P-11-01

The role of cognitive-behavioural intervention in improving psychophysical health in hemodialysis patients

K. Bargiel-Matusiewicz, K. Kucia, A. Trzcieniecka-Green, A. Trzcieniecka-Green. Medical University of Silesia Dept. of Psychology, Katowice, Poland

Objective: The great progress that has been made in application of dialyses lets the patients with chronic kidney disorders live in satisfactory somatic state for many years. The patients' quality of life becomes thus more and more often raised question. The psychological problems accompanying this form of treatment have many aspects that are worth paying attention. Depression symptoms are significant, early indication of bad prognosis as to survival of patients treated with dialyses. The aime of psychological intervention of behavioural and cognitive nature is improving psychophysical health in hemodialysis patients.

Methods: The prepared therapeutic programme includes a series of behaviouraI - cognitive interventions. Evaluation of the project has been made on the basis of application the following research tools: The Questionnaire of Illness Situation Cognitive Appraisal, The Questionnaire of Emotional State and the Questionnaire of Following Doctor's Instructions.

Results: In order to appraise the results the method of path analysis has been used (Level of statistical significance 0.001). It has shown improvement of emotional state, increase of the level of self-acceptance, improvement in following doctor's instructions, increase of the feeling of freedom, independance, concentration upon possible form of activity, forming constructive ways of coping with stress as well as to improvement of social contacts.

Conclusion: The presented intervention makes it possible for the patients to perceive the areas in which they may realize their plans, achieve successes and fullfillment. The applied relaxation technique also helps decreasing psychophysical tension and thus mood improvement.

P-11-02

Improvement of psychosocial adjustment to HIV-I infection through a cognitive-behavioral oriented group psychotherapy program

J. Blanch, A. Rousaud, M. Hautzinger, E. Martinez, J. M. Peri, J. De Pablo, J. M. Gatetl. Institute of Neurosciences Psychiatly, Barcelona, Spain

Objective: Given that recent pharmacological advances, particularly the advent of highly active antiretroviral therapy (HAART), have increased life expectancies for persons living with HIV, the quality of life and psychosocial functioning of these patients have become important concerns. The present study sought to evaluate the efficacy of a structured cognitive-behavioral group therapy program in improving psychosocial adjustment to HIVinfection, and to identify baseline variables predictive of greater improvement.

Methods: The outcome of 47 completing patients was analysed, comparing the measures between T1 (one month before beginning of the therapy), and T2 (during the first session), and between T2 and T3 (during the last session) using the Wilcoxon matched-pairs signed-ranks test for each dimension of the PAIS. The therapy consisted of 16 weekly two-hour sessions following a structured time-limited cognitive-behavioral group psychotherapy program.

Results: During the intervention time (between T2 and T3) an improvement was observed in health care orientation (p = 0.006), vocational environment (p = 0.039), domestic environment (I0 = 0.016), sexual relations (p < 0.001), extended family relationships (p = 0.037), social environment (p < 0.001), and total Psychosocial Adjustment to Illness Scale (PAIS) score (p < 0.001). There were no changes during baseline (between T1 and T2) in any of the PAIS subscales, or in the total PAIS score. Sexual route of transmission was independently associated with an improvement in health care orientation (b = 2.525, p = 0.009). Time since HIV diagnosis (b = 0.022, p = 0.016) and being in employment (b = 2.548, p = 0.012) were independently associated with an improvement in adjustment to vocational environment. Homosexual patients showed a poorer improvement in adjusting to family relations after the intervention Co = - 2.548, p = 0.049). Finally, a lower CD4 count (b = -0.005, p = 0.002) and being in employment (b = 3.054, p = 0.024) were independently associated with an improvement in adjustment to social environment.

Conclusion: Our psychotherapy program for HIV infected patients improved psychosocial functioning in a heterogeneous sample of HIV-1 infected patients referred to a consultation-liaison psychiatry unit.

P-11-03

Does Efavirenz (EFV) produce neuropsychological disturbances in HIV-1 infected patients?

J. Blanch, T. Raspall, J. L. Blanco, J. Mallolas, M. Sarasa, T. Boget, M. Salamero, J. M. GatelI. Institute of Neurosciences Psychiatry, Barcelona, Spain

Objective: Neuropsiquiatric disturbances is a well known side effect related with EFV. The objective of this study is to assess whether the initiation of an EFV containing regimen produces neuropsychological disturbances in HIV-1 infected patients and his potential correlation with EFV plasma levels.

