die Freigabe der Kinski−Akten im konkreten Einzel− fall erlauben, muss sich die psychiatrische Fach− öffentlichkeit jetzt der Frage stellen, wie zukünf− tig mit dem Archivmaterial unserer Kliniken und Einrichtungen verfahren werden soll. Die ärztli− che Schweigepflicht ist eine der traditionellen Säulen eines vertrauensvollen Arzt−Patienten− Verhältnisses. Die Verschwiegenheit des Arztes wird bereits im Eid des Hippokrates eingefordert und ist noch heute über die Berufsordnungen der Landesärztekammern Teil des ärztlichen Stan− desrechts. Auch der Bundesgesetzgeber hat die über den Tod des Patienten hinausreichende Ärztliche Schweigepflicht in §203 StGB unter Strafandrohung festgeschrieben. Das Bundesver− fassungsgericht räumt der Schweigepflicht des Arztes in einer sehr ausführlich begründeten Ent− scheidung aus dem Jahr 1972 ebenfalls herausra− gendes Gewicht ein: 1Wer sich in ärztliche Be− handlung begibt, muss und darf erwarten, dass al− les, was der Arzt im Rahmen seiner Berufsaus− übung über seine gesundheitliche Verfassung er− fährt, geheim bleibt und nicht zur Kenntnis Unbe− fugter gelangt. Nur so kann zwischen Patient und Arzt jenes Vertrauen entstehen, das zu den Grund− voraussetzungen ärztlichen Wirkens zählt, weil es die Chancen der Heilung vergrößert und damit ± im Ganzen gesehen ± der Aufrechterhaltung einer leistungsfähigen Gesundheitsfürsorge dient“ [2]. Wer sich in psychiatrische Behandlung begibt, der muss also darauf vertrauen können, dass sei− ne intimsten Lebensgeheimnisse dauerhaft ge− wahrt und vor einer neugierigen Öffentlichkeit

Assisted suicide on TV—the public ‘License to Kill’?

n 10 December, a British satellite television channel telecast the documentary ‘Right to Die’, which shows the assisted suicide of 59-year old US citizen Craig Ewert at the Dignitas clinic in Switzerland. Amyotrophic lateral sclerosis patient Ewert’s last 4 days were covered, finally showing him drinking a lethal dose of barbiturates before turning off his lung ventilator with a mouth-operated switch. Beneath being relevant to the ‘Right to Die’ debate and the question of legalization of doctor-assisted dying, 1 another aspect has to be considered urgently. In terms of suicide prevention, an increase of imitative suicides due to the ‘Werther effect’, i.e. the increase of suicide rates after detailed reports about suicide in the media, cannot be excluded. The Werther effect had been proved for the first time after a twice broadcast (1981, 1982) of the six-episode serial ‘Death of a student’ in Germany. 2 The number of railway suicides had increased over extended periods up to 175%, most clearly observable in groups age and sex congruent. 2 An Austrian research group showed that after an increase of subway suicides in Vienna between 1984 and 1987, a decrease of 75% could be achieved by a working group of the Austrian Association for Suicide Prevention who had developed media guidelines and initiated discussion with the media over suicide coverage, culminating in an agreement to refrain from reporting suicides. 3 Based on such studies, it has to be assumed that even for assisted suicides within the framework of euthanasia a Werther effect could be induced. Especially, the extremely detailed report of a seemingly peaceful suicide in the context of a TV documentation may tempt terminally ill people to choose suicide as both an adequate and acceptable way to solve their problem. Evidence for this comes from a Swiss study: after the media had reported extensively about the assisted double suicide of a prominent couple, a considerable rise of suicides—especially among women older than 65 years—occurred for a period of 2 years after the event. 4 Here, the almost enthusiastic kind of reporting might have led to the Werther effect. The German Association of Suicide Prevention recommend in their media guidelines for reporting on suicides to avoid inadvertently romanticizing or idealizing the suicide or labelling the act as a heroic one (e.g. ‘He didn’t want to be a burden for someone’). Also classifying the suicide as comprehensible, inevitable or even positive may encourage others. As well, the detailed description of the suicide method has to be avoided therefore. But with broadcasting ‘suicide documentations’— in this case the assisted suicide of Craig Ewert—the suicide method is apparent to the highest extend. Furthermore, it has to be considered that >90% of suicides are based on mental disorders. 5 According to the German Alliance against Depression, 40–70% of all suicidents suffer from depressive disorders. Assuredly patients who are terminally ill are a special case and their wish to die cannot be labelled with ‘mental disorder’ just by implication. Current studies, however, demonstrate an association of the wish to die or desire to receive euthanasia and psychiatric illness, especially depression, for the latter group, too. Hopelessness and depression were the most relevant predictors of desire for hastened death in a sample of advanced AIDS patients. 6 Similarly, diagnosis of major depression is associated with desire for euthanasia or physician-assisted suicide in palliative cancer patients. 7 Even for patients with amyotrophic lateral sclerosis, willingness to contemplate assisted suicide goes along with elevated levels of depressive symptoms and hopelessness. 8 These results highlight that also in terminally ill subjects the mental status has to be scrutinized thoroughly, otherwise protection of patients whose choices are influenced by depression might fail. Unfortunately, as results from Oregon show, an adequate screening for depression or psychiatric evaluation cannot be guaranteed and current practice may fail to protect these patients. 9,10

[Assisted suicide in prime time: the "right to die"].

1I love you, sweetheart, so much.“ ± mit diesen Worten verabschiedete sich der 59−jährige US− Bürger Craig Ewert in der am 10. Dezember bei Sky Real Lives in Großbritannien ausgestrahlten Fernsehdokumentation 1Recht zu Sterben“ von seiner Frau. Die Dokumentation zeigt den beglei− teten Suizid des an amyotropher Lateralsklerose erkrankten pensionierten Universitätsprofessors in einer Klinik der Schweizer Sterbehilfeorgani− sation 1Dignitas“. Zu guter Letzt nimmt Ewert zur besten Sendezeit um 21 Uhr einen Becher mit Barbituraten zu sich und betätigt mit dem Mund eine Zeitschaltuhr, die 45 Minuten später sein Beatmungsgerät abschaltet.

Aufklärung und Dokumentation in der Psychiatrie

Es gehorte schon immer zu den Aufgaben des Arztes, den Kranken uber die Art seines Leidens, uber die Moglichkeiten und Risiken der Behandlung, uber die Prognose sowie daruber aufzuklaren, was er selbst durch eine Anderung seiner Lebensweise zum Behandlungserfolg beitragen kann. Seit dem Inkrafttreten des Patientenrechtegesetzes (PRG) am 26. Februar 2013 liegen jetzt erstmals die von Fachgesellschaften und Rechtsprechung uber Jahrzehnte entwickelten Aufklarungs- und Dokumentationserfordernisse in einer vom Gesetzgeber kodifizierten Form vor.