Schweizer Archiv für Neurologie, Psychiatrie und Psychotherapie – Archives suisses de neurologie, psychiatrie et psychothérapie
114 Chiara S. Haller, Bernhard Walder Severe traumatic brain injury in high-income countries
120 Yahya Elsaghe Identitätsbildende und -konsolidierende Funktion fiktionaler Texte
4 25.5. 2016
Swiss Archives of Neurology, Psychiatry and Psychotherapy
108 Norman Sartorius Psychiatry and society, 2015
www.sanp.ch www.asnp.ch
125 Fabienne Giuliani, Pierre El Korh Troubles du spectre de l’autisme: stratégies compensatoires
105
TABLE OF CONTENTS
Editorial Board Prof. Dr. Joachim Küchenhoff, Liestal (Ed. in chief); Prof. Dr Jacques Besson, Lausanne (Ed. in chief); Prof. Dr. Silke Bachmann, Littenheid; Dr. Katharina Blatter, Basel (Managing editor); Prof. Dr Philippe Conus, Prilly; Prof. Dr. Daniel Hell, Meilen (Senior editor); Prof. Dr. Marc Graf, Basel; CC Dr Dora Knauer, Genève; Dr. Bernhard Küchenhoff, Zürich; Dr. Natalie Marty, Basel (Managing editor); Prof. Dr. Egemen Savaskan, Zürich; Prof. Dr Andreas Steck, Epalinges; Dr. Karl Studer, Münsterlingen; Dr. Thomas von Salis, Zürich Advisory Boards The members of the advisory boards are listed on www.sanp.ch
In memoriam
Daniel Hell, Meilen
107 Markus Binswanger (1949–2016)
Review articles
Psychiatry and society, 2015
The development of psychiatry, perhaps even more than other medical disciplines, depends on
Norman Sartorius
108
socioeconomic and cultural factors in the environment in which the discipline is to function.
Severe traumatic brain injury in high-income countries
Severe traumatic brain injury is a silent epidemic, and a medical, social and economic burden
Chiara S. Haller, Bernhard Walder
114
in high-income countries.
Original articles
Yahya Elsaghe
120
Identitätsbildende und -konsolidierende Funktion fiktionaler Texte Ein komplexes Identifikationsangebot an die Leserinnen und Leser.
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106
TABLE OF CONTENTS
Troubles du spectre de l’autisme: stratégies compensatoires La personne TSA reste dans un processus réactif mettant en jeu un feed-back perceptif continu.
Fabienne Giuliani, Pierre El Korh
125
Film analysis
Les troubles dissociatifs dans le film Spellbound
Tina Mazza, Julien Manetti, Daniele Zullino, Gerard Calzada
130
132 Buchbesprechung
Book review
Wenn Bilder reden, gehen, klingen Dieses Buch präsentiert eine grosse Ideensammlung zum Bildnerischen Gestalten. Die Ideen von Otto Heigold zum Erschaffen, Experimentieren, für das Wahrnehmen, Vernetzen und Üben führen mitten hinein in die Welt des Bildes – die Schaffenden können sagen: ICH BIN IM BILD. Die Anregungen des Primarlehrers und Künstlers sind bestechend einfach und faszinierend, kombinier- und erweiterbar. Bildnerisches Gestalten von der Basisstufe bis zur 6. Klasse. Und für alle, die an ästhetischen Prozessen interessiert sind.
Otto Heigold ¡ ICH BIN IM BILD
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Swiss Archives of Neurology, Psychiatry and Psychotherapy – Schweizer Archiv für Neurologie, Psychiatrie und Psychotherapie – Archives suisses de neurologie, psychiatrie et psychothérapie Founded in 1917 by C. von Monakow.
Cover image: Galerie ERGASIA du service de psychiatrie communautaire du CHUV.
