Stefan Weinmann - Academia.edu (original) (raw)

Papers by Stefan Weinmann

Journal of Psychopharmacology, 2009

Guidelines for the treatment of attention-deficit hyperactivity disorder (ADHD) in adults advocat... more Guidelines for the treatment of attention-deficit hyperactivity disorder (ADHD) in adults advocate methylphenidate as first-line treatment. The aim of this study was to review the effectiveness of methylphenidate treatment of adult ADHD and to examine the influence of methods on meta-analytic results. Electronic databases were searched to identify clinical trials comparing methylphenidate with placebo in the treatment of adult ADHD. Studies were summarised with meta-analytic methods. Subgroup analyses were conducted with respect to parallel group versus cross-over trials and self versus observer ratings. The relationship between dosage and effect size was explored by weighted regression analysis. The results were tested for publication bias, and several sensitivity analyses were performed. Findings and methods were compared with a previous meta-analysis. Eighteen studies met the inclusion criteria of which 16 were included in the meta-analysis. The overall effect size (d = 0.42) was significantly different from zero, but was only half the size expected on the basis of a previous meta-analysis. No significant differences could be observed in the subgroup analyses. The regression analysis showed no significant influence of mean daily dose on effect size. These results contradict findings of a previous meta-analysis and challenge guideline recommendations. Methodological issues in meta-analyses are discussed.

BMC Geriatrics, 2010

Background: The benefit of Ginkgo biloba has been discussed controversially. The aim of this revi... more Background: The benefit of Ginkgo biloba has been discussed controversially. The aim of this review was to assess the effects of Ginkgo biloba in Alzheimer's disease as well as vascular and mixed dementia covering a variety of outcome domains.

Journal of Clinical Psychopharmacology, 2010

Case reports indicate that antipsychotics can cause priapism, a persistent penile erection possib... more Case reports indicate that antipsychotics can cause priapism, a persistent penile erection possibly leading to erectile dysfunction. The mechanism of antipsychotic-induced priapism is thought to be related to blockade of alpha1 adrenergic receptors, but clinical data supporting this hypothesis are lacking. The aim of this study was to investigate if the presence of safety signals for antipsychotics and priapism is associated with their alpha1 affinity. Spontaneous reports of adverse drug reactions contained in the US Adverse Event Reporting System database were used to calculate reporting odds ratios (RORs) of priapism for antipsychotics. In total, 426 cases of priapism with 144 of them attributed to antipsychotics were identified. For antipsychotics with high alpha1 affinity, the adjusted ROR was markedly elevated (ROR = 9.9; 95% CI, 7.9-12.4), whereas a weaker signal was observed for antipsychotics with low/medium alpha1 affinity (ROR = 3.6; 95% CI, 2.4-5.2). Signals were present for chlorpromazine, quetiapine, risperidone, ziprasidone, and aripiprazole. After restricting the analysis to cases with medical intervention or disability, the safety signal remained evident only for antipsychotics with high but not for those with low/medium affinity. The observed pattern of signals indicates a relationship between alpha1 affinities of antipsychotics and the occurrence of priapism.

Pediatric Allergy and Immunology, 2003

The aim of this study was to estimate costs accrued by the health care of children with asthma in... more The aim of this study was to estimate costs accrued by the health care of children with asthma in comparison to children with atopic eczema and seasonal rhinitis and to investigate cost determinants. From the multicenter cohort study (MAS-90), we selected children with an asthma, atopic eczema and/or seasonal rhinitis diagnosis during the first 8 years of life, and overall 8-year health care utilization was estimated retrospectively by reviewing medical records. Asthma treatment (n = 76) incurs an average cost of 627 US dollars per year, 44% due to hospital stays. Atopic eczema treatment (n = 91) cost on average 219 US dollars and seasonal rhinitis (n = 69) 57 US dollars per year. In asthma and atopic eczema, costs increase significantly with disease severity. Allergy diagnostics use accounts for only 1% of total costs. Costs for asthma and atopic eczema treatment are highest in those years when topical steroids are used for the first time, but decrease with every further year of steroid use. A remarkable 25% of asthmatic children with severe symptoms were not treated according to national guidelines, so that most steroid treatment was initiated during the first hospital stay. In the case of asthma, total direct costs increased until the 3rd year of the disease, and then decreased with further years of diagnosis, while steroid use continued to increase. These results indicate a 'learning effect' in the treatment of asthma and atopic eczema for each patient as well as considerable cost-saving potential by preventing severe asthma. Moreover, the importance of considering cost-driving factors and using cohort or longitudinal designs in cost-of-illness approaches is emphasized.

