Olaf Kuhnigk

A test of concordance between patient and psychiatrist valuations of multiple treatment goals for schizophrenia

Background  While much discussion has been placed on the problem of poor compliance in the treatment of schizophrenia, there has been little discussion on the concordance between patients and psychiatrists, an important contributing factor to patient‐centred care.

Valuation and attainment of treatment goals in schizophrenia: perspectives of patients, relatives, physicians, and payers.

Objective. This study investigated and compared the valuation and perceived attainment of multiple treatment goals in schizophrenia from the perspectives of four different groups of stakeholders. Method. Twenty treatment goals (identified in a qualitative patient-based pre-study) were ranked and rated according to their relevance in standardized interviews. Goal attainment was also rated. A rank correlation was computed to identify congruencies among the stakeholder groups. A hierarchical cluster analysis of the data from the stakeholders groups was also conducted. Results. In this study, 105 outpatients, 160 physicians, 50 relatives, and 30 payers were interviewed. All goals were considered very relevant by all stakeholder groups. “Improved cognitive abilities” was ranked among the top three goals by patients, physicians, and relatives, while “reduced disease-related symptoms” was ranked first by relatives and second by physicians. Payers gave the highest priority to goals that were more likely to affect costs (i.e., ability to resume work, reduced disease-related symptoms, less hospitalization/ need for outpatient visits). Pairwise agreement rates ranged from 38.9% to 63.3%. Rank correlations were found between relatives and patients (r=0.51; P=0.002), relatives and physicians (r=0.43; P=0.008), and payers and patients (r=0.43; P=0.008). The cluster analysis revealed a relevant congruency among patients, relatives, and physicians. Goal attainment was rated lower than goal relevance by all groups, with patients judging attainment the best on average, followed by relatives, physicians, and payers. Reduction in disease-related symptoms was rated as the goal that was best achieved. Conclusion. Discordances among the groups with respect to their valuation of treatment goals should encourage stakeholders to better understand others’ preferences as a prerequisite for improved shared decision making and potentially improved treatment outcomes. (Journal of Psychiatric Practice 2012;18:321–328)

Psychiatric disorders and health service utilization in unemployed youth

AimYouth unemployment is associated with increased levels of anxiety, depression, alcohol abuse, reduced self-esteem and satisfaction with life. Up to date data based on standardized psychiatric diagnostic assessments in adolescent or young adult unemployment is very scarce. To our knowledge, this study has, for the first time, assessed both Axis-I (non-personality) and Axis-II (personality) psychiatric disorders and related constructs in a preselected sample of unemployed individuals.Subjects and methodsSubjects were aged 16–24 and lived in the large urban region of Essen, Germany. They were referred by case managers of the vocational services centre to the on-site psychiatric out-patient unit. SCID-I and II were administered to assess DSM-IV diagnoses. Symptom Checklist 90 R, Beck Depression Inventory and Client Sociodemographic Service Receipt Inventory were used to measure severity of psychopathology and health service utilization.ResultsIn all, 98% of the unemployed young adults suffered from mental disorders. Mood and anxiety disorders were the most common Axis-I disorders (47.9 and 33.4%). Altogether, 58.2% of probands met diagnostic criteria for a personality disorder; a borderline personality disorder accounted for one half of these disorders. Despite a 49% rate of Axis-I and II comorbidity and severe psychopathology, the majority of subjects were untreated and mental health service utilization in general was low. The diagnosis of a personality disorder was related to a 2.7-fold risk of dropping out of job reintegration programmes.ConclusionUnemployed young adults referred for a psychiatric assessment have a high rate of both Axis-I and II disorders, which need to be considered upon planning individual-based vocational rehabilitation programs.

Cinemeducation in psychiatry: a seminar in undergraduate medical education combining a movie, lecture, and patient interview.

