Course Of Inpatient Treatment Research Articles

Nighttime sleep quality & daytime sleepiness across inpatient psychiatric treatment is associated with clinical outcomes

Prior research has demonstrated the strong link between sleep disturbance and mental health outcomes, including the importance of examining nighttime sleep quality and daytime sleepiness as separate constructs in relation to mental health outcomes. As such, the current study examined patients’ self-reported nighttime sleep quality and daytime sleepiness trajectories over the course of inpatient treatment and how these trajectories related to treatment outcomes. Participants were 1,500 adults who voluntarily admitted to an inpatient psychiatric hospital. Mental health outcomes measured were emotion regulation problems, anxiety severity, depression severity, nightmare severity, and suicide risk. Group-based trajectory modeling was used to determine nighttime sleep quality and daytime sleepiness trajectory groups. Multivariate analyses of covariance (MANCOVA) were used to determine between group differences on mental health outcomes. Patients fit into distinct groups based on their trajectories of nighttime sleep quality and daytime sleepiness across inpatient psychiatric treatment: Low, Moderate, and High. Individuals with greater nighttime sleep disturbance and greater daytime sleepiness throughout treatment (High group) demonstrated significantly increased suicide risk, higher nightmare severity, more anxiety, more depression, and more emotion regulation difficulties at discharge. Results suggest an important connection exists between nighttime sleep quality and excessive daytime sleepiness and mental health outcomes for inpatient psychiatry.

Demographics and functional outcome of shallow water diving spinal injuries in northern Germany - A retrospective analysis of 160 consecutive cases

AimTo describe demographic findings, typical injuries and functional neurological outcomes in patients with cervical trauma and tetraplegia sustained after diving into shallow water. Patients and methodsA retrospective study was performed including all patients treated in BG Klinikum Hamburg suffering from tetraplegia after jumping into shallow water between 1st June 1980 and 31st July 2018. ResultsOne hundred and sixty patients with cervical spinal injuries and tetraplegia following a dive into shallow water were evaluated. Of these, 156 patients (97.5%) were male. The mean age was 24.3 years ± 8.1 and the accidents occurred most often in inland waters (56.2%) and mostly between May and August (90.6%). In all cases there was one vertebra fractured, whereas in 48.1% of cases, two vertebrae were severed. In the majority of cases (n = 146), a surgical procedure was performed. Overall, the mean hospital stay was 202 days (±72, range: 31–403) and one patient died. On admission, 106 patients (66.2%) showed a complete lesion according to AIS A, with incomplete lesions in the remaining 54 patients (AIS B: n = 25 [15.6%], AIS C: n = 26 [16.3%], AIS D: n = 3 [1.9%]). In two thirds of the patients, the level of paralysis on admission was at the level of segments C4 (31.9%) or C5 (33.7%). Seventeen patients (10.6%) needed prehospital resuscitation. In 55 patients (34.4%), the neurological findings improved during the course of inpatient treatment and rehabilitation. Sixty-eight patients (42.5%) developed pneumonia, of which 52 patients (76.5%) were ventilated. In addition, 56.5% of patients with paralysis levels C0–C3 required ventilation, whereas only 6.3% of patients with paralysis levels C6–C7 were affected. Three patients (1.9%) were discharged from hospital with continuous ventilation. Overall, 27.4% of all AIS A patients, 56% of all AIS B patients and 46.2% of all AIS C patients improved neurologically, with 17% of all patients being able to walk. ConclusionsThe consequences of a cervical spine injury after diving into shallow water are severe and lifelong. Functionally, patients may benefit from care in a specialised centre, both in the acute phase and during rehabilitation. The more incomplete the primary paralysis, the greater the possibility of neurological recovery.