Nervenarzt, 2005

In Deutschland wird gegenwärtig kontrovers diskutiert, welche gemeindepsychiatrischen Strukturen ... more In Deutschland wird gegenwärtig kontrovers diskutiert, welche gemeindepsychiatrischen Strukturen gefördert und ausgebaut werden sollen, um den besonderen Bedürfnissen der schwer psychisch Erkrankten gerecht zu werden. Anhand eines Literatur-Reviews systematischer Metaanalysen und kontrollierter Studien wird gezeigt, dass eine Reihe von gut evaluierten psychiatrischen Versorgungsbestandteilen existiert, von denen jedoch nur Teile in Deutschland verfügbar sind. Am Beispiel der Schizophrenie wird deutlich, dass strukturelle Voraussetzungen für eine Implementation evidenzbasierter nichtstationärer Behandlungs- und Versorgungsmodule in Deutschland nicht ausreichend vorhanden sind. Teambasierte aufsuchende Behandlung, Kriseninterventionsteams und andere gemeindepsychiatrische Teams sowie moderne berufliche Rehabilitationsprogramme, die zumeist im angelsächsischen Raum entwickelt wurden, konnten für die deutsche psychiatrische Versorgung bisher nur unzureichend adaptiert werden. Gleichzeitig sind viele in Deutschland praktizierte Versorgungsmodelle kaum wissenschaftlich evaluiert. Vor diesem Hintergrund wird zu künftigen Anforderungen und sinnvollen Weiterentwicklungen in der Psychiatrie und zur Deckung des zunehmenden Versorgungsbedarfs bei schweren psychischen Erkrankungen Stellung genommen. In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.

European Psychiatry, 2011

Nervenarzt, 2009

In diesem Artikel werden mittels eines narrativen Literatur-Reviews innovative Modelle psychiatri... more In diesem Artikel werden mittels eines narrativen Literatur-Reviews innovative Modelle psychiatrischer Versorgung für Menschen mit Schizophrenie beschrieben, strukturelle Aspekte der psychiatrischen Versorgung, insbesondere hinsichtlich einer integrierten Versorgung schizophren Erkrankter, werden behandelt sowie neue Paradigmen und Forschungsansätze diskutiert. Ein wichtiges Ziel bleibt die Verbesserung der therapeutischen Kontinuität, die Einrichtung teambasierter gemeindenaher Behandlung, insbesondere bei schwer psychotisch Erkrankten, die Verbesserung der Zusammenarbeit aller Therapeuten und die Integration von medizinischer Behandlung und sozialer Betreuung. In fast allen Modellen integrierter Versorgung ist eine verstärkte Einbindung psychosozialer Behandlungen vorgesehen. Die Herausforderung eines psychiatrischen Versorgungsmodells besteht darin, einerseits Ziele der Betroffenen abzubilden und gleichzeitig die biologische Vulnerabilität und die Krankheitssymptome und kognitiven Beeinträchtigungen der Patienten zu berücksichtigen, die spezifische Interventionen erfordern. Leitgedanke einer integrierten Versorgung sollte das Ziel einer möglichst selbstbestimmten Lebensführung sein. Dies beinhaltet, dass die Betroffenen immer die Behandlung erhalten sollten, die bei gleicher Zielsetzung mit den wenigsten Einschränkungen für sie verbunden ist. In a narrative literature review, innovative models of mental health care for people with schizophrenia are described. Structural aspects of mental health care such as the integration of services, new care paradigms, and innovative research questions are discussed. Key targets of innovative care include: improving continuity of care, introducing team-based community care, improving cooperation of all therapists, and integrating mental health, medical care, and social services. Models of current care for people with schizophrenia such as case management, crisis intervention, home treatment, and supported employment are described; and the evidence supporting these interventions is discussed. In the models of integrated care, there is an enhanced integration of psychosocial modules or service elements. One of the key challenges in mental health service systems is to consider the needs and aims of people with severe mental illness, to take into account biological vulnerability, symptoms of illness, and cognitive impairment of patients (whenever interventions are possible). One of the guiding principles is patient/user autonomy and a focus on user perspective. This implies that people suffering from schizophrenia should have the right to live in the least restrictive environment possible.