Methods: Twenty seven consecutive HIV-1 infected outpatients in whom EFV was prescribed (EFV group) and 9 HIV-1 infected outpatients who started antiretroviral therapy (ART) not included EFV (control group), were underwent a neuropsychological assessment. Comprehensive neuropsychological battery and a standardized questionnaire of anxiety and depression (HAD) were performed in all patients at baseline and at 2, 4, and 12 weeks. Neuropsychiatric side effects (NPSE) and laboratory measures. EFV plasma levels were performed in patients of EFV group al weeks 2,4 and 12.

Results: No differences were obtained in any of the cognitive domains assessed between EFV group and control group. Within EFV patients, a trend towards significance were obtained between negative affect and neuropsychiatric side effects. Patients who reported NPSE tend to feel more anxious symptoms than patients who did not report NPSE. EFV plasma levels did not correlate with the performance in any of the neuropsychological test.

Conclusion: We could not find evidence of neuropsychological disturbances neither impairment on the neuropsychological functions assessed when using a standardized neuropsychological battery associated with the initiation of EFV containing regimen.

P-11-04

Attention and working memory deficits in systemic lupus erythematosus patients with mild depressive and axiety symptoms

K. Krzysztof, A. Klasik, I. Krupka-Matuszczyk, P. Kotyla, E. J. Kucharz, B. Sliwinska-Kotyla. Medical University of Silesia Psychiatl3J and Psychotherapy, Katowice, Poland

Objective: In Systemic Lupus Erythematosus (SLE) the involvement of the central nervous system may worsen the outcome of the disease. The American College of Rheumatology (ACR) defined in 1999 criteria for 19 neuropsychiatric syndromes in SLE including cognitive dysfunction, which seems to be a relatively stable feature of the disease.

Methods: Eleven female patients aged 19 to 37 with SLE underwent the investigation.The Vienna Test System was applied to measure the cognitive functioning. All subjects were also diagnosed with Stait and Trait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI).

Results: The scores of the BDI were 5 to 25 which excluded a comorbid depression. State and trait anxiety as measured with STAI was only mild or moderate. The analysis of the scores in the Vienna Test System showed presence of different cognitive deficits in 27 to 45 % of the patients.

Conclusion: The results show considerable deficits in attention and working memory mechanisms in examined subjects. As in the beginning of the study the influence of anxiety and depression was excluded as a potential factor affecting the results, we can assume that observed cognitive deficits in SLE are functional and not reactive.

P-11-05

The problem of anosognosia in acute period of brain concussion

I. V. Dorovskikh. Moscow Research hzstitute of Psychiatry, Moskau, Russia

Objective: Objective and methods: With the purpose of a clinical estimation of anosognosia, arising in the acute period of brain concussion we investigated 327 patients using clinical psychopathological method.

Results: The given syndrome was marked at 11% of patients. It was expressed in denying own unhealthy condition or in decreasing criticism according to the absence of adequate own representations of illness. It was possible to ascertain misunderstanding of illness corresponding to the superficial relation towards recommendations of medical staff about bed rest, taking drugs and necessity of examination. It was combined with insistence on the fastest discharge although objectively registered inequality still remained. Rather expressed disruption of memory, somatovegetative and neurologic disturbances remained without proper subjective evaluation. Though, actually, damage almost to any area of brain may lead to denying or underestimation of cognitive disturbances, it is reckoned, that especially bright syndrome of neglect is frequently correlated with trauma of parietal area/Taylor M., 1999/.

Conclusion: Thus, anosognosia expressed in decreasing of critical abilities of patient, adequate self-estimation and estimation of suffered trauma, changes in behaviour reflecting underestimation of severity of trauma and manifestations of a disease, in the issue drives to objective decline of its condition and impugnes the prognosis for full recovery.

P-11-06

The burden of day care for patients in psychosomatic rehabilitation

M. Linden. Charite Berlin Rehab. Centre Seehof, Teltow/Berlin, Germany

Objective: Day care clinics are an important alternative to hospitals in the care for patients with mental disorders. One indication for hospitalization is to take patients away from burdening and distressing home environment. The question is, when patients should or can be treated under which condition and whether day care hospitalization can help to reduce burdens from the patient.

Methods: Patients who were treated for mental disorders in day care and full hospitalization were compared in respect to how they experienced their treatment.

Results: When compared to full hospitalization patients, day care patients felt more burdened, had less opportunity to relax, and more distress at home. Their treatment outcome was significantly worse.

Conclusion: Day care puts additional burdens and stress on patients. Special requirements are needed to prevent such negative effects.