ObjectivePsychiatric educators are often faced with students’ negative attitudes toward psychiatry. A new type of seminar has been established in order to enable students to gain a deeper understanding of psychiatric illness.MethodsA “cinemeducation seminar,” combining a movie, a lecture, and a patient interview, has been established as part of the undergraduate curriculum at Hamburg Medical School, where 1,032 students attended 39 cinemeducation seminars between 2005 and 2008. A student evaluation covering different aspects of education took place after each seminar.ResultsThe students valued the combination of a movie and a seminar and found the movie and the additional patient interview useful for accessing the subject of Psychiatry and understanding the underlying psychiatric illnesses shown in the movies.ConclusionFrom the students’ perspective, this type of seminar seems to be helpful for providing an impression of psychiatric illnesses and enabling students to put themselves in the position of a person suffering from these illnesses. Therefore, we judged the cinemeducation seminar to be an appropriate teaching format in undergraduate medical education.

Structural barriers in the context of opiate substitution treatment in Germany - a survey among physicians in primary care

BackgroundOpiate substitution treatment (OST) is the most widely used treatment for opioid dependence in Germany with substantial long-term benefits for the patient and for society. Due to lessened restrictive admission criteria, the number of registered OST patients in Germany has increased continuously in the recent years, whereas the number of physicians providing OST has remained constant. Previous data already indicated a deteriorating situation in the availability or quality of OST delivered and that structural barriers impede physicians in actively providing OST. The present survey among a sample of primary care physicians in Germany aimed to identify and assess potential structural barriers for the provision of health care in the context of OST.MethodsAn anonymous written questionnaire was sent out to a sample of 2,332 physicians across Germany providing OST. Physicians contacted were identified through databases of the Federal State Chambers of Physicians and/or of the Federal Associations of Statutory Health Insurance Physicians. Data obtained were analysed descriptively.ResultsThe response rate was 25,5% and the majority of 596 physicians sampled viewed substantial problems in terms of the regulatory framework of OST care in the German context. Furthermore, financial remuneration, insufficient qualification, as well as inadequate interdisciplinary cooperation in the treatment of comorbidities of opiate substituted patients were regarded as problematic. The number of physicians providing OST in Germany is expected to substantially decrease in the near future.ConclusionDespite less restrictive admission criteria for OST in Germany, the legal regulation framework for OST is still a limiting factor through raising concerns on the provider and consumer side to be unable to adhere to the strict rules. To avoid future shortages in the provision of OST care on the system level in Germany, revisions to the legal framework seem to be necessary. In regards to adequate care for drug use-related infectious diseases and psychiatric comorbidities commonly found in opiate substituted patients, efforts are required to improve professional qualifications of physicians providing OST as well as respective interdisciplinary collaboration.

Psychometric Properties of the Posttraumatic Diagnostic Scale (PDS) in Alcohol-Dependent Patients

BACKGROUND A high prevalence of comorbid posttraumatic stress disorder (PTSD) is found in patients with substance use disorders (SUDs). In the few existing studies, mixed results regarding the psychometric properties of common screening instruments for PTSD have been reported for patients with SUDs. No results are available for the Posttraumatic Diagnostic Scale (PDS), an established self-report measure for PTSD. METHODS The authors assessed 105 patients with alcohol dependence according to DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) (70% male) 2 weeks after their admission to an inpatient detoxification unit. Participants were administered the PDS, the PTSD module of the Structured Clinical Interview for DSM-IV (SCID), as well as measures of depression and anxiety. Patients with other substance use disorders were excluded as were patients reporting no traumatic event. RESULTS Internal consistencies were good to very good for the total scale (.93) and the subscales of the PDS (.82-.91). In our sample, the PDS had a high specificity (.89) but only moderate sensitivity (.57). Diagnostic agreement with the SCID was 83% (.46). The results of a receiver operating characteristic (ROC) analysis suggested that a PDS score of 8 was the optimal cutoff to screen for PTSD. The highest diagnostic agreement between PDS and SCID (89%; .60) was achieved using a cutoff score of 24. CONCLUSIONS These findings confirm previous results suggesting that the psychometric properties of self-report measures of PTSD in patients with SUDs might differ from those in the general population. When the PDS is used in recently detoxified patients with alcohol dependence, it seems advisable to modify the cutoff score of this instrument to improve its sensitivity and diagnostic accuracy.

Sustained change in didactic skills--does teacher training last?