PRINCIPLES OF TREATMENT AND REHABILITATION OF PATIENTS WITH SCHIZOPHRENIA WITH CONCOMITANT DIABETES MELLITUS

In the course of the differentiated treatment and rehabilitation measures carried out, in the majority of patients with schizophrenia with concomitant diabetes mellitus, after a course of inpatient treatment, psychotic symptoms were completely or partially reduced, relative criticism of their condition was formed, and the subjective assessment of their quality of life improved significantly. The revealed differences in the frequency of rehospitalizations between the first (with a higher level of QoL at admission) and the second (with a lower level of QoL at admission) subgroups of patients indicate better curability of patients with an initially higher quality of life and the advisability of a differentiated (taking into account QoL) treatment and rehabilitation approach to patients. It is assumed that the further use of the proposed treatment and rehabilitation programs focused on a dynamic detailed (by spheres and sub spheres) study of the quality of life of patients will lead to an increase in the compliance of mentally ill patients, the prevention of stigmatization and self-stigmatization, an increase in long-term remissions, as well as an improvement in their quality of life and social adaptation. Keywords: stigmatization and self-stigmatization, spheres and sub spheres.

Determinants of compulsory hospitalisation at admission and in the course of inpatient treatment in people with mental disorders—a retrospective analysis of health records of the four psychiatric hospitals of the city of Cologne

BackgroundWe aimed to identify differences in predictors of involuntary psychiatric hospitalisation depending on whether the inpatient stay was involuntary right from the beginning since admission or changed from voluntary to involuntary in the course of in-patient treatment.MethodsWe conducted an analysis of 1,773 mental health records of all cases treated under the Mental Health Act in the city of Cologne in the year 2011. 79.4% cases were admitted involuntarily and 20.6% were initially admitted on their own will and were detained later during the course of in-patient stay. We compared the clinical, sociodemographic, socioeconomic and environmental socioeconomic data (ESED) of the two groups. Finally, we employed two different machine learning decision-tree algorithms, Chi-squared Automatic Interaction Detection (CHAID) and Random Forest.ResultsMost of the investigated variables did not differ and those with significant differences showed consistently low effect sizes. In the CHAID analysis, the first node split was determined by the hospital the patient was treated at. The diagnosis of a psychotic disorder, an affective disorder, age, and previous outpatient treatment as well as the purchasing power per 100 inhabitants in the living area of the patients also played a role in the model. In the Random Forest, age and the treating hospital had the highest impact on the accuracy and decrease in Gini of the model. However, both models achieved a poor balanced accuracy. Overall, the decision-tree analyses did not yield a solid, causally interpretable prediction model.ConclusionCases with detention at admission and cases with detention in the course of in-patient treatment were largely similar in respect to the investigated variables. Our findings give no indication for possible differential preventive measures against coercion for the two subgroups. There is no need or rationale to differentiate the two subgroups in future studies.

Ineffective Drugs: Cerebrolysin and Piracetam

The study of drug efficacy is greatly importance, since the data obtained can be used as a scientific tool for re-evaluating drugs. The aim of the study is to evaluate the efficacy of cerebrolysin and piracetam in patients with acute ischemic stroke. The study included 124 patients with moderate acute ischemic stroke (AIS). All patients were divided into two experimental groups and one control group. The control group included 40 people receiving standard therapy (acetylsalicylic acid, lisinopril, nebivolol, pentoxifylline, L-lysine escinate). The cerebrolysin group consisted of 42 patients who additionally received cerebrolysin (10ml) in a volume of 200ml (0.9% NaCl) once a day. The piracetam group included 42 patients who additionally received piracetam (10ml) in a volume of 200ml (0.9% NaCl) three times a day. The course of inpatient treatment lasted 3 weeks. At the end of treatment, there was a significant (p <0.05) regression of neurological symptoms in patients with acute ischemic stroke in all comparison groups by 1.75 (p <0.05) times in the control group, by 1.85 (p < 0.05) in the cerebrolysin group and by 1.78 (p <0.05) in the piracetam group. There was no statistically significant intergroup difference (p> 0.05). The study results do not demonstrate clinical benefits of cerebrolysin and piracetam for treating acute ischemic stroke.