P-11-07

Impact of expected and unexpected cardiac events on patients coping strategies

J. Grkovic, T. Franciskovic, I. Roncevic. Clinical Hospital Cent. Rijeka Dept. of Psychiatry , Rijeka, Croatia

Objectives: The aim of the study was to establish whether the type of the stressor - an unexpected, sudden cardiac event (heart attack) or the expected intervention (open heart surgery) influenced and/or distinguish coping styles, psychic status and recovery of cardiac patients.

Methods: Two groups of cardiac patients, first examined in coronary unit after myocardial infarction (N1=75), and second group examined in cardiosurgery unit after having open heart surgery (N2=75), were given psychometric instruments to measure their stress perception (Stress Intensity Scale), anxiety (State and Trait Anxiety Inventory), depression (Beck Depression Inventory) and coping styles (COPE) during the first week of their recovery; SIPPS package of statistical analysis was applied.

Results: Preliminary results show that older age (65 years and more) was significantly associated with poorer coping skills and higher scores on stress, depression and anxiety scales. Also, the difference in coping skills and psychic status between two groups based on type of stressful event was not significantly supported.

Conclusions: Older age could be the predictor for poorer coping skills in cardiac patients. Findings suggest that characteristics of the patients affected the recovery of the patient more than characteristics of the stressful event.

P-11-08

Cerebrolysin in the combined treatment of abuse headache

T. Larikova, N. Starikova. State Medical Academy, Perm, Russia

Objective: To study Cerebrolysin as an additional drug in the therapy of abuse headache (AHA).

Methods: 37 patients satisfying the IHS criteria for AHA were investigated in an open trial dta-ing the withdrawal therapy. 25 of them received 10,0 ml of Cerebrolysin daily (20 intravenous infusions) and amitriptyline 25 mg twice a day. The group of comparison consisted of 12 age-and sex-matched patients with the headache of the same type treated with amitriptyline only. Methods included Spilberger's inventory, Beck's depression inventory, 10-point Visual analogous scale, Goetheborg quality of life inventory, Autonomous impairment questionary, Attention Test Score, Headache index.

Results: Results: In both groups significant clinical improvement was achieved: frequency and duration of headaches reduced as well as the analgesic intake. Cerebrolysin group showed the additional reduction of anxiety and improvement of attention. No side effects of Cerebrolysin were marked. Cerebrolysin demonstrated safety and efficiency in the combined treatment of AHA, minimizing side effects of amitriptiline and improving patients' quality of life.

P-11-09

The origin of language and mind

R. Kalb. University Erlangen-Nuremberg Psychiatry, Erlangen, Germany

Objective: Historical linguistics has asked the question whether there existed a common archaic language in early human history. This hypothetical language has been called the human protolanguage or protoworld. There have been many attempts to reconstruct this protolanguage by comparing the words of different modern languages and constructing language families.

Methods: Hypotheses about the human protolanguage were implemented in a computer program. This program was used to propose the hypothetical original meaning of several thousand English, African, and Australian words in the protolanguage. The hypothetical reconstruction was validated by comparing the original meaning with the modern meaning of each word.

Results: The program processed more than 6000 English words and several thousand words from African and Australian languages. It proposed a hypothetical original meaning in the protolanguage for each of these modem word

Conclusion: The reconstruction of the protolanguage would give us new evidence about the evolution of the human mind. Modern words would be the oldest documents of mankind and reading their original meaning would tell us something about the thinking of their inventors.

P-11-10

Make it easy, make it simple, make it fun - Which psychiatric information service do primary care physicians want?

D. F. Zullino, Y. Khazaal, M. Preisig, E. Frrsard, M. Stankovic, F. Borgeat. University Lausanne Psychiatry, Prilly-Lausanne. Switzerland

Objective: Effective, safe and economical use of psychiatric treatment has become a major challenge for primary care physicians, not least because of the ever-increasing availability of a wide range of pharmaceutical products. Intending to launch a psychiatric information service for primary care physicians of the Lausanne area in Switzerland, a survey was done in order to assess their specific needs and preferences.

Methods: From 300 questionnaires sent to local primary care physicians, 110 were received back within 6 weeks. Items of the questionnaire were: specialty; personal preferences for consultations by phone or e-mail; priorities with regard to simplicity and rapidity, gratuity, written reports and possibility to sent the patient for personal consultations; need for advice in different domains (drug treatment, addictions, legal aspects etc) and attitude with regard to shared responsibility.