Journal of Clinical Psychiatry, 2004

Within a pharmacoepidemiologic study, characteristics of patients with schizophrenia switched fro... more Within a pharmacoepidemiologic study, characteristics of patients with schizophrenia switched from first- to second-generation antipsychotics (FGAs and SGAs, respectively) or to antipsychotic polypharmacy were compared with those of patients maintained on treatment with FGAs. The primary aim was to assess factors associated with antipsychotic switching and to compare disease course with regard to mental state and social functioning. Adult inpatients with an ICD-10 diagnosis of schizophrenia or schizoaffective disorder were assessed in 7 psychiatric hospitals. Data were collected between 2001 and 2002. For those patients (N = 847) with an antipsychotic prescription at discharge, t tests and covariance and logistic regression analyses were used to evaluate the relationship between demographic and clinical characteristics and antipsychotic switching. Patients switched from FGAs to SGAs had fewer previous psychiatric admissions, a shorter illness duration, fewer substance disorders, and a higher probability of working in a competitive setting but more pronounced symptoms than those maintained on treatment with FGAs. Mental state and social functioning after case-mix adjustment were more favorable in the group switched to SGA monotherapy but not in those patients administered FGAs and SGAs concurrently at discharge. Logistic regression controlling for demographic and clinical variables revealed that a short disease duration (p <.05), fewer previous psychiatric hospitalizations (p <.01), voluntary admission (p <.05), and pronounced thought disorder (p <.05) were significantly associated with switching from FGAs to SGAs. Hospital differences were also observed. Remaining on FGAs or switching to SGAs in schizophrenia care depends strongly on institutional practices in addition to the previous disease course and health care utilization.

Acta Psychiatrica Scandinavica, 2010

Objective: Schizoaffective disorder is a common diagnosis in mental health services. The aim of ... more Objective: Schizoaffective disorder is a common diagnosis in mental health services. The aim of the present article was to review treatment studies for schizoaffective disorder and draw conclusions for clinical decision making.Method: We searched MEDLINE and Cochrane Library for relevant clinical trials and review articles up to the year 2008.Results: Thirty-three studies using standardized diagnostic criteria, 14 of which were randomized controlled trials, could be identified. The comparability of studies is limited by the use of different diagnostic criteria. The studies reviewed do not permit consistent recommendations as to whether schizoaffective disorder should be treated primarily with antipsychotics, mood stabilizers or combinations of these drugs. The relevance of diverse subtypes of schizoaffective disorder for treatment recommendations is unclear.Conclusion: The pertinent empirical database is small and heterogeneous. The lack of conclusive recommendations is related to issues of nosological status, plurality of diagnostic criteria and validity of the concept of schizoaffective disorder.

European Psychiatry, 2010

Psychiatrische Praxis, 2007

To provide an overview of diagnostics, outcome and treatment of &... more To provide an overview of diagnostics, outcome and treatment of "non-schizophrenic psychotic disorders" (ICD-10: delusional disorders, acute and transient psychotic disorders and schizoaffective disorders). Literature was identified by searches in "Medline" and "Cochrane Database of Systematic Reviews". The frequency of "non-schizophrenic psychotic disorders" within the whole diagnostic group "schizophrenia, schizotypal and delusional disorders" (ICD-10) ranges between 22% and 49%. Patients with these disorders show a more favourable long-term outcome than those with schizophrenia. With regard to therapy, as yet only a small empirical database exists. The comparability of those studies is limited by the use of different diagnostic criteria. There are only few evidence-based treatment guidelines for these disorders. There is a substantial need for controlled studies on the treatment of…

Psychopharmacology, 2008

Rationale A number of reviews have claimed that the selective serotonin and noradrenalin re-uptak... more Rationale A number of reviews have claimed that the selective serotonin and noradrenalin re-uptake inhibitor venlafaxine is more effective than selective serotonin re-uptake inhibitors (SSRIs) in achieving remission and symptom reduction in major depression. Objectives The aim of this study was to systematically review studies on the efficacy of venlafaxine vs SSRI and to evaluate the influence of methodological issues on the effect sizes. Materials and methods Following a systematic literature search, we pooled data on depression scores, response, remission and dropout rates. We also performed sub-group analyses. Results Seventeen studies were included. We found no significant superiority in remission rates (risk ratio [RR] = 1.07, 95% confidence intervals [95%CI] = 0.99 to 1.15, numbers needed to treat [NNT] = 34) and a small superiority in response rates (RR = 1.06, 95%CI = 1.01 to 1.12, NNT = 27) over SSRIs. There was a small advantage to venlafaxine in change scores (effect size = −0.09, 95%CI = −0.16 to −0.02, p = 0.013), which did not reach significance when post-treatment scores were used (effect size = −0.06, 95%CI = −0.13 to 0.00). Discontinuation rates due to adverse events were 45% higher in the venlafaxine group. The main reasons for the differences between this analysis and previous reviews were the exclusion of studies with methodological limitations, avoiding to pool selectively reported study results and exclusion of studies available as abstracts only. Conclusions Our analysis does not support a clinically significant superiority of venlafaxine over SSRIs. Differences between our study and previous reviews were not accounted for by technical aspects of data synthesis, but rather by study selection and choice of outcome parameters.

Cardiovascular Research, 2006

The purpose of this study was to calculate the proportion of patients with schizophrenia receivin... more The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia.

