Costs of schizophrenia - what we know (not)?

Schizophrenia is regarded as one of the most expensive mental illnesses because of its specific symptoms and characteristics. The care of schizophrenic patients consumed approx. 2 % of the total German health care expenditures in 1994, according to the scarce data provided by routine German health reporting. Despite this enormous impact, health-economical research in schizophrenia in Germany is widely neglected. While few empirical studies on direct cost of care for schizophrenic patients suggest that adequate comprehensive community care in Germany during the mid-nineties was about DM 27 000 to DM 28 000 per patient and year, there is a serious lackage of cost-effectiveness-studies, relating cost of care to outcome. Thus, the most basic data for any health care planning in schizophrenia is missing. This paper reviews the studies on cost of schizophrenia in Germany. It identifies the most serious knowledge gaps and describes the obstacles for an adequate research in this field.     

How can we help masochistic inpatients not to sabotage psychiatric treatment before it even starts?

Upon admission for psychiatric hospitalization, some patients present the treating staff with alienating or antagonistic behaviors that threaten to sabotage the treatment before it even begins. These may include passive-aggressive behavior, withdrawal and isolation, contention against unit rules, protestations about the futility of treatment efforts, or oppositional behavior. Diagnostically, many such patients fall into the category of narcissistic-masochistic personality disorder, and their alienating behavior contrasts with their underlying sense of neediness. An important element in treating these patients, in addition to processing countertransferences, is to reframe the behaviors early on as being a self-defeating defense. Reframing in this way can help to defuse the emotional intensity around alienating or antagonistic behavior, and to focus the treatment upon the issue that is most damaging to the patient, namely the tendency toward self-defeat.     

The premature fetus: not as defenseless as we thought, but still paradoxically vulnerable?

Traditionally, it has been believed that the cardiovascular and hormonal responses to asphyxia in preterm fetuses are immature, and this immaturity contributes to their apparent vulnerability to neural injury. However, these data were derived from studies using relatively mild insults, which did not allow for the greater cardiac glycogen reserves and anaerobic capacity of the brain near midgestation. Here, we review the maturation of the cardiovascular and cerebrovascular and cerebral responses to asphyxia in experimental animals and how these relate to the apparent vulnerability of the human premature brain. Most such investigations have been performed in the chronically instrumental fetal sheep. Recent studies have demonstrated that the premature fetus has highly adaptive and relatively mature responses to asphyxia, and that in absolute terms the preterm brain is very resistant to asphyxial injury. These data suggest that the premature fetus is able to survive much more prolonged periods of asphyxia than the near-term fetus, but that, paradoxically, such survival is associated with exposure to prolonged periods of hypotension and hypoperfusion and consequently greater risk of severe neural damage.     

What do we (not) know about the management of blood pressure in acute stroke?

Although it is indisputable that high blood pressure should be treated to prevent a first or a recurrent stroke, the management of high blood pressure in the first hours and days after stroke remains controversial. There is no high-quality evidence from randomized controlled trials to guide treatment in the 80% of patients who have elevated blood pressure during the first days after stroke. Theoretically, there are pros and cons for manipulating blood pressure after onset of stroke. Most treatment guidelines suggest leaving blood pressure untouched based on pathophysiologic principles. Post-hoc analyses from randomized trials, however, suggest that elevated blood pressure is associated with recurrent stroke and higher mortality, even after adjustment for potential confounders. On the other hand, preliminary studies have suggested that voluntarily increasing blood pressure might be beneficial in a selected subgroup of patients. In this overview, we present a summary of recent studies on this topic.     

Circadian effects on stroke outcome – Did we not wake up in time for neuroprotection?

The occurrence of stroke in humans peaks in the morning. A recent study revealed that time of day mitigates the therapeutic impact of neuroprotective paradigms. These findings might not only explain the previous failure of translation of neuroprotective therapies but inspire new paradigms in stroke chronopathophysiology research. Taking chronotype into account may complement the many factors that influence efficacy of experimental therapies in stroke.     

Recovery-based practice: do we know what we mean or mean what we know?

The concept of recovery is now widely promoted as the guiding principle for the provision of mental health services in Australia and overseas. While there is increasing pressure on service providers to ensure that services are recovery oriented, the way in which recovery-based practice is operationalized at the coalface presents a number of challenges. These are discussed in the context of five key questions that address (i) the appropriateness of recovery as a focus for service delivery, (ii) the distinction between recovery as a process and an outcome, (iii) the assessment of recovery initiatives, (iv) the alignment of recovery with current service delivery models, and (v) the risks associated with recovery-based practice. It is argued that these questions provide a framework for a debate that must extend beyond patients and providers of mental health services to the broader public, whose attitudes will ultimately determine the possibilities and limits of recovery-oriented practice.     

Measuring anxiety: are we getting what we need?

This article discusses several studies describing either the reevaluation and validation of existing scales for measuring anxiety (i.e., the Spielberger Trait Anxiety Inventory, the Liebowitz Social Anxiety Scale for adults and for children and adolescents, the Clinical Global Impression Scale, the Self-Rating Inventory for Posttraumatic Stress Disorder, and the Yale-Brown Obsessive Compulsive Scale Symptom Checklist), or the development and validation of new scales (i.e., the Social Thoughts and Beliefs Scale, the Social Phobia Diagnostic Questionnaire, the Aberdeen Trauma Screening Index and the Health Anxiety Inventory). As an increasing number of rating scales have been developed over the past several years, a critical review of their usefulness and psychometric properties seems pertinent and prudent.     

Have we met?

Over 160 adults attending day workshops for people with mental handicap were interviewed regarding the persons they had talked to in the community and who was usually with them on these occasions. The number of community contacts was heartening, with most occurring around the neighbourhood, fewer in the city, and least of all at home. However, there were only three groups of people with whom the majority of respondents had recent contact – local shopkeepers, bus conductors, and chemists. In general, community contacts were rarely in the company of friends – cinema-going was the only exception. Usually they were with their family, or alone. Results from surveys of this type can help to establish the effectiveness of our social education programmes, can challenge parental assumptions about their son or daughter's abilities, and can identify groups within the community who would best benefit from guidance on how to interact with a person who is mentally handicapped.