107
IN MEMORIAM
«Begegnung auf gleicher Augenhöhe»
Markus Binswanger (1949–2016) Daniel Hell, Meilen
tät und Solidarität, die ihn als Chef glaubwürdig
Herzversagen. Die Schweizer Psychiatrie und Psycho
machten.
therapie verliert mit ihm eine enorm kompetente, ein
In den Gremien des Schweizer Gesundheitswesens,
satzfreudige und weitsichtige Persönlichkeit. Markus
insbesondere in denjenigen der Psychiatrie, nahm er
Binswanger hat als früherer Chefarzt und Mitglied vie
auf eine ebenso vornehm zurückhaltende wie sachlich
ler Gremien in den letzten Jahrzehnten unser Fach
überzeugende Weise Einfluss auf viele Entscheidun
gebiet wesentlich mitgeprägt.
gen. Trotz seiner profilierten Ansichten ging es ihm
Wie ein Vermächtnis sind seine Worte im Internet
aber auch hier um ein Miteinander statt um ein Gegen
nachzuhören, die er kurz vor seinem Tode am Schwei
einander. Er war Erneuerer und Vermittler zugleich.
zer Radio DRS 1 über sein ihn prägendes familiäres
Nach seiner Pensionierung als ärztlicher Direktor im
Milieu zum Ausdruck brachte. Aus seinen bewegenden
März 2012 engagierte er sich weiter für die Aus , Weiter
Sätzen – gerade auch über seinen Grossvater Ludwig
und Fortbildung in Psychiatrie und Psychotherapie,
Binswanger, den Begründer der Daseinsanalyse – ist
aber auch für die besonderen Interessen und Bedürf
zu schliessen, was auch für ihn im Zentrum stand:
nisse psychisch Kranker zum Beispiel in Selbsthilfe
«Begegnung auf gleicher Augenhöhe». Damit ist ein
gruppen. Beides, wissenschaftliche Bildung und mit
Eingehen auf den Kranken ohne Scheuklappen ge
menschliches Engagement, ging für ihn Hand in Hand.
meint, ein Teilnehmen, das sich weder aufdrängt noch
Daneben führte er zusammen mit seiner Frau, Anita
sich als Subjekt herausnimmt.
Landolt Binswanger, eine Privatpraxis in Wil. Hier
Markus Binswanger ist in der Privatklinik Bellevue
konnte er seine dialogische Grundhaltung nochmals
in Kreuzlingen aufgewachsen. «Den Tisch teilten wir
auf neue Weise praktizieren, was ihm viel Freude
mit Angestellten, Ärzten, Pflegenden und Patienten.
machte. Was er in therapeutischen Begegnungen
Alle lebten auf der grossen Anlage, wir musizierten
wahrnahm, schärfte seinen kritischen Blick für die
zusammen, spielten zusammen Tennis. Für mich als
gesellschaftlichen Bedingungen heutiger psychischer
Kind war es unbedeutend, ob jemand Angestellter oder
Problemstellungen. Er veröffentlichte wesentliche
Patient war.»
Beiträge zum Zusammenhang von Persönlichkeits
Nach dem Medizinstudium wandte er sich, wie vier
entwicklung und Soziokultur. Dabei analysierte er
Generationen vor ihm, der Psychiatrie und Psycho
auch die Folgen heutiger gesellschaftlicher Verhält
therapie zu. Seine Facharztweiterbildung absolvierte
nisse auf bestimmte psychiatrische Krankheitsbilder.
er im Raum Zürich, wobei ihn in dieser Zeit vor allem
Ein besonderes Risiko sah er darin, dass extra und
die Psychoanalyse faszinierte. Nach einer mehrjähri
intrapsychische Konflikte und Ambivalenzen unge
gen Tätigkeit als Oberarzt und leitender Arzt an der
nügend ausgehalten und durchgearbeitet werden.
Psychiatrischen Klinik Hohenegg übernahm er 1991 als
Mit dem Tod von Markus Binswanger ist eine Stimme
Chefarzt und ärztlicher Direktor die Klinik Littenheid.
verstummt, die für unser Fach wichtig war und für
Das sollte sich für diese Klinik als Glücksfall erweisen.
die schwierige Zukunft sicher noch wichtiger wäre.