Biological Psychiatry, 2009

Pid - Psychotherapie Im Dialog, 2007

Psychopharmacology, 2006

Rationale Short- and long-term compliance to prescribed antipsychotic drugs is of particular conc... more Rationale Short- and long-term compliance to prescribed antipsychotic drugs is of particular concern in regard to medication choice and treatment outcome in the care of psychotic disorders. Objective We evaluated patient-related and treatment-related factors associated with medication compliance in inpatients with a diagnosis of schizophrenia, schizoaffective disorder, or other psychotic disorder. Methods Within a naturalistic study in seven psychiatric hospitals, individuals with a psychotic disorder were assessed weekly on mental state, social functioning, side effects, and medication compliance. Logistic regression analyses were computed to assess patient and clinical predictors of medication compliance. Results We found a significant association between medication compliance and substance abuse (OR 0.52, CI 0.32–0.85), involuntary admission (OR 0.60, CI 0.41–0.89), history of aggressive behavior (OR 0.57, CI 0.38–0.85), and no school graduation (OR 0.59, CI 0.41–0.86). Individuals with pronounced paranoid or negative symptoms were also less compliant in taking their prescribed medication. There was no association between the initial inpatient antipsychotic medication regime and patients’ compliance. Individuals who switched from a typical to an atypical antipsychotic drug were more compliant than those with their typical antipsychotic drug maintained. Those with higher medication compliance showed significantly greater improvement of their psychiatric symptoms during the inpatient stay. Conclusion Patient-related in addition to disease-related factors may strongly influence medication compliance. Besides more compliance with atypicals supposed by the literature, there may be a higher propensity for atypical drugs to be prescribed to those assumed to be more compliant.

Nervenarzt, 2005

Behandlungsergebnisse und Leitlinienkonformität in ausgewählten Indikationsbereichen bei der stat... more Behandlungsergebnisse und Leitlinienkonformität in ausgewählten Indikationsbereichen bei der stationären Schizophreniebehandlung wurden anhand von 597 Patienten aus 7 psychiatrischen Kliniken systematisch dargestellt und verglichen. Es zeigten sich deutliche Unterschiede in der Patientenstruktur und den angewandten Behandlungsverfahren zwischen den Kliniken. Patientenmerkmale, insbesondere die Psychopathologie bei Aufnahme und die Chronizität der Erkrankung stellten sich als die stärksten patientenbezogenen Prädiktoren für den klinischen Status bei Entlassung heraus. Eine Beurteilung der Behandlungsqualität in den Kliniken mittels definierter Indikatoren ist nur eingeschränkt und nach einer Case-Mix-Adjustierung unter Berücksichtigung prognostisch relevanter Parameter möglich. In diesem Modell war ein ungünstigeres durchschnittliches Behandlungsergebnis im Klinikvergleich mit geringerer Leitlinienkonformität bei einer Reihe von Indikationsbereichen verbunden. Diese Ergebnisse unterstützen die Verwendung der Leitlinienkonformität in der Schizophreniebhandlung als zu vergleichendes Klinikmerkmal zur datengestützten internen Qualitätsoptimierung und lassen die Entwicklung von Strategien zur Steigerung der Leitlinienorientierung sinnvoll erscheinen. Patient outcome and guideline conformity in inpatient schizophrenia treatment was systematically evaluated and compared with 597 patients across seven psychiatric hospitals. Patient structure and treatment processes showed a great variability between hospitals. Patient characteristics, especially mental state, and the chronicity of the disease were the strongest predictors of clinical outcome. Outcome evaluation using quality indicators is only possible after case-mix adjustment taking into account prognostic factors. A poorer average clinical outcome was associated with lower guideline conformity in a variety of treatment domains. After case-mix adjustment, benchmarking is an opportunity to improve quality of treatment and promote guideline conformity.

Acta Psychiatrica Scandinavica, 2007

Objective: To identify evidence from comparative studies on the effects of psychiatric guideline... more Objective: To identify evidence from comparative studies on the effects of psychiatric guideline implementation on provider performance and patient outcome. Effects of different implementation strategies were reviewed.Method: Articles published between 1966 and March 2006 were searched through electronic databases and hand search. A systematic review of comparative studies of structured implementation of specific psychiatric guidelines was performed. Rates of guideline adherence, provider performance data, illness detection and diagnostic accuracy rates were extracted in addition to patient relevant outcome data.Results: Eighteen studies (nine randomized-controlled trials, six non-randomized-controlled studies and three quasiexperimental before-and-after studies) were identified. Effects on provider performance or patient outcome were moderate and temporary in most cases. Studies with positive outcomes used complex multifaceted interventions or specific psychological methods to implement guidelines.Conclusion: There is insufficient high-quality evidence to draw firm conclusions on the effects of implementation of specific psychiatric guidelines.