Study of motor load regulation training with visual feedback in patients with diabetic polyneuropathy

BACKGRAUND: Violation of gait and body balance in patients with diabetic polyneuropathy actualizes the development of new effective measures of motor rehabilitation. In this regard, an observation was carried out in which biofeedback training was used for the reference reaction in the conditions of variable feedback parameters.AIMS: To investigate the effect of a stepwise change in the depth of feedback (sensitivity) in a motor-cognitive task with visual feedback on the reference response to the result of its execution.METHODS: Single-sample observational observation with controlled conditions. 27 patients with diabetic polyneuropathy. All patients were treated according to modern standards. The observation was performed in one series at the beginning of the course of inpatient treatment. Estimation of body balance on a power platform — stabiloplatform) — stabilometry. The procedure included 5 stages of management, in which the patient followed the instructions (training) in which there was a stepwise increase in the depth of feedback («sensitivity») at each stage from 10 to 50% of the conditional «normal», with a step of 10%. A quantitative assessment of the external result (execution of instructions) and parameters of regulation of the vertical posture was carried out.RESULTS: All patients included in the follow-up showed that the implementation of instructions with increasing depth of feedback decreased sharply when the conditionally «normal» value was exceeded by 30–35%. At the same time, the initial parameters of vertical posture control in the sample patients did not affect the dynamics of results when performing the task with visual feedback. Factor analysis indicates the presence of the only significant factor associated with the effectiveness of performing a motor-cognitive task here — changes in the depth of feedback. The accepted significance level α = 0.05.CONCLUSIONS: The depth of feedback in motor-cognitive tasks with visual feedback is a key characteristic that affects performance. The ability to increase the depth of feedback in the range of about 35; from conditionally «normal», can be useful for ensuring differentiation of loads during motor rehabilitation of patients in order to increase the effectiveness of training. In addition, in theoretical terms, the proposed model of the motor-cognitive problem can be relevant in the study of «dual» problems, where the relationship of motor and cognitive components is studied.

The Role of Partnership Status and Relationship Satisfaction in Inpatient Mother-Child Treatment in Postpartum Mental Disorders

The Role of Partnership Status and Relationship Satisfaction in Inpatient Mother-Child Treatment in Postpartum Mental Disorders The study examines the partnership status and satisfaction in connection with symptoms of postpartum mental disorders, mother-child attachment and outcome of inpatient mother-child treatment. Two sub-studies were carried out. In the first study, N = 126 mothers with postpartum mental disorders who went to a preliminary consultation for inpatient mother-child treatment stated their symptom burden (SCL-90), mother-child attachment (PBQ) and satisfaction with their partner relationship (PFB-K). Mothers with stressed relationships showed the highest level of symptom burden and impaired attachment. Mothers without a partner reported the least amount of impairment in mother-child attachment. In the second study, N = 41 mothers were examined over the course of inpatient treatment (within-subject design with a waiting-list). The initial relationship satisfaction was not predictive of symptom reduction or improvement in mother-child attachment. An increase in satisfaction during the treatment was though correlated with an improvement in mother-child attachment.

Nutritional status and anxious and depressive symptoms in anorexia nervosa: a prospective study

The interweaving of malnutrition and symptoms of anxiety and depression in anorexia Nervosa (AN) is mentioned without any consensus regarding the course of anxious-depressive symptoms in relation to nutritional status in the course of treatment of patients with AN. The objectives of the current study in a large sample of AN inpatients were to assess the relationships between anxiety and depression symptoms and nutritional status both over the course of inpatient treatment and at discharge. 222 consecutive inpatients with AN (DSM-IV TR) were assessed (entrance and discharge) for duration of illness, psychiatric treatments, sociodemographic data and with psychometric scales for different psychopathological symptoms [depressive (BDI), anxiety and depressive (HAD scale), obsessive–compulsive (MOCI) and social phobia (LSAS fear score)]. Nutritional status was assessed with Body Mass Index (BMI) and body composition by bioelectrical impedance. The Fat free mass index [FFMI = FFM (kg)/height (m2)] was considered for the analysis. Two models were developed where the dependent variables were each psychopathological score at discharge (BDI, HAD anxiety, MOCI, and LSAS fear) in the cross-sectional model, and their variation in the longitudinal model (where a positive score reflected symptom decrease at discharge). A fixed set of predictors, defined on presumed clinical and statistical relevance (FFMI in the cross-sectional model and Variation of FFMI in the longitudinal model), were considered in each model, without any model selection procedure. This is the first study to confirm a positive relationship between the course of eating disorder symptoms and that of anxious-depressive symptoms during inpatient treatment of AN even after adjustment on a vast array of possibly confounding factors.

