Manfred Wolfersdorf

Phosphatidylethanol as a sensitive and specific biomarker: comparison with gamma-glutamyl transpeptidase, mean corpuscular volume and carbohydrate-deficient transferrin.

Phosphatidylethanol (PEth), a direct ethanol metabolite, is detectable in blood for more than 2 weeks after sustained ethanol intake. Our aim was to assess the usefulness of PEth [comparing sensitivity, specificity and the area under the curve (AUC)] as compared with carbohydrate‐deficient transferrin (CDT), gamma‐glutamyl transpeptidase (GGT) and mean corpuscular volume (MCV), calculating the results from sober patients against those from alcohol‐dependent patients during withdrawal. Fifty‐six alcohol‐dependent patients (ICD‐10 F 10.25) in detoxification, age 43 years, GGT 81 U/l, MCV 96.4 fl, %CDT 4.2, 1400 g ethanol intake in the last 7 days (median), were included in the study. Over the time of 1 year, 52 samples from 35 sober forensic psychiatric addicted in‐patients [age 34 years, GGT 16 U/l, MCV 91 fl, CDT 0.5 (median)] in a closed ward were drawn and used for comparison . PEth was measured in heparinized whole blood with a high‐performance liquid chromatography method. GGT, MCV and %CDT were measured using routine methods. A receiver operating characteristic curve analysis was carried out, with ‘current drinking status’ (sober/drinking) as the state variable and PEth, MCV, GGT and CDT as test variables. The resulting AUC was 0.974 (P < 0.0001, confidence interval 0.932–1.016) for PEth. At a cut‐off of 0.36 µmol/l, the sensitivity was 94.5% and specificity 100%. The AUC for CDT, GGT and MCV were 0.931, 0.894 and 0.883, respectively. A significant Spearman’s rank correlation was found between PEth and GGT (r = 0.739), CDT (r = 0.643), MVC (r = 0.639) and grams of ethanol consumed in the last 7 days (r = 0.802). Our data suggest that PEth has potential to be a sensitive and specific biomarker, having been found in previous studies to indicate longer lasting intake of higher amounts of alcohol.

Phosphatidylethanol: normalization during detoxification, gender aspects and correlation with other biomarkers and self-reports.

Phosphatidylethanol (PEth) is a direct ethanol metabolite, and has recently attracted attention as biomarker of ethanol intake. The aims of the current study are: (1) to characterize the normalization time of PEth in larger samples than previously conducted; (2) to elucidate potential gender differences; and (3) to report the correlation of PEth with other biomarkers and self‐reported alcohol consumption. Fifty‐seven alcohol‐dependent patients (ICD 10 F 10.25; 9 females, 48 males) entering medical detoxification at three study sites were enrolled. The study sample was comprised of 48 males and 9 females, with mean age 43.5. Mean gamma glutamyl transpeptidase (GGT) was 209.61 U/l, average mean corpuscular volume (MCV) was 97.35 fl, mean carbohydrate deficient transferrin (%CDT) was 8.68, and mean total ethanol intake in the last 7 days was 1653 g. PEth was measured in heparinized whole blood with a high‐pressure liquid chromatography method, while GGT, MCV and %CDT were measured using routine methods. PEth levels at day 1 of detoxification ranged between 0.63 and 26.95 µmol/l (6.22 mean, 4.70 median, SD 4.97). There were no false negatives at day 1. Sensitivities for the other biomarkers were 40.4% for MCV, 73.1% for GGT and 69.2% for %CDT, respectively. No gender differences were found for PEth levels at any time point. Our data suggest that PEth is (1) a suitable intermediate term marker of ethanol intake in both sexes; and (2) sensitivity is extraordinary high in alcohol dependent patients. The results add further evidence to the data that suggest that PEth has potential as a candidate for a sensitive and specific biomarker, which reflects longer‐lasting intake of higher amounts of alcohol and seemingly has the above mentioned certain advantages over traditional biomarkers.

[Psychiatric-psychotherapeutic inpatient treatment for depression. Process and outcome quality based on a model project in Baden-Wurttemberg].