Journal of Psychopharmacology, 2009

Guidelines for the treatment of attention-deficit hyperactivity disorder (ADHD) in adults advocat... more Guidelines for the treatment of attention-deficit hyperactivity disorder (ADHD) in adults advocate methylphenidate as first-line treatment. The aim of this study was to review the effectiveness of methylphenidate treatment of adult ADHD and to examine the influence of methods on meta-analytic results. Electronic databases were searched to identify clinical trials comparing methylphenidate with placebo in the treatment of adult ADHD. Studies were summarised with meta-analytic methods. Subgroup analyses were conducted with respect to parallel group versus cross-over trials and self versus observer ratings. The relationship between dosage and effect size was explored by weighted regression analysis. The results were tested for publication bias, and several sensitivity analyses were performed. Findings and methods were compared with a previous meta-analysis. Eighteen studies met the inclusion criteria of which 16 were included in the meta-analysis. The overall effect size (d = 0.42) was significantly different from zero, but was only half the size expected on the basis of a previous meta-analysis. No significant differences could be observed in the subgroup analyses. The regression analysis showed no significant influence of mean daily dose on effect size. These results contradict findings of a previous meta-analysis and challenge guideline recommendations. Methodological issues in meta-analyses are discussed.

BMC Geriatrics, 2010

Background: The benefit of Ginkgo biloba has been discussed controversially. The aim of this revi... more Background: The benefit of Ginkgo biloba has been discussed controversially. The aim of this review was to assess the effects of Ginkgo biloba in Alzheimer's disease as well as vascular and mixed dementia covering a variety of outcome domains.

Journal of Clinical Psychopharmacology, 2010

Case reports indicate that antipsychotics can cause priapism, a persistent penile erection possib... more Case reports indicate that antipsychotics can cause priapism, a persistent penile erection possibly leading to erectile dysfunction. The mechanism of antipsychotic-induced priapism is thought to be related to blockade of alpha1 adrenergic receptors, but clinical data supporting this hypothesis are lacking. The aim of this study was to investigate if the presence of safety signals for antipsychotics and priapism is associated with their alpha1 affinity. Spontaneous reports of adverse drug reactions contained in the US Adverse Event Reporting System database were used to calculate reporting odds ratios (RORs) of priapism for antipsychotics. In total, 426 cases of priapism with 144 of them attributed to antipsychotics were identified. For antipsychotics with high alpha1 affinity, the adjusted ROR was markedly elevated (ROR = 9.9; 95% CI, 7.9-12.4), whereas a weaker signal was observed for antipsychotics with low/medium alpha1 affinity (ROR = 3.6; 95% CI, 2.4-5.2). Signals were present for chlorpromazine, quetiapine, risperidone, ziprasidone, and aripiprazole. After restricting the analysis to cases with medical intervention or disability, the safety signal remained evident only for antipsychotics with high but not for those with low/medium affinity. The observed pattern of signals indicates a relationship between alpha1 affinities of antipsychotics and the occurrence of priapism.

Pediatric Allergy and Immunology, 2003

The aim of this study was to estimate costs accrued by the health care of children with asthma in... more The aim of this study was to estimate costs accrued by the health care of children with asthma in comparison to children with atopic eczema and seasonal rhinitis and to investigate cost determinants. From the multicenter cohort study (MAS-90), we selected children with an asthma, atopic eczema and/or seasonal rhinitis diagnosis during the first 8 years of life, and overall 8-year health care utilization was estimated retrospectively by reviewing medical records. Asthma treatment (n = 76) incurs an average cost of 627 US dollars per year, 44% due to hospital stays. Atopic eczema treatment (n = 91) cost on average 219 US dollars and seasonal rhinitis (n = 69) 57 US dollars per year. In asthma and atopic eczema, costs increase significantly with disease severity. Allergy diagnostics use accounts for only 1% of total costs. Costs for asthma and atopic eczema treatment are highest in those years when topical steroids are used for the first time, but decrease with every further year of steroid use. A remarkable 25% of asthmatic children with severe symptoms were not treated according to national guidelines, so that most steroid treatment was initiated during the first hospital stay. In the case of asthma, total direct costs increased until the 3rd year of the disease, and then decreased with further years of diagnosis, while steroid use continued to increase. These results indicate a 'learning effect' in the treatment of asthma and atopic eczema for each patient as well as considerable cost-saving potential by preventing severe asthma. Moreover, the importance of considering cost-driving factors and using cohort or longitudinal designs in cost-of-illness approaches is emphasized.