Time in treatment: Examining mental illness trajectories across inpatient psychiatric treatment

Early discharge or reduced length of stay for inpatient psychiatric patients is related to increased readmission rates and worse clinical outcomes including increased risk for suicide. Trajectories of mental illness outcomes have been identified as an important method for predicting the optimal length of stay but the distinguishing factors that separate trajectories remain unclear. We sought to identify the distinct classes of patients who demonstrated similar trajectories of mental illness over the course of inpatient treatment, and we explore the patient characteristics associated with these mental illness trajectories. We used data (N = 3406) from an inpatient psychiatric hospital with intermediate lengths of stay. Using growth mixture modeling, latent mental illness scores were derived from six mental illness indicators: psychological flexibility, emotion regulation problems, anxiety, depression, suicidal ideation, and disability. The patients were grouped into three distinct trajectory classes: (1) High-Risk, Rapid Improvement (HR-RI); (2) Low-Risk, Gradual Improvement (LR-GI); and (3) High-Risk, Gradual Improvement (HR-GI). The HR-GI was significantly younger than the other two classes. The HR-GI had significantly more female patients than males, while the LR-GI had more male patients than females. Our findings indicated that younger females had more severe mental illness at admission and only gradual improvement during the inpatient treatment period, and they remained in treatment for longer lengths of stay, than older males.

Peptide YY3\u201336 concentration in acute- and long-term recovered anorexia nervosa

PurposeThe gut–brain axis could be a possible key factor in the pathophysiology of anorexia nervosa. The neuropeptide peptide YY3–36, secreted by endocrine L cells of the gastrointestinal tract, is a known regulator of appetite and food intake. The objective of this study was to investigate peptide YY3–36 plasma concentrations at different stages of anorexia nervosa in a combined cross-sectional and longitudinal design to differentiate between effects of acute undernutrition and more enduring characteristics.MethodsWe measured fasting plasma peptide YY3–36 concentrations in young patients with acute anorexia nervosa (n = 47) and long-term recovered patients (n = 35) cross-sectionally in comparison to healthy control participants (n = 58), and longitudinally over the course of inpatient treatment. Physical activity was controlled as it may modulate peptide YY secretion.ResultsThere was no group difference in peptide YY3–36 concentration among young acutely underweight anorexia nervosa patients, long-term recovered anorexia nervosa patients, and healthy control participants. Longitudinally, there was no change in peptide YY3–36 concentration after short-term weight rehabilitation. For acute anorexia nervosa patients at admission to treatment, there was a negative correlation between peptide YY3–36 concentration and body mass index.ConclusionsThe current study provides additional evidence for a normal basal PYY3–36 concentration in AN. Future studies should study multiple appetite-regulating peptides and their complex interplay and also use research designs including a food challenge.

CARDIOVASCULAR INDICATORS AFTER ACUTE NEUROTOXIC POISONING

The aim of the study was to assess the recovery of the cardiovascular system after acute poisoning with neurotoxic substances at the time of discharge from the hospital. The results of treatment and observation of 28 cases of moderate, severe and extremely severe poisonings have been studied by the evaluation of indicators of the cardiovascular system at rest and during the orthostatic tests. It has been shown that in persons with acute poisoning with neurotoxic substances, the state of health is not fully restored by the end of the course of inpatient treatment. The indicators of the cardiovascular system showed the state of pronounced sympathicotonia in these patients at the time of discharge from the hospital. Persons with acute carbon monoxide poisoning have a pronounced tension in the mechanisms of regulation of the heart rhythm. In patients with acute oral poisoning with psychotropic drugs, an orthostatic test revealed an increased tone of the sympathetic part of the autonomic nervous system. The data of rhythmocardiography indicate a pronounced tension of the regulation mechanisms. Patients in this category require further observation and medical rehabilitation.