Results: Consultations by phone were preferred by the interviewed physicians to those by e-mail (p<0.001). They pointed to rapidity (mean rank 1.8 ± 1.0) and simplicity (1.9 ± 1.1) as the main priorities, and indicated a personal relationship to the expert as a further quality criterion (mean rank 3.7 ± 1.7). Gratuity (4.6 ± 2.0) and a written report (5.7 ± 1.4), on the other hand, were of much less concern for the respondents. The most important domains for which the physicians would search advice were: Pharmacotherapy (mean rank 1.6 ± 1.3), diagnosis (3.7 ± 2.0) and information on the institutional care network (3.9 ± 2.0).

Conclusion: The survey revealed an important need for a simple and easy accessible information service, and the importance of personal commitment of the experts, which should preferably be experienced psychiatrists with adequate skills in pharmacotherapy and familiar with the local care networks.

P-11-11

Psychologists and social workers self-perception of DSM-IV psychopathology in Israel

T. Nachshoni, R. Strous. Beet Yaakov Hospital Department C, Beer Yaakov, Israel

Objective: The objective of this study was to explore the subjective perception of mental disorder amonst psychologists and social workers.

Methods: Psychologists and social workers in a number of sites and settings were asked to complete a self-evaluation questionnaire in which they were asked to self diagnose the presence of DSM-IV disorders.

Results: The sample(60% response rate)included 128 subjects (63 psychologists and 65 social workers) with a sex segregation of 40 males and 85 females (3 missing), between the ages of 25 and 57.91.25% reported Axis I traits, with the 3 most frequent traits being mood disorder, eating disorder and somatoform disorder. Females reported higher levels of mood, eating problems and sleep problems compared to males. Psychologists reported higher levels of mood disorders compared to social workers, with social workers reporting higher levels of psychotic disorder (at sub threshold levels). Axis II traits were indicated by 73.4% of the subjects, the 3 most frequent conditions being narcissistic, avoidant and obsessive compulsive personality traits. Males reported higher levels of obsessive compulsive and avoidant personality traits compared to females. Psychologists reported higher level of Axis II triats, compared to social workers, especially of paranoid, narcissistic and avoidant traits.

Conclusion: Manifestations of sub threshold psychiatric conditions, as self diagnosed by psychologists and social workers, was prominently reported. Our findings may be relevant to encouraging the implementation of staff support, occuptaional support groups and treatment availability options for the mental health care professions.

P-11-12

The schedules for clinical assessment in neuropsychiatry (SCAN); version 2.1 experiences in using computerised diagnostic algorithms: Concordance between computerised IShell- and research diagnoses

L. Jurjanz, M. Schützwohl, T. Kallert. Uniklinik Carl Gustav Carus Klinik für Psychiatrie, Dresden, Germany

Objective: The Schedules for Clinical Assessment in Neuropsychiatry is a comprehensive set of instruments developed by the World Health Organization. The SCAN 2.1 core is a semistructured clinical interview (PSE-10.2) used to assess, measure and classifiy psychopathology and behaviour associated with the major psychiatric disorders in adult life. To yield diagnoses according to the ICD-10 and DSM-IV, data gathered can be processed using the diagnostic computer program IShell for SCAN 2.1. The poster presents analysis on the diagnostic agreement between computerised IShell-diagnoses and researchers' diagnoses.

Methods: Within a randomised controlled trial comparing psychiatric day-hospital treatment to inpatient treatment, 202 acute mentally ill patients were interviewed by SCAN 2.1 trained clinicians. Concordance measures were analysed.

Results: The IShell program generated significantly more diagnoses per patient than the researchers. On the level of diag-nostic classes, a moderate to almost perfect concordance was found between researchers and IShell. However, for the IShell program a lower sensitivity for psychotic disorders and a moderate specificity for depressive orders emerged. In assessing the course of depressive disorders, researchers more often accounted for the presence of earlier episodes. Researchers more often classified a current depressive episode as severe.

Conclusion: An examination of IShell algorithms revealed enors in some diagnostic categories. Thus. further amendment of the algorithms is needed and currently being done. However, the sometimes low concordance is not only attributable to the algorithms. Researchers, even though being trained, did not always enter data correctly into IShell, so its capabilities were in part underestimated.

P-11-13

An anthropological review of SCAN

A. Janca. Univ of Western Australia School of Psychiatry., Perth, Australia

Objective: To evaluate cultural appropriateness of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) as a tool for the assessment of psychopathology in the Australian indigenous people.

Methods: An extensive exploratory review of the SCAN glossary definitions, interview questions and rating scales was performed using anthropological and qualitative research methods and procedures in the context of a project aimed at developing a culturally appropriate approach to the assessment of Aboriginal mental health problems in Australia.