Nervenarzt, 2005

In Deutschland wird gegenwärtig kontrovers diskutiert, welche gemeindepsychiatrischen Strukturen ... more In Deutschland wird gegenwärtig kontrovers diskutiert, welche gemeindepsychiatrischen Strukturen gefördert und ausgebaut werden sollen, um den besonderen Bedürfnissen der schwer psychisch Erkrankten gerecht zu werden. Anhand eines Literatur-Reviews systematischer Metaanalysen und kontrollierter Studien wird gezeigt, dass eine Reihe von gut evaluierten psychiatrischen Versorgungsbestandteilen existiert, von denen jedoch nur Teile in Deutschland verfügbar sind. Am Beispiel der Schizophrenie wird deutlich, dass strukturelle Voraussetzungen für eine Implementation evidenzbasierter nichtstationärer Behandlungs- und Versorgungsmodule in Deutschland nicht ausreichend vorhanden sind. Teambasierte aufsuchende Behandlung, Kriseninterventionsteams und andere gemeindepsychiatrische Teams sowie moderne berufliche Rehabilitationsprogramme, die zumeist im angelsächsischen Raum entwickelt wurden, konnten für die deutsche psychiatrische Versorgung bisher nur unzureichend adaptiert werden. Gleichzeitig sind viele in Deutschland praktizierte Versorgungsmodelle kaum wissenschaftlich evaluiert. Vor diesem Hintergrund wird zu künftigen Anforderungen und sinnvollen Weiterentwicklungen in der Psychiatrie und zur Deckung des zunehmenden Versorgungsbedarfs bei schweren psychischen Erkrankungen Stellung genommen. In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.

European Psychiatry, 2011

Nervenarzt, 2009

In diesem Artikel werden mittels eines narrativen Literatur-Reviews innovative Modelle psychiatri... more In diesem Artikel werden mittels eines narrativen Literatur-Reviews innovative Modelle psychiatrischer Versorgung für Menschen mit Schizophrenie beschrieben, strukturelle Aspekte der psychiatrischen Versorgung, insbesondere hinsichtlich einer integrierten Versorgung schizophren Erkrankter, werden behandelt sowie neue Paradigmen und Forschungsansätze diskutiert. Ein wichtiges Ziel bleibt die Verbesserung der therapeutischen Kontinuität, die Einrichtung teambasierter gemeindenaher Behandlung, insbesondere bei schwer psychotisch Erkrankten, die Verbesserung der Zusammenarbeit aller Therapeuten und die Integration von medizinischer Behandlung und sozialer Betreuung. In fast allen Modellen integrierter Versorgung ist eine verstärkte Einbindung psychosozialer Behandlungen vorgesehen. Die Herausforderung eines psychiatrischen Versorgungsmodells besteht darin, einerseits Ziele der Betroffenen abzubilden und gleichzeitig die biologische Vulnerabilität und die Krankheitssymptome und kognitiven Beeinträchtigungen der Patienten zu berücksichtigen, die spezifische Interventionen erfordern. Leitgedanke einer integrierten Versorgung sollte das Ziel einer möglichst selbstbestimmten Lebensführung sein. Dies beinhaltet, dass die Betroffenen immer die Behandlung erhalten sollten, die bei gleicher Zielsetzung mit den wenigsten Einschränkungen für sie verbunden ist. In a narrative literature review, innovative models of mental health care for people with schizophrenia are described. Structural aspects of mental health care such as the integration of services, new care paradigms, and innovative research questions are discussed. Key targets of innovative care include: improving continuity of care, introducing team-based community care, improving cooperation of all therapists, and integrating mental health, medical care, and social services. Models of current care for people with schizophrenia such as case management, crisis intervention, home treatment, and supported employment are described; and the evidence supporting these interventions is discussed. In the models of integrated care, there is an enhanced integration of psychosocial modules or service elements. One of the key challenges in mental health service systems is to consider the needs and aims of people with severe mental illness, to take into account biological vulnerability, symptoms of illness, and cognitive impairment of patients (whenever interventions are possible). One of the guiding principles is patient/user autonomy and a focus on user perspective. This implies that people suffering from schizophrenia should have the right to live in the least restrictive environment possible.