Implementing an evidence-based psychological intervention for suicidal thoughts and behaviors on an inpatient unit: Process, challenges, and initial findings

ObjectiveBarriers to implementing evidence-based psychological treatments for suicidal thoughts and behaviors in busy hospital settings exist. Transdiagnostic interventions may serve to facilitate training in evidence-based treatment and more efficiently treat individuals with multiple psychiatric comorbidities. We describe the rationale for, process of, and initial data from implementing the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) on an inpatient unit for adults with suicidal thoughts and behaviors and affective disorders. MethodWe analyzed clinical intake and outcome data from a subsample of patients admitted during the six months before and six months after UP implementation (n = 133 and n = 61, respectively), and available acceptability and fidelity data from the month following UP implementation. ResultsPatients improved significantly over the course of inpatient treatment before and after UP implementation. Effects for depression, suicidal ideation, anxiety, and emotion regulation were similar before and after UP implementation. Patients generally reported high acceptability of the UP and clinician fidelity to the protocol was variable during the month following UP implementation. ConclusionsThe UP may be a promising evidence-based intervention for inpatient settings that treat individuals with suicidal thoughts and behaviors. Well-controlled, randomized trials are needed to determine efficacy, particularly regarding suicidal behavior after discharge.

The effects of music therapy on the interaction of the self and emotions—An interim analysis

ObjectivesMusic therapy is a well-established non-verbal treatment method in psychiatry and psychosomatic medicine. However, empirical data of its impact on emotion modulation processes and personality dimensions are still sparce. An interesting concept is the use of music for emotion modulation in everyday life. The purpose of this interim study was to assess the interplay of personality dimensions and emotion modulation strategies in patients treated with music therapy versus patients without music therapy. DesignA cross-sectional design was used. SettingThe study was conducted during the course of inpatient treatment in a general psychiatric hospital. Data from n = 137 patients was included in the analysis. Main outcome measuresAccording to the mediator model a regression analysis was performed using personality variables as potential predictors and emotion modulation variables as outcome criteria. ResultsIn the music therapy group, insecurity predicted the use of music for both cognitive problem solving and positive stimulation in everyday life. In the non-music therapy group, cooperation and insouciance predicted the use of music for reduction of negative activation. ConclusionsSpecific personality dimensions predict greater targeted emotion modulation strategies if music therapy is applied than without it. That is, music therapy helps patients acquire more conscious (i.e. cognitive-related strategies) emotion modulation techniques by means of including their individual personality, whereas patients without music therapy simply "vent" their negative emotions (i.e. non-cognitive strategies). Conversely, the data suggest that music therapy can contribute to modify personality dimensions through the development of these emotion modulation strategies. This could be a plausible explanation for beneficial long-term effects of music therapy.

Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme

Previous research has demonstrated links between anorexia nervosa and autism spectrum disorder however, few studies have examined the possible impact of symptoms of autism spectrum disorder on clinical outcomes in anorexia nervosa. The aim of this study was to examine the association between symptoms of autism spectrum disorder and eating disorders, and other psychopathology during the course of inpatient treatment in individuals with anorexia nervosa. Participants with anorexia nervosa (n = 171) completed questionnaires exploring eating disorder psychopathology, symptoms of depression and anxiety, and everyday functioning at both admission and discharge. Characteristics associated with autism spectrum disorder were assessed using the Autism Spectrum Quotient, short version. Autism spectrum disorder symptoms were significantly positively correlated with eating disorder psychopathology, work and social functioning, and symptoms of depression and anxiety, but not with body mass index. Autism Spectrum Quotient, short version scores remained relatively stable from admission to discharge but there was a small, significant reduction in scores. There was no interaction between time and Autism Spectrum Quotient, short version scores on clinical symptom change. In anorexia nervosa, autism spectrum disorder symptoms appear to be associated with a more severe clinical presentation on admission to inpatient care. Autism spectrum disorder symptoms as assessed by self-report measures may be exacerbated by other mental health psychopathology, which warrants further investigation.

ADMINISTRATION OF IRON(III)-HYDROXIDE POLYMALTOSE IN THE TREATMENT OF IRON DEFICIENCY ANEMIA IN CHILDREN

Purpose of the study. To study the clinical efficacy and safety of iron(III)-hydroxide polymaltose (Maltofer) in the treatment of iron deficiency anemia in children. Material and methods . A retrospective study of medical records of pediatic patients with iron deficiency anemia who received iron(III)-hydroxide polymaltose in standard doses during the course of inpatient treatment. Results. Administraton of iron(III)-hydroxide polymaltose was associated with a positive dynamics of the studied hematological parameters. No adverse reactions were reported. Girls demonstrated a more significant increase in hemoglobin levels and a more significant increase in the color index and mean cell hemoglobin compared to boys.