ZusammenfassungIn den Jahren 1998–2000 wurde in insgesamt 24 psychiatrisch-psychotherapeutischen Fachkliniken Baden-Württembergs ein externes Qualitätssicherungsprogramm zur Diagnostik und Behandlung depressiver Erkrankungen durchgeführt. Anhand von Indikatoren der Prozess- und Ergebnisqualität wurde die stationäre Behandlung von über 3000 depressiven Patienten bei Aufnahme und Entlassung dokumentiert. Zentrale Fragen sind Behandlungsmaßnahmen, -dauer, -erfolg sowie Patientenzufriedenheit und ihre Wechselwirkungen. Zu den wichtigsten Ergebnissen zählen die hohe Zufriedenheit der Patienten mit der Behandlung und die hohen Prä-post-Effektstärken der stationären Depressionsbehandlung.AbstractDuring 1998–2000 a quality assurance program for diagnosis and treatment of depression was conducted in 24 hospitals for psychiatry and psychotherapy in Baden-Württemberg (southern Germany). Process and outcome quality of 3,000 depressive patients was documented at admission and discharge. The article focuses on therapeutic measures, duration, outcome, patient satisfaction, and their interactions. The results show that the patients’ satisfaction with the care received is very high and the pre-post effect sizes of inpatient treatment for depression are high.

Stationäre psychiatrisch-psychotherapeutische Depressionsbehandlung

ZusammenfassungIn den Jahren 1998–2000 wurde in insgesamt 24 psychiatrisch-psychotherapeutischen Fachkliniken Baden-Württembergs ein externes Qualitätssicherungsprogramm zur Diagnostik und Behandlung depressiver Erkrankungen durchgeführt. Anhand von Indikatoren der Prozess- und Ergebnisqualität wurde die stationäre Behandlung von über 3000 depressiven Patienten bei Aufnahme und Entlassung dokumentiert. Zentrale Fragen sind Behandlungsmaßnahmen, -dauer, -erfolg sowie Patientenzufriedenheit und ihre Wechselwirkungen. Zu den wichtigsten Ergebnissen zählen die hohe Zufriedenheit der Patienten mit der Behandlung und die hohen Prä-post-Effektstärken der stationären Depressionsbehandlung.AbstractDuring 1998–2000 a quality assurance program for diagnosis and treatment of depression was conducted in 24 hospitals for psychiatry and psychotherapy in Baden-Württemberg (southern Germany). Process and outcome quality of 3,000 depressive patients was documented at admission and discharge. The article focuses on therapeutic measures, duration, outcome, patient satisfaction, and their interactions. The results show that the patients’ satisfaction with the care received is very high and the pre-post effect sizes of inpatient treatment for depression are high.

Are hospital suicides on the increase? A survey of reports on hospital suicides in the psychiatric literature of the 19th and 20th century.

SummaryThe first part of our paper provides an overview of literature on clinic suicides in regard to suicide numbers and rates. The main focus of attention is on articles from the last 30 years. The second part examines the hypothesis that there exists a linear increase in both the number of admission and the absolute number of suicides, and thus a connection between increases in admissions and discharges and in suicides. Using selected examples, we found less where there was a direct connection between patient turnover and the number of suicides (with the suicide rate remaining constant), and others in which suicide rates also increased, seeming to indicate the influence of other factors. A list of selected studies from the psychiatric literature of the 19th century suggests that clinic suicide is one of the oldest problems known to psychiatry and that suicide rates calculated from 19th century data are by and large comparable to those of today. Clinic suicide would thus appear to be a problem of psychiatry in general and not only one of modern psychiatry or of modern methods of treatment.

Delusional depression and suicide

ABSTRACT: After a short survey of the relevant literature, the authors discuss the significance of delusional depression symptoms for suicidality, whereby they do not regard such symptoms alone as a sufficient condition for classifying a delusional patient as suicidal. In a comparison of delusional depressed patients with a non‐delusional control group (matched pairs), the former were adjudged to be significantly less suicidal than the control group and did not differ from the control group in regard to suicide frequency.