Results: SCAN interview and rating conventions might have significant limitations in Australian indigenous settings. The potential difficulties include differences in terminology, psychopathology and recall of psychiatric symptoms and episodes. The inclusion of alternative time frames and visual symptom severity rating scales seems to be neccessary in the context of the SCAN interview process.

Conclusion: Although designed as a semi-structured and relatively flexible psychiatric assessment tool, SCAN might have a limited applicability in Australian indigenous settings. Significant SCAN adaptations or development of a novel and Aboriginal culture-specific psychiatric assessment instrument might be required.

P-11-14

Psychopathology scales derived from the schedules for clinical assessment in neuropsychiatry (SCAN 2.1)

M. Schützwohl, T. W. Kallert, L. Jurjanz. Universitätskrankenhaus, Dresden, German)

Objective: The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a comprehensive set of clinical assessment instruments developed by the World Health Organisation. The poster will show possibilities of using the latest version - SCAN 2.1 - for dimensional measures of psychopathology.

Methods: Within a randomized controlled trial comparing psychiatric day-hospital treatment to inpatient treatment, 202 acute mentally ill patients were interviewed by clinically experienced interviewers. Forty-seven items of SCAN 2.1 were selected for constructing dimensional measures. Six scales were generated using principal component analyses (PCA). They were compared to five scales constructed according to the items' affiliation to specific sections.

Results: Cronbach's alpha coefficients qualified reliability of most scales as moderate (.50 < a < .70) or as substantial (a > .70). Correlation coefficients between SCAN 2.1 scales and BPRS 4.0 and SCL-90-R prove the scales' convergent validity.

Conclusion: With respect to high correlations between the scales generated using PCA and the section specific scales using the latter is recommended.

P-11-15

Towards medical audit in a psychiatric training hospital

W. Verhoeven, K. D'Hoine, J. I. Egger, S. Tuinier. Vincent van Gogh Institute for Psychiatry, Venray. Netherlands

Objective: The diagnostic process in psychiatry has seemingly become easier since the general acceptance of categorical systems like the DSM. Although these systems were originally developed for medical use only, the common practice is that professionals from various disciplines are now able to establish a quick psychiatric diagnosis. It should be stressed, however, that many of the diagnoses are of doubtful validity and that there is a substantial and significant co-occurrence of diagnoses both within and between major classes of disorders.

Methods: Anglo-American countries have introduced so called audit systems that are defined as a systematic and critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment.

Results: The audit process starts with the identification of a problem, followed by a decision what should happen according to certain standards. Subsequently, practice is observed and compared with standards. Then, change has to be implemented and the effect should be monitored.

P-11-16

Help-seeking behaviour in the general population

K. Dahlberg, B. Runeson, Y. Forsell, K. Damström-Thakker. Karolinska Institute Deph Clin. Neuroscience, Skövde, Sweden

Objective: To investigate factors that may influence helpseeking behaviour for mental health problems.

Methods: A questionnaire was distributed to two samples, an urban site (n=10 441) and a rural site (n=3538) with Swedish citizens 20-64 years of age. Self-rated health, contact with health care and self-report instruments (covering anxiety, depression and substance abuse) were included. In the rural sample the questionnaire was followed by an interview (n=358) including a diagnostic instrument SCAN, a personality inventory SSP and a vignette describing a depressed person. The rural sample was split into three sub samples of cases with symptoms of mental disorders with and without contact with health care, and healthy controls.

Results: Factors associated with increased use of health care were female gender, age and living in an urban area. In the urban area, respondents had contact with health care even if they reported a good or very good health. Data from interview of rural sample: Subjects with contact with health care for mental problems had higher values in neuroticism-related personality traits. Subjects with own experience of pharmacological treatment were more positive to treatment for depression.

Conclusion: Urban residency, neurotic personality traits and positive experiences of care increased help-seeking for mental health problems.

P-11-17

Psychiatric episode severity and competence to consent to psychiatric hospitalization

D. Fraguas, J. J. De la Pefia, E. Chapela, S. Terán, F. García-Solano, A. Calcedo. Gregorio Maranon General Hospt Psychiatry, Madrid, Spain

Objective: The study analyzes if any association exists between APIS and CQ changes along admission.