In seinem 22 jährigen Wirken als Chefarzt gelang es
Manche aus unserem Fachgebiet verlieren einen
ihm, in einem komplizierten Umfeld mit vielfältigen
Menschen, auf den man zählen konnte, der in lie
Vertragsbeziehungen die Klinik so zu positionieren,
benswürdiger und humorvoller Weise auf kritische
dass sie Vorbildcharakter bekam. Dazu trugen sein
Punkte hinweisen konnte. Er hat mit seinem weiten
ausserordentliches Engagement, sein stupendes Wis
Herzen viel gegeben, bis es plötzlich aufgehört hat
sen und sein grosses Interesse an berufspolitischen
zu schlagen.
SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY
2016;167(4):107
-
-
-
-
-
Fragen bei, aber auch seine unbeschränkte Loyali
völlig unerwartet im 67. Lebensjahr an einem akuten
Am 11. April 2016 verstarb Dr. med. Markus Binswanger
108
REVIEW ARTICLE
Based on a lecture at the annual meeting of the Swiss Society of Psychiatry
Psychiatry and society, 2015 Norman Sartorius President, Association for the improvement of mental health programs, Geneva, Switzerland
The commoditification trend is particularly harmful
Summary
to psychiatry. Most of the seriously mentally ill find
The development of psychiatry, perhaps even more than other medical
because of stigma and discrimination, partly because of self stigmatisation – and it is not easy to make an -
disciplines, depends on socioeconomic and cultural factors in the environ-
it very difficult to enter the work force again – partly
ment in which the discipline is to function. In this article I shall review
the impact of some of the trends in society’s development, then refer to changes in the form and frequency of mental disorders and finish with a review of paradigms of mental health care which may need to be reexamined and possibly changed.
economic argument for a massive investment into their treatment and rehabilitation. The commodifica tion trend also affects the choice of postgraduate train ing, which will to a significant degree depend on an
assessment of the benefits that a young graduate can
Key words: social psychiatry, humanities, health services, psychiatry, mental health
expect when selecting a particular discipline for post graduate training: in this respect psychiatry fares
poorly, as witnessed by the continuing reduction in numbers and proportions of those selecting psychia
Trends of society’s development with particular relevance for psychiatry
try as their profession in many countries. Since quality is measured by cost, family members and other non professional carers will also try to have their relatives treated in the best – and now the most expensive – institution, which will often completely deplete
“Commodification”, a word that has entered the Eng
their resources: if the treatment has to continue, they
lish language only recently, refers to the trend of mea
often find themselves unable to continue in the role
suring all things with economic indicators, as if they
of carer.
Commodification
were a commodity – like sugar, cotton, timber or iron. Demographic changes and trends are also affecting
introduced into fields such as medicine. When this
psychiatry. The increasing numbers and proportions
happens economic indicators prevail in the evaluation
of the elderly in the populations increase the probabil
of performance, in the manner and place of invest
ity of an increase of prevalence of comorbidity of men
ment and in the mechanisms of control of quality.
tal and physical diseases. The increasing prevalence of
Thus a hospital will be judged by the profit it makes,
comorbidity is also a reflection of medicine’s successes
not by the numbers of patients who have been treated
in the prolongation of life of people with chronic dis
agreeably and in an effective way. Prescribing the
eases – people who are at particularly high risk of ac
cheapest medication of a class will be allowed: the pre
quiring mental diseases in addition to their chronic
scription of any other drug of that class will have to be
ailment. This represents a major challenge for the
justified in a sometimes complex manner. Hospital
health care systems in industrialised countries and
directors will encourage the use of new and often
soon also in other countries. The health systems are
expensive diagnostic procedures in wards housing
not prepared to deal with the comorbidity of mental
patients who have a good health insurance contract
and physical illness. Psychiatrists have often not kept
because their use can give the hospital a handsome
abreast with developments in medicine in general and
different in the instance
profit and sometimes help in making the correct
feel incompetent – and in part for that reason also un
of depression – many
diagnosis. The replacement of the ethical imperative
willing – to deal with physical illness in people who
specialists of internal
to help those in distress – such as patients – by the
have mental disorders. The situation is similar with
medicine will prescribe
economical imperative to make money using medi
general practitioners and with specialists in various
patients who have depres
cine affects practice and other components of medi
disciplines of medicine, all of whom do not feel confi
sive symptoms – regard
cine such as medical education, research and colla
dent when it comes to the treatment of mental illness.