The change process in adult anorexia nervosa inpatient treatment: a path model.

Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment. We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model. The sample had a mean age of 27.1years (SD=8.9years) and a mean BMI at admission of 15.0kg/m2 (SD=1.6kg/m2). A greater basic need satisfaction and a greater emotional involvement and commitment to treatment at t0 positively influenced the BMI at t1. Furthermore, greater basic need satisfaction at t0 led to less AN-specific cognitions and behaviours at t2. The results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.

Exploration of Friendship Experiences, before and after Illness Onset in Females with Anorexia Nervosa: A Qualitative Study.

BackgroundDifficulties with social relationships have been implicated in both the development and maintenance of Anorexia Nervosa (AN) but the friendship experiences of individuals with AN have not been explored in depth.MethodTen adults with AN took part in a semi-structured interview about their friendship experiences both before and since the onset of their illness.ResultsFive principle themes were identified through thematic analysis: Social Concern; Impact of AN; Social Connectedness; Inflexibility and Preferred Social Activity. Difficulties with friendship were present prior to the onset of AN in all cases, with participants experiencing anxiety in relation to various aspects of their friendships. Participants described mixed experiences of how their AN has affected their friendships but most participants described having less contact with their friends since becoming unwell.ConclusionThis research highlights the role that social difficulties may play in the development of AN, whilst also emphasising the importance of addressing problems with friendship in the course of inpatient treatment.

Emotional Intolerance and Core Features of Anorexia Nervosa: A Dynamic Interaction during Inpatient Treatment? Results from a Longitudinal Diary Study.

ObjectiveThe role of emotion dysregulation with regard to the psychopathology of anorexia nervosa (AN) is increasingly discussed. It is both assumed that AN symptoms have an impact on difficulties in tolerating aversive emotions and that—conversely—emotion dysregulation influences AN. To date, such conclusions are drawn on the basis of cross-sectional data not allowing for inferences on the temporal dynamics. The current study investigates the longitudinal interaction between emotional intolerance and core AN symptoms over the course of inpatient treatment by comparing patients with high (BMI<15 kg/m2) vs. low symptom severity (HSS vs. LSS).MethodThe study adopted a longitudinal, process-oriented design with N = 16 analysed electronic diaries. Throughout the course of their inpatient treatment, the patients answered questions daily about emotional intolerance and their AN-specific cognitions and behaviours. The temporal dynamics between emotional intolerance and these variables were analysed using a multivariate time series approach.ResultsThe time series of the processes under investigation adequately reflected the individual treatment courses. The majority of significant linear time trends was found for HSS patients. Most importantly, analysis revealed significant temporal interactions between emotional intolerance and AN symptoms in almost 70% of HSS patients. Thereby, up to 37% of variance in eating restraint and up to 23% in weight concern could be attributed to changes in emotional intolerance.ConclusionsThe findings support the notion that intolerable unpleasant emotions in severely affected AN patients influence their psychopathology. Additionally, time series analysis outlined the inter-individual heterogeneity of psychosomatic treatment courses of AN patients.

Optimized Patient Transfer through Innovative Multidisciplinary Assessment: Project Description of Phase I