Methods: A series of 96 consecutive admissions to a psychiatric ward in a university general hospital in Madrid between May and July 2004 were administered Competence Questionnaire (CQ) and Acuity of Psychiatric Illness Scale (APIS) (Spanish adaptation) on admission and discharge. CQ assesses competence to consent to psychiatric hospitalization, while APIS assesses severity of psychiatric breakdown. Inter-rater reliability was checked and recruitment began when appropriate scores were obtained. Informed consent for investigation was obtained from each patient.

Results: CQ and APIS scores at admission covariates according a negative correlation. CQ mean score at admission was 8.2 ± 2.9 (N 88). CQ mean score at discharge was 9.1 ± 2.9 (N 50). Mean CQ change along hospitalization was 0.9, clinically irrelevant. APIS mean score at admission was 12.2 ± 5.0 (N 94). APIS mean score at discharge was 2.5 ± 3.3 (N 96). Mean APIS change along hospitalization was -9.7, a clinical and statistically significant difference (t = 16.7; p<0.01).

Conclusion: Magnitude of hospitalization effect on APIS score (psychiatric episode severity) is greater than on CQ score (competence). As psychiatric episode is more severe on admission, patient score on CQ on admission is lower. The greater the reductions on psychiatric episode severity along hospitalization, the higher competence improvement.

P-11-18

Psychiatric illness severity and competence to consent to psychiatric hospitalization

J. J. de la Pena Esbri, D. Fraguas Herráez, S. Teran, E. Chapela, F. García Solano, A. Calcedo Barba. Hospital Gregorio Maranon Psiquiatria, Madrid, Spain

Objective: The study analyzes if any association exists between CQ on admission and SPIS.

Methods: A series of 96 consecutive admissions to a psychiatric ward in a university general hospital in Madrid between May and July 2004 were administered Competence Questionnaire (CQ) and Severity of Psychiatric Illness Scale (SPIS) (Spanish adaptation) on admission. CQ assesses competence to consent to psychiatric hospitalization, while SPIS assesses severity of psychiatric illness. Inter-rater reliability was checked and recruitment began when appropriate scores were obtained. Informed consent for investigation was obtained from each patient.

Results: CQ mean score on admission was 8.2 ± 2.9 (N 88). 28.4% patients scored “non-competent” (CQ<7), whereas 71.6% scored “competent”. Males and females didn't differ in their competence to consent to psychiatric hospitalization, but mean SPIS in males (19.5) was significantly higher (p<0.01) than in females (15.7). SPIS mean scores among competent and noncompetent patients was 16.1 and 19.4 respectively (p<0.05). Mean SPIS score among involuntarily admitted patients was 20.4, whereas among voluntarily admitted ones it resulted 15.9 (p<0.01).

Conclusion: Psychiatric illness severity was significantly higher in our sample among male patients. Males didn't differ from females in their competence to consent to psychiatric hospitalization. Involuntary admissions associate in our sample with greater psychiatric illness severity. A negative correlation exists between psychiatric illness severity score and competence to consent psychiatric admission.

P-11-19

Ethical and methodical solutions for conducting a randomized controlled trial comparing seclusion and restraint

J. Bergk, T. Steinert. ZfP Weissenau - Dep. I Utzi Ulm Versorgungsforschung, Ravensburg, Germany

Objective: Is there any difference between seclusion and restraint? In guidelines the “least restrictive alternative” is recommended, but a Cochrane Review did not find any articles that could meet the minimal inclusion criteria of a RCT. While planning the study ethical and methodical problems had to be solved and will be discussed.

Methods: Possible outcome measures and different study designs with their advantages and drawbacks are presented.

Results: A cohort study with optional randomization combines a high internal with a high external validity. As the patients are not able to give their informed consent before the intervention, we acquire the informed consent in accordance to emergency medicine not for the coercive intervention but for subsequent participation in interviews and data recording. Main objective is the human Dignity during COercive Procedure (DICOP), a score that sums up different aspects of human rights from the patients' point of view.

Conclusion: RCTs on coercive interventions in psychiatry are feasible and will be helpful in decision making on “least restrictive alternatives” and establishing ethical guidelines.

P-11-20

A randomized controlled trial comparing seclusion and restraint in psychiatry. Preliminary results

J. Bergk, T. Stcinert. ZfP Weissenau - Dep. I Uni Ulm Versorgungsforschung, Ravensburg, Germany

Objective: Seclusion and restraint are widely used for people with serious mental disorders. In most countries one intervention is preferred while the other is considered as inhuman or not sufficiently safe, but identical arguments refer to different preferences. There is a lack of evidence from well-designed studies on compulsory measures in psychiatry. In a Cochrane Review on Seclusion and restraint no articles could be found that met the minimal inclusion criteria of a RCT. At present we conduct the first RCT comparing seclusion and restraint.