boration with other scientific disciplines and social
The tradition of geographic separation of psychiatric
services.
and general medical institutions makes things worse.1
less of whether these are part of a depressive
disorder or not.
SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY
antidepressants to their
general practitioners and
1 The situation is somewhat
Demographic changes
ties but becomes profoundly disturbing once it is
This is fine and acceptable for dealing with commodi
2016;167(4):108–113
109
Urbanisation
schizophrenia or of obsessional disorders in a person
The demographic changes are partly due to the now
with severe myxoedema – or any other combination of
ubiquitous rapid urbanisation. In most countries of
diseases whose management requires solid knowledge
the world more than 50% of the population live in
of the comorbid diseases and their treatment – is likely
towns, and the numbers of urban dwellers are growing.
to be much less often competently handled by a single
Urbanisation presents some difficulties and some
physician. The strategy of having two or more special
advantages to mental health service. The advantage is
ists participate in the treatment is also not yet a solu
that people with mental health problems who, while
tion – the collaboration between specialists in care
dwelling in remote villages, could not reach mental
often presents difficulties even when there are many of
health services now can do so. The difficulty is that
them and easily accessible: the situation is of course
mental health services in towns are often overbur
worse in countries or regions in which the numbers of
dened by the influx of people with mental illness and
specialists is limited.
that the previously existing communities in towns are
The treatment of a kidney disease in a person with
REVIEW ARTICLE
losing their cohesion, identity and readiness to help
Changes of family structure
those in need.
The changes of family structure and its functioning are Rural–urban migration leads to massive changes of
bers of stable and lasting families in many countries
society, particularly when it is simultaneous with the
weakens the role of the family as provider of care for its
immigration of people from other countries. The poor
members. This change is not yet ubiquitous, but it is
est countries receive by far the greatest numbers of
likely that it will become universal. Second, the family
ref ugees and immigrants, but the numbers of those
has been the main transmitter of culture, and growing
entering highly industrialised countries has also
up in a family was a way of adopting a system of values
grown in the past few decades. Immigrants bring with
and becoming a member of a group with shared tradi
them their ways of being ill, which gradually change so
tions: entering into the world without that orientation
that the ways of expressing their diseases are no longer
and with an uncertainty about values that should
similar to the way of disease expression of their home
govern action makes maturing into a useful and well
country and not yet similar to the way in which dis
-
at least two major ways. First, the reduction in the num
Migration and immigration
another demographic factor relevant to psychiatry, in
difficult to recognise and treat. This is only one of the
view of the changes to the educational system, which
problems that immigration creates for health services.
in developed countries continues to postpone the
Others stem from the sudden increase in needs for
placement of responsibility on the shoulders of those
services and from the fact that migrants who arrive in
growing up. Whereas in a number of countries girls
developed countries rarely come accompanied by fam
aged 15 years are married and in others boys have to
ilies who could provide them with help if they fall ill.
work for their upkeep from an even earlier age the vast
Migration produces even more difficulties for the
majority of youngsters of highly industrialised coun
donor countries. Continuously losing able bodied and
tries are in schooling and free of any responsibility
healthy members, the communities in many of the
until they reach the age of 20 or – if they enter univer
host countries are ailing – they are composed of chil
sity – the age of 26 or more. The long lasting latency of
dren, those who could not migrate because of disease
responsibility of fully grown up young people repre
(particularly because of mental disorder) and disabil
sents a risk factor for mental disorders and for socially
ity, and those who had to return from the richer coun
unacceptable behaviour that is often the result of the
tries because of illness. The main source of income for
tendency of youth to seek to overcome challenges. The
such communities is the money sent home by mi
misbehaving adolescent and adolescents with mental
grants who have found employment abroad or in
disorders or passing through a crisis – the subject of
towns. With time this kind of support is drying up,
many a conference and consultation – are clearly an
thus creating problems for which no country has yet
issue for society and health services in the developed
found a satisfactory solution.