Introduction: OPTIMA is a multi-professional quality management and research project, conducted at the Cantonal Hospital of Aarau (KSA), Switzerland in cooperation with post-acute care institutions from November 2009 until December 2012. Objective: The goal of this study was to optimize patient care pathways and to provide patient-centered, costeffective care that is conform with the introduction of the Diagnosis Related Groups (DRG) in 2012. Methods: The “Post-Acute Care Discharge Scores” (PACD) was applied to assess the risk for transfer to postacute care facilities in 240 patients suffering from lower respiratory tract infections during the first phase of the study (OPTIMA I) from October 2009 until April 2010. In order to assess the patients’ self-care ability, the “Self-Care Index” (SPI) tool was applied on admission and during the course of inpatient treatment. Results: The PACD predicted that 55% of patients (N=202) were at medium to high risk of requiring post-acute care. According to the SPI, 38% of patients (N=217) showed reduced ability to care for themselves. The discharge of 69% of medically stable patients (N=43) was postponed due to shortage of beds in post-acute care facilities. Correspondingly, 62% of the medically stable patients (N=141) could imagine receiving post-acute care in a “Nurseled Unit” (NLU). Despite being medically stable, one third of the patients (N=124) was not ready to return to their homes because they felt too weak or insecure to cope with everyday life. Conclusion: Using standardized tools to predict patients at risk for transfer to post-acute care facilities and reduced self-care abilities and the continuous evaluation of medical stability are all methods that could be applied to enhance interdisciplinary care and optimize discharge management. Furthermore, setting up NLU is expected to unburden the occupancy of acute care beds by a considerable amount of patients who are in need of post-acute care.

Clinical Anecdotes: A Logic in Madness

Clinical Anecdotes:A Logic in Madness Aaron J. Hauptman (bio) Key Words autonomy, rationality, mental illness, ethics The ultimate language of madness is that of reason. (Foucault 1961/1988, 95) In short, under the chaotic and manifest delirium reigns the order of a secret delirium. In this second delirium, which is, in a sense, pure reason, reason delivered of all the external tinsel of dementia, is located the paradoxical truth of madness. And this in a double sense, since we find here both what makes madness true (irrefutable logic, perfectly organized discourse, faultless connection in the transparency of a virtual language) and what makes it truly madness (its own nature, the special style of all its manifestations, and the internal structure of delirium). (Foucault 1961/1988, 91) At the urging of his parents, Mr. A, a college-age young man with a past diagnosis of Asperger’s syndrome, presented for assessment to an inpatient psychiatric hospital after making suicidal statements. He had been in his normal state of health and functioning well until a few months before presentation, at which point he had precipitously fallen into a severe depression. The trigger was the abrupt end of a 1-year-long relationship. This had been an exclusively online, romantic relationship that ended terribly and with a sudden shock after being cruelly manipulated by the other party. For his part, he had seen his partner as the love of his life and expected that they would meet in person and marry. A series of frantic moves after his significant other failed to show up for their planned in-person tryst resulted in his discovering the extent to which he was being manipulated, and the relationship was immediately broken off. A bright young man with classic symptoms of high-functioning autistic spectrum disorder, including concrete thinking and often considerable struggle with interpersonal relationships secondary to challenges in intuiting other peoples’ mental and emotional states, he had never been in a romantic relationship before and this turn of events was crushing. On assessment, he was clearly depressed. He admitted to sleep disturbance, loss of interest in activities, long periods of low energy that he spent in bed, weight loss owing to lack of appetite, subjective depression, and thoughts of death, all classic symptoms of severe major depression. He had been unable to get out of bed for months before this assessment and had ceased showering and changing clothes except for infrequent instances that came about at the desperate urging of his family. At the time of his presentation, he was increasingly vocal about desiring to let himself starve to death and he had already lost considerable weight. Clearly, he posed a risk to himself and his situation warranted a course of inpatient treatment. Begrudgingly, he accepted voluntary hospital admission. Once settled in, however, he made it very clear that under no circumstances would he use psychotropic medication. Electroconvulsive [End Page 303] therapy: clearly also not an option. Despite his depression, he had a doggedness with rationality, characteristic of his diagnosis of autism, and, although he still would not shower or shave, he would settle in readily to debate the logic of his treatment. His argument went along the following lines: I am depressed for a very good reason and if, because of that, I have these feelings then it is right for me to have these feelings. An artificial change of course, he seemed to feel, would be dishonest. He was still in love. He knew at this point that his love’s object was a fiction, but to him this did not change things. An improvement based on anything but an internally driven shift in his thinking was indefensible to him. A number of people tried to argue with him. “You could have started off depressed for a good reason,” one would say, “but then it became something organic.” “Depression is always organic, isn’t it? It is in your brain!” he would reply. He would argue that reneging on the love of his life would make him despicable and dishonest. He seemed to feel that the only thing left to attach him to the emotion and the promise of...