First Experiences in Combination Therapy Using Olanzapine with SSRIs (Citalopram, Paroxetine) in Delusional Depression

In an open prospective study, 26 patients with delusional depression (mood-congruent psychotic features: DSM-IV 296.4) were treated over 5 weeks with a combination of SSRI (citalopram, n = 22, or paroxetine, n = 4) and the neuroleptic olanzapine. The course of therapy was evaluated with the Hamilton depression scale (HAMD). Not only the total HAMD score, but also the subscores for affectivity and delusional symptoms decreased significantly. After the end of the 5-week combination therapy, 18 out of 26 patients (69%) could be discharged as responders to outpatient treatment. The course of treatment was characterized by excellent tolerance.

STATIONARE BEHANDLUNG DEPRESSIVER PATIENTEN : KONZEPTUELLE UBERLEGUNGEN UND ERGEBNISSE EINES PILOTPROJEKTS ZUR QUALITATSSICHERUNG IN BADEN-WURTTEMBERG

ZusammenfassungQualitätssicherungsmaßnahmen werden in den nächsten Jahren in der Psychiatrie zunehmend an Bedeutung gewinnen. Gegenüber anderen medizinischen Teildisziplinen zeichnen sie sich im Bereich der Psychiatrie durch eine Reihe von Besonderheiten aus und zwar sowohl im Hinblick auf die Struktur-, Prozeß- als auch Ergebnisqualität. Gleiches gilt auch für die Durchführung von Qualitätssicherungsprojekten aufgrund von methodischen Überlegungen. Diese speziellen konzeptuellen sowie methodischen Aspekte wurden versucht, bei der Durchführung eines Pilotprojekts zur stationären Behandlung depressiver Patienten zu berücksichtigen. Über Erfahrungen, Ergebnisse sowie weiterführende Überlegungen wird berichtet.SummaryQuality-assurance activities will become more important in psychiatry during the next few years. In relation to other medical disciplines, some special aspects concerning structure, process and outcome quality as well as practical realization and methodologic aspects must be considered. These specific issues were the focus of a study dealing with the treatment of depressed inpatients. The experiences and results as well as considerations concerning future quality-assurance projects are discussed.

Pharmacotherapy of Delusional Depression: Experience with Combinations of Antidepressants with the Neuroleptics Zotepine and Haloperidol

The combination of an antidepressant with a neuroleptic is standard pharmacotherapy for delusional depression today. The neuroleptics used are rarely specified: occasionally haloperidol or perphenazine are mentioned. In two different open-treatment studies, consecutively admitted delusional depressed inpatients received a butyrophenone [haloperidol, bromperidol, approximately 10 mg/day (n = 16)] or zotepine [150-200 mg/day (n = 15)] as a neuroleptic in combination with a tri- or tetracyclic antidepressant (amitriptyline, maprotiline, 150 mg/day). There was a significant improvement in both groups in the sum score of the Hamilton depression scale (24-item version), in a subscore of so-called delusional items (items 2, 17, 19, 20, 23, and 24 together), in the subscore of remaining items and also in most single items such as mood, inhibition, agitation, feelings of guilt or hopelessness.

Suicidal behaviour and electrodermal activity in depressive inpatients

Within the context of a habituation experiment, the electrodermal activity (EDA) of suicidal depressed patients was measured. Twenty‐four patients had a suicide attempt in their most recent history; these attempts were divided into attempts with violent or nonviolent methods. All the patients who had used a violent method habituated quickly, as was the case for 4 of 5 patients who committed suicide in the year following the experiment. Just as many patients who used nonviolent methods habituated quickly or slowly. There was no indication that age, sex or medication had any influence. For 18 of these 24 patients, comparable groups, in terms of age and sex distribution, were formed containing either nonsuicidal depressed patients or patients with suicidal thoughts. No differences between groups concerning any of the EDA variables could be found. In accordance with these results, EDA cannot be considered to be a valid predictor for suicide‐proneness. The relations between violent suicide attempts and nonreactivity should, however, be further examined and the group of non‐reactive patients in EDA should be treated as a risk group for clinical reasons.