-
-
eases are seen in the host country. They are therefore
The latter development is all the more important in
balanced person a much more chancy process.
world, likely soon to become universal. Handling these
The changing position of women in society
lack of an organised transition and of collaborative
The changing position of women in society also has
arrangements between the mental health services
consequences for mental health care. Traditionally, in
offered to children, adolescents and adults.
many societies women brought up children, trans
SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY
problems is made even more difficult because of the
2016;167(4):108–113
110
to those in the Third World. In addition to the move
eased and elderly, took care of the home and partici
ment of goods, globalisation also contributed to the
pated in the work in the fields. The entrance of women
transfer of value systems and ideals of social organisa
into professions meant an extra burden for them
tion from the economically powerful industrialised
because there were no ready candidates to take on the
world to settings where survival depended on other
roles that they play in society. Sometimes they break
sociocultural rules. An example of this development
down under the load of responsibilities with condi
was the insistence on personal independence as a goal
tions such as “exhaustion depression” described by
of treatment and rehabilitation of people with mental
P. Kielholz nearly a century ago. Others reduce their
illness in settings in which interdependence has been a
engagement in traditional roles, which means that the
strategy of survival for the sick and the healthy from
need for care for the chronically disabled becomes
time immemorial.
mitted cultural values, looked after the disabled, dis
REVIEW ARTICLE
greater, that the education of children is passed on to the schools (which often refuse to take it on, arguing that they will transmit knowledge but that the educa tion of the child for life is by and large the responsibil
Mental disorders and their changes in recent years
ity of the parents) and that societies begin to lose their General education in developed countries has reached
countries seek the solution to this problem by increas
almost all children and adolescents and it is possible
ing the number of part time employment opportuni
that the disappearance of some of the dramatic forms
ties and facilitating the participation of fathers in child
of schizophrenia (such as its catatonic and hebephrenic
upbringing by granting paternal leave after childbirth;
forms) and of other psychoses in general is linked
others rely more heavily on immigrants (who are
to education and increasing capacity to express
sometimes poorly trained and do not speak the lan
experiences and inner feelings learned in school and
guage of the parents very well) taking on the rearing of
by exposure to ever more present media. The fact that
children and other roles traditionally played by
dramatic forms of mental illness are still seen in poor
women. An equitable solution allowing both women
countries and that they seem to be becoming rarer in
and men to work and share their responsibilities in
parallel with the increased coverage of the population
fulfilling the tasks previously completed by women
by schooling, television and other technological com
has yet to be found: meanwhile the problems listed
munication innovations might be seen as support for
above will continue to present a significant risk for the
this hypothesis.
health of the population.
In addition to the disappearance of dramatic forms
-
previously helped the functioning of the society. Some
Changes of the clinical picture of mental illness
cultural identity and adherence to a value system that
of psychoses (such as extreme megalomaniac delu of mental disorders have also been recorded in recent
mental health and for the organisation of mental
years. They are not as well described as those that were
health services: “insularisation” and globalisation. The
portrayed in the 19th and 20th century, possibly
first, “insularisation”, refers to the paradox of commu
because their symptoms are still changing. Depres
nication in modern society where – in parallel to the
sion, early onset of bipolar disorder in children and
ever greater possibility of being in touch with others
attention deficit hyperactivity disorder (ADHD) are
with e mail, iPhones, Internet links and related devel
among these, but the list is much longer.
opments – there is an increasing number of people
There are also problems that are linked to longer life
who feel lonely and miss direct human contacts, old
expectancy, such as in the instance of schizophrenias.