Teacher training programmes are necessary assets in faculty development. Few data exist on their long-term effects on participants’ teaching skills. Our aim was to study participants’ didactic competencies up to four years after attending a newly established faculty development workshop at Hamburg Medical School. Of the 322 participants who attended our teacher training between 2006 and 2009, 313 received a self-assessment and evaluation questionnaire in 2010. This follow-up self-assessment (t2) was compared with their self-assessment of the same didactic competencies before (t0) and directly after (t1) the training. Correlations between participants’ personal reasons to attend the workshop and their assessment of didactic competencies were investigated. Self-assessment was significantly higher at the time of follow-up (t2) for all cohorts compared to the assessment before the workshop (t0). Personal reasons for participation differed greatly between voluntary and mandatory. However, self-assessment of the didactic competencies (t2) was not different between these groups. Participants involved in objective structured clinical examinations (OSCE) rated their competency in this field higher than participants without OSCE involvement. In conclusion, teacher training can be effective in the long run even when participation is mandatory. Competencies seem to be retained best when the content of the training fits participants’ teaching activities.

Effect of Medical Education on Students’ Attitudes Toward Psychiatry and Individuals With Mental Disorders

ObjectiveThis study aimed to explore the effect of medical education on students’ attitudes toward psychiatry and psychiatric patients, and examined the usefulness of a new evaluation tool: the 6-item Psychiatric Experience, Attitudes, and Knowledge (PEAK-6).MethodAuthors studied the attitudes of 116 medical students toward psychiatry and individuals with mental disorders, using two questionnaires before and after a 12-week module of “psychosocial medicine. ” Results of the 30-item questionnaire Attitudes Toward Psychiatry (ATP-30) were compared with the results of PEAK-6.ResultsWith the ATP-30, no change in attitudes toward psychiatry was observed at the end of the module. With the PEAK-6, the item “attitude toward psychiatry” significantly improved. Knowledge of and experience with psychiatry as well as knowledge of and experience with individuals with mental disorders improved significantly; however, attitudes toward individuals with mental disorders did not improve.ConclusionPEAK-6 seems to be a promising tool with regard to nuanced information about psychiatric learning experiences. Participation in a psychiatric module may be associated with a positive effect on students’ knowledge about, experience with, and attitudes toward psychiatry, but not attitudes toward psychiatric patients.

[Internet presence of neurologists, psychiatrists and medical psychotherapists in private practice].

OBJECTIVE The world wide web provides new options to physicians in terms practice marketing, information brokerage, and process optimization. This study explores prevalence and content of homepages of neurologists, psychiatrists and medical psychotherapists in private practice. METHODS Through the legal bodies of physicians in private practice in six northern German states neurologists, psychiatrists and medical psychotherapists were identified. According to a standardized and operationalized criteria catalogue, homepages were rated. RESULTS 1804 physicians were identified, 352 (19.5 %) had operated a homepage. Higher frequencies of homepages found for male physicians (vs. female physicians), practice centres (vs. single practices) and urban practices (vs. rural practices). In average, practices reached 18.8 (± 5.3) of 42 points; contact data and accessibility information were generally available; information as to qualification and specialization was provided more infrequently. Legal specifications were not considered in more than every second homepage, interactive elements like online appointment of follow-up prescription were only rarely offered. CONCLUSIONS Only every fifth neurological or psychiatric practice operates an own homepage, higher competition (urban area) and higher professionalization (practice centres) seem to act as promotors. The legal framework has to be focused, and patient needs should be taken into account.

Homepages of German medical faculties--an overview.

Introduction: The Internet represents a central communication medium for patients and physicians. Some national information is available regarding the design of physicians‘ homepages and patient requirements regarding homepages of physicians in private practice. To date, no data are available for homepages of medical faculties and their users‘ needs. Methods: In 2008 the homepages of the 36 German medical faculties were analyzed according to a catalogue of 128 criteria assigned to five domains which had been developed from the literature. Structure, content and extent were compared. Results: The homepages covered the criteria to a very different extent. The best homepage reached 80%, the worst only 26% of the achievable points. The mean was slightly above 50% . Faculties addressed mainly applicants and students as their target groups, less frequently lecturers and alumni. Conclusion: This study shows differences in quality and quantity of the „teaching section“ on websites of medical faculties. The results allow faculties to use the criteria to adjust their websites with regard to addressing the relevant target groups of students, applicants, lecturers and alumni comprehensively.