Methods: As principle outcome variable we chose the reduction in human rights in the patients' point of view. To assess the subjective violation of human rights we constructed a score summing up different aspects of human rights (human Dignity during COercive Procedure, DICOP). As design we chose a cohort study with optional randomization. Mann Whitney Rank Test was used to compare the data of seclusion and restraint.

Results: Preliminary Results: 8 months after starting the study n=39 patients were included, 12 patients were randomized. As the sample size of randomized patients yet was to small for statistical analysis we did not make a difference between randomized and non randomized patients for each intervention. The duration of coercive treatment was longer in the group of patients with restraint. The patients treated with restraint were more agitated and hostile. Significant differences in the DICOP-score between seclusion and restraint could not be found. Apart from the measure performed, and assuming that some type of measure was necessary, the patients thought seclusion would have been the most adequate intervention. Main stressors during seclusion were: “I feared the measure would last forever”, “I felt my dignity was taken away” and “others made decisions on me”. Main stressors during restraint were: “restriction of ability to move”, “others made decisions on me” and “I didn't know what to expect”.

Conclusion: Randomized controlled trials on coercive interventions in psychiatry are feasible. The preliminary results didn't differentiate between randomized and non randomized group due to small sample size. There were no significant differences between seclusion and restraint in the reduction of human rights.

P-11-21

The course of early career job stress in physicians with emphasis on interference with family and social life

R. Jan Ole, R. Tyssen. Basic Sciences in Medicine Behavioural Sciences in Medici, Oslo, Norway

Objective: To explore the course of early career job stress in physicians in a longitudinal design to identify risk factors for burnout and foster sound working climates to better patient care.

Methods: Prospective mailed survey of a nationwide cohort of physicians. Approached at internship (T1), during specialization (T2) and after nine years (T3). Participants: all physicians that graduated in Norway 1993/94. Cohort to be followed:N=262. Main outcome:job stress. Statistics: Repeated measures tests used to test for change in job stress, across gender.Contributors to interference with family and social life were explored with linear regressions.

Results: Significant reduction in job stress over the nine years observation period, (F=61.0, p<0.001). Women were more stressed than men (F=5.6, p<0.05) The stressors emotional pressure, time pressure and fear of complaints and criticism decreased significantly in the observation period. However, the stressor interference with family and social life increased . Women were higher on emotional pressure. Lack of support from colleagues contributed the most to interference with family and social life.

Conclusion: Work specific dimensions of physician stress decreases with time, however, stress arising from the job - privacy junction increases during the first nine years of physician career. Addressing the working climate, enhancing a caring, supportive attitude and good team conditions could be enhanced as an intervention on an organisational level.

P-11-22

Mother-and-Baby Unit: An alternative treatment of psychiatric disorders in women

G. Laux, M. Fric, S. Eigner, S. Artmann. District Hospital Gabersee Department of Psychiatry, Wasserburg am Inn, Germany

Objective: Gender differences with regard to psychiatric illnesses are known since a long time Physiological conditions like menstrual cycle, pregnancy, childbirth, postpartal period and climacterium are special females conditions prone to affective disorders makng differential treatment procedures necessary. The first Mother-and-Baby Unit for the treatment of postpartal psychoses was oppened in England 1959. In Germany, those facilities are sparse though 9.6 hospital-beds per one million inhabitants are seen to be necessary.

Methods: Our Mother-and-Baby Unit with modified conception was installed at the end of the year 2001. Until the year 2004 n = 88 women with one or two children in preschool age have been treated, 29 of them with a diagnosis related to pregnancy or postpartum (ICD-10:099 pre- or postpartal psychiatric disorders).

Results: The mean age of the 88 in-patients was 32 “ 5.7 yrs, the most frequent diagnoses were neurotic, adjustment and somatoform disorders (21.8 %), affective psychoses (20%), personality disorders (15.2 %) and schizophrenia (11.5 %). 51% of the treated women were man-led, 22.7 % unmarried, 13.6 % lived in solid relationship, 6.8 % were divorced. 83 % reported important life events (e.g. death of relatives in 14.2 %, sexual assault/ violation in 12.6 %). In our patients no accumulation of risk factors like education by onself, lower class, low education and role conflicts was observed.

Conclusion: According to our experiences Mother-and-Baby Units are efficient and required for psychiatric routine treatment. Severe life events were prominent in our population. Contrasting to the literature an increase of social risk factors was not seen in our patient sample.