Journal of Clinical Psychiatry, 2004

Within a pharmacoepidemiologic study, characteristics of patients with schizophrenia switched fro... more Within a pharmacoepidemiologic study, characteristics of patients with schizophrenia switched from first- to second-generation antipsychotics (FGAs and SGAs, respectively) or to antipsychotic polypharmacy were compared with those of patients maintained on treatment with FGAs. The primary aim was to assess factors associated with antipsychotic switching and to compare disease course with regard to mental state and social functioning. Adult inpatients with an ICD-10 diagnosis of schizophrenia or schizoaffective disorder were assessed in 7 psychiatric hospitals. Data were collected between 2001 and 2002. For those patients (N = 847) with an antipsychotic prescription at discharge, t tests and covariance and logistic regression analyses were used to evaluate the relationship between demographic and clinical characteristics and antipsychotic switching. Patients switched from FGAs to SGAs had fewer previous psychiatric admissions, a shorter illness duration, fewer substance disorders, and a higher probability of working in a competitive setting but more pronounced symptoms than those maintained on treatment with FGAs. Mental state and social functioning after case-mix adjustment were more favorable in the group switched to SGA monotherapy but not in those patients administered FGAs and SGAs concurrently at discharge. Logistic regression controlling for demographic and clinical variables revealed that a short disease duration (p <.05), fewer previous psychiatric hospitalizations (p <.01), voluntary admission (p <.05), and pronounced thought disorder (p <.05) were significantly associated with switching from FGAs to SGAs. Hospital differences were also observed. Remaining on FGAs or switching to SGAs in schizophrenia care depends strongly on institutional practices in addition to the previous disease course and health care utilization.

Acta Psychiatrica Scandinavica, 2010

Objective: Schizoaffective disorder is a common diagnosis in mental health services. The aim of ... more Objective: Schizoaffective disorder is a common diagnosis in mental health services. The aim of the present article was to review treatment studies for schizoaffective disorder and draw conclusions for clinical decision making.Method: We searched MEDLINE and Cochrane Library for relevant clinical trials and review articles up to the year 2008.Results: Thirty-three studies using standardized diagnostic criteria, 14 of which were randomized controlled trials, could be identified. The comparability of studies is limited by the use of different diagnostic criteria. The studies reviewed do not permit consistent recommendations as to whether schizoaffective disorder should be treated primarily with antipsychotics, mood stabilizers or combinations of these drugs. The relevance of diverse subtypes of schizoaffective disorder for treatment recommendations is unclear.Conclusion: The pertinent empirical database is small and heterogeneous. The lack of conclusive recommendations is related to issues of nosological status, plurality of diagnostic criteria and validity of the concept of schizoaffective disorder.

European Psychiatry, 2010

Psychiatrische Praxis, 2007

To provide an overview of diagnostics, outcome and treatment of &... more To provide an overview of diagnostics, outcome and treatment of "non-schizophrenic psychotic disorders" (ICD-10: delusional disorders, acute and transient psychotic disorders and schizoaffective disorders). Literature was identified by searches in "Medline" and "Cochrane Database of Systematic Reviews". The frequency of "non-schizophrenic psychotic disorders" within the whole diagnostic group "schizophrenia, schizotypal and delusional disorders" (ICD-10) ranges between 22% and 49%. Patients with these disorders show a more favourable long-term outcome than those with schizophrenia. With regard to therapy, as yet only a small empirical database exists. The comparability of those studies is limited by the use of different diagnostic criteria. There are only few evidence-based treatment guidelines for these disorders. There is a substantial need for controlled studies on the treatment of…

Psychopharmacology, 2008

Rationale A number of reviews have claimed that the selective serotonin and noradrenalin re-uptak... more Rationale A number of reviews have claimed that the selective serotonin and noradrenalin re-uptake inhibitor venlafaxine is more effective than selective serotonin re-uptake inhibitors (SSRIs) in achieving remission and symptom reduction in major depression. Objectives The aim of this study was to systematically review studies on the efficacy of venlafaxine vs SSRI and to evaluate the influence of methodological issues on the effect sizes. Materials and methods Following a systematic literature search, we pooled data on depression scores, response, remission and dropout rates. We also performed sub-group analyses. Results Seventeen studies were included. We found no significant superiority in remission rates (risk ratio [RR] = 1.07, 95% confidence intervals [95%CI] = 0.99 to 1.15, numbers needed to treat [NNT] = 34) and a small superiority in response rates (RR = 1.06, 95%CI = 1.01 to 1.12, NNT = 27) over SSRIs. There was a small advantage to venlafaxine in change scores (effect size = −0.09, 95%CI = −0.16 to −0.02, p = 0.013), which did not reach significance when post-treatment scores were used (effect size = −0.06, 95%CI = −0.13 to 0.00). Discontinuation rates due to adverse events were 45% higher in the venlafaxine group. The main reasons for the differences between this analysis and previous reviews were the exclusion of studies with methodological limitations, avoiding to pool selectively reported study results and exclusion of studies available as abstracts only. Conclusions Our analysis does not support a clinically significant superiority of venlafaxine over SSRIs. Differences between our study and previous reviews were not accounted for by technical aspects of data synthesis, but rather by study selection and choice of outcome parameters.

Cardiovascular Research, 2006

The purpose of this study was to calculate the proportion of patients with schizophrenia receivin... more The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia.

Biological Psychiatry, 2009

Pid - Psychotherapie Im Dialog, 2007

Psychopharmacology, 2006

Rationale Short- and long-term compliance to prescribed antipsychotic drugs is of particular conc... more Rationale Short- and long-term compliance to prescribed antipsychotic drugs is of particular concern in regard to medication choice and treatment outcome in the care of psychotic disorders. Objective We evaluated patient-related and treatment-related factors associated with medication compliance in inpatients with a diagnosis of schizophrenia, schizoaffective disorder, or other psychotic disorder. Methods Within a naturalistic study in seven psychiatric hospitals, individuals with a psychotic disorder were assessed weekly on mental state, social functioning, side effects, and medication compliance. Logistic regression analyses were computed to assess patient and clinical predictors of medication compliance. Results We found a significant association between medication compliance and substance abuse (OR 0.52, CI 0.32–0.85), involuntary admission (OR 0.60, CI 0.41–0.89), history of aggressive behavior (OR 0.57, CI 0.38–0.85), and no school graduation (OR 0.59, CI 0.41–0.86). Individuals with pronounced paranoid or negative symptoms were also less compliant in taking their prescribed medication. There was no association between the initial inpatient antipsychotic medication regime and patients’ compliance. Individuals who switched from a typical to an atypical antipsychotic drug were more compliant than those with their typical antipsychotic drug maintained. Those with higher medication compliance showed significantly greater improvement of their psychiatric symptoms during the inpatient stay. Conclusion Patient-related in addition to disease-related factors may strongly influence medication compliance. Besides more compliance with atypicals supposed by the literature, there may be a higher propensity for atypical drugs to be prescribed to those assumed to be more compliant.

Nervenarzt, 2005

Behandlungsergebnisse und Leitlinienkonformität in ausgewählten Indikationsbereichen bei der stat... more Behandlungsergebnisse und Leitlinienkonformität in ausgewählten Indikationsbereichen bei der stationären Schizophreniebehandlung wurden anhand von 597 Patienten aus 7 psychiatrischen Kliniken systematisch dargestellt und verglichen. Es zeigten sich deutliche Unterschiede in der Patientenstruktur und den angewandten Behandlungsverfahren zwischen den Kliniken. Patientenmerkmale, insbesondere die Psychopathologie bei Aufnahme und die Chronizität der Erkrankung stellten sich als die stärksten patientenbezogenen Prädiktoren für den klinischen Status bei Entlassung heraus. Eine Beurteilung der Behandlungsqualität in den Kliniken mittels definierter Indikatoren ist nur eingeschränkt und nach einer Case-Mix-Adjustierung unter Berücksichtigung prognostisch relevanter Parameter möglich. In diesem Modell war ein ungünstigeres durchschnittliches Behandlungsergebnis im Klinikvergleich mit geringerer Leitlinienkonformität bei einer Reihe von Indikationsbereichen verbunden. Diese Ergebnisse unterstützen die Verwendung der Leitlinienkonformität in der Schizophreniebhandlung als zu vergleichendes Klinikmerkmal zur datengestützten internen Qualitätsoptimierung und lassen die Entwicklung von Strategien zur Steigerung der Leitlinienorientierung sinnvoll erscheinen. Patient outcome and guideline conformity in inpatient schizophrenia treatment was systematically evaluated and compared with 597 patients across seven psychiatric hospitals. Patient structure and treatment processes showed a great variability between hospitals. Patient characteristics, especially mental state, and the chronicity of the disease were the strongest predictors of clinical outcome. Outcome evaluation using quality indicators is only possible after case-mix adjustment taking into account prognostic factors. A poorer average clinical outcome was associated with lower guideline conformity in a variety of treatment domains. After case-mix adjustment, benchmarking is an opportunity to improve quality of treatment and promote guideline conformity.

Acta Psychiatrica Scandinavica, 2007

Objective: To identify evidence from comparative studies on the effects of psychiatric guideline... more Objective: To identify evidence from comparative studies on the effects of psychiatric guideline implementation on provider performance and patient outcome. Effects of different implementation strategies were reviewed.Method: Articles published between 1966 and March 2006 were searched through electronic databases and hand search. A systematic review of comparative studies of structured implementation of specific psychiatric guidelines was performed. Rates of guideline adherence, provider performance data, illness detection and diagnostic accuracy rates were extracted in addition to patient relevant outcome data.Results: Eighteen studies (nine randomized-controlled trials, six non-randomized-controlled studies and three quasiexperimental before-and-after studies) were identified. Effects on provider performance or patient outcome were moderate and temporary in most cases. Studies with positive outcomes used complex multifaceted interventions or specific psychological methods to implement guidelines.Conclusion: There is insufficient high-quality evidence to draw firm conclusions on the effects of implementation of specific psychiatric guidelines.