P-11-23

Internal referrals in a Mental Health Center

E. Panagoulias, P. Papadopoulos, D. Maldidelis, K. Dailianis. P. Psychiko-Atlms, Greece

Objective: The purpose of this study was to examine the referred cases from Child Sector of our Center to the Adult one and evaluate a) the appropriateness of the referrals and b) the correlation between the parent's problems and those of the children.

Methods: Data from 60 referred cases (parent/s with one at least child under therapeutic process by the Child Sector) were examined. We analyzed parameters as: age, sex, family status, occupation, cause of referral or diagnosis (concerning the parents) and age, sex and diagnosis (concerning the children).

Results: From the results we will discuss the most outstanding: about 50% of the referrals didn't come to be examined or we didn't find any psychopathology leading to necessity for therapeutic intervention.

Conclusion: In order to explain this fact and take measures to reduce it, we must reexamine all the procedures of referral concerning both sectors (Child and Adult) of our Center.

P-11-24

Bioethical principles in treatment of psychiatric patients in croatia

S. Katalinic, A. Frkovic. Opatija, Croatia

Objective: Health protection of every person has to be carrying out through principle of humanity and right of protection as a patient. This is specially related to mentally ill persons. Because of mental condition, these patients might be deprived of their own will. It is very important to stick on bioethical principles in medical treatment of patients with mental disorders, nevertheless of all challenges in modem psychiau'ic approach.From 1998 in Croatia we have the Law on protection of persons with mental disorders. This Law regulates fundamental principles, organization, protection, and presumption for conduction of measures and procedures toward patients with mental disorder. Nevertheless of difficulty, mentally ill person has a right to informed consent for conduction of every medical procedures planed in treatment. Every mentally ill person has to know about the purpose, nature, consequences, benefits and dangers of such procedures and about alternative possibilities of treatment, based on her/his mental capacities. Croatia is long for a modern and bioethical acceptable approach to health protection. Very soon Croatian Parliament will proclaim the Law on protection of patients' rights. In the draught of this Law is an article on protection of patients with severely mental disease. In this article is said that is possible to conduct all medical procedures even without patient's consent to prevent her/his further health damage. In that situation the consent is given by patient's legal representative. Because of specifics of mentally ill persons there is a special problem in clinical psychiatric researches. For participation in such research sometime is impossible to have informed consent from psychiatric patient. In this case as in previous one, Law entitle patient's legal representative to give consent. If there is no legal representative, the consent could be given by ethical council of institution where research will take place.

P-11-25

Rapidly measurable general muscle relaxation induced by local back massage with an automated massage chair

D. F. Zullino, C. Eichenberger, E. Panchaud, R. Marbehant, S. Krenz, M. Stankovic, E. Frfsard, F. Borgeat, Y. Khazaal. University Lausanne Psychiatry, Prilly-Lausanne, Switzerland

Objective: Massage therapy has recently received empirical support for reducing pain and alleviating stress, depression, and anxiety in the context of various somatic and psychiatric disorders. Whereas an extensive literature exists on vibrator stimulation suggesting significant therapeutic effects at least for pain reduction, the application of other mechanical massage techniques has not been investigated until now. The objective of the present pilotstudy was to investigate the effect of 3 massage techniques applied on the back by an automated massage chair with regard to relaxation in other muscle groups.

Methods: Ten healthy volunteers participated to the experiment, consisting in four 5-minute-periods: Relaxation without massage, Roll-Stretch Massage, Shiatsu-Massage, Beat Massage. A NAIS chair was used. Subjects were randomized as to the presentation order. EMG data was collected via a ProComp+/Biograph system over the m.frontalis (reflecting primarily affective states) and over the left m.gastrocnemius (reflecting general level of tension).

Results: Self-Assessment Mannequins analysis indicates that Roll-Stretch and Shiatsu-Massage were regarded by participants as more pleasant than the control condition (p<0.05). No differences were found with regard to arousal. Whereas the four conditions were similar with regard to the mean frontal EMG values, they differed regarding the gastrocnemius EMG: Roll-Stretch-Massage 1.79±1.16mV; Shiatsu-Massage 1.91+1.27mV; relaxation only 3.36±2.18mV (for both comparisons: p<0.05). The Beat Massage (3.38±3.19mV) did not differ from control condition.

Conclusion: Automated Roll-Stretch-Massage and Shiatsu- Massage applied on the back induced rapidly measurable relaxation in distant muscles not directly massaged, whereas Beat Massage did not. Back massage applied by an automated massage chair may be an efficient and inexpensive general relaxation approach, especially interesting for patients disliking being touched.