-
sions), several other changes in the form and severity
Two further trends are of significant relevance for
-
Insularisation and globalisation
deprived of the support of their mothers and fathers,
ducive to good health and quality of life. The other
who might have died or been struck by dementia and
major development is globalisation – a trend that at its
other ailments frequent at older age. Their clinical
beginning was seen as being very positive, promising
picture presents a mixture of symptoms of chronic
open borders, a free exchange of goods and ideas and a
schizophrenia and of signs of accelerated cognitive
stronger effort to help the world’s poorest – but over
decline, and their capacity to look after themselves
time became little more than a one way transfer of
(and sometimes also after their old parents) may be
goods and ideas from the highly developed countries
minimal. The reduction of the capacity of mental
-
2016;167(4):108–113
SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY
countries, often reaching old age and find themselves
particularly in older age groups, most of them not con
Persons with schizophrenia are now, in industrialised
Loneliness has a variety of psychological consequences,
fashioned friendships and emotional engagement.
111
orders in the past and to the rarity of well designed
reasons) of the previously promoted transitional in
studies of incidence in most parts of the world in our
stitutions such as day and night hospitals, sheltered
times. The reports about the increasing prevalence and
housing and foster family accommodation makes the
incidence of mental disorders have probably also been
management of problems of this type a major and
influenced by the fact that the development of services
growing challenge.
for mental illness and the possibility of treating them
-
hospitals and the disappearance (mainly for economic
REVIEW ARTICLE
with medications like other diseases has increased the psychiatric help.
number of people who come forward asking for
A variety of psychological conditions including burn
-
The uncertainty about “marginal” states out syndromes, malaise, marital problems, child misbe
Some new forms of mental disorder have also been
many others have emerged as candidates for disorders
described and their frequency and consequences are
that should be handled by psychiatrists, psychologists
a serious concern for public health authorities. These
or alternative medical practitioners (e.g., those prac
include behavioural addictions severely damaging in
ticing homeopathy, Ayurveda or acupuncture). The evi
dividuals who acquire them – such as addiction to
dence of efficacy of methods employed to deal with
gambling, to excessive physical exercise, to the Inter
most of these conditions is feeble or nonexistent but
net – and a new set of cognitive impairment syn
none of the professions listed has until now because of
dromes. The latter are related to the increasing com
that categorically refused to deal with them. Most of
plexity of the modern world that makes mild cognitive
these states are not life threatening although they are
impairment a significant disadvantage and obstacle
sometimes the “straw that breaks the camel’s back”, a
for normal life and to the aging of populations which
problem that comes as an addition to other life prob
brings with it an increase in the number of people with
lems and illnesses and triggers destructive acts such as
senescent memory difficulties.
-
New forms of mental disorders
eating, mild cognitive problems of senescence and
haviour, some posttraumatic states, occasional binge
suicide.
Increasing prevalence of mental illness The prevalence and the apparent prevalence – the
Paradigms of mental health service: need for revisions defined in the second part of the 20th century included:
seem to have grown in recent decades. Among the rea
a) a continuous effort to reduce the number of mental
sons for this increase are the extension of life
hospitals and reduce the size of those that have not
The principles of mental health service organisation
well defined psychiatric syndromes such as depression -
awareness of the presence of disorders – of some of the
been disestablished;
expectancy of people with mental disorders (although
b) the placement of mental health services in the pri
higher than the mortality of people without mental
mary health care services in communities which
the mortality of people with mental disorders is still disorders), the better recognition of depressive disor
they are to serve; c) the reliance on the strategy of community care
and the changes of the demographic structure with an
for the mentally ill and impaired (including their
ders by medical practitioners and by the population,
other disorders have appeared in recent years, thus for
treatment of mental illness to the general practi
example the mental disorders due to acquired immu
tioners and other services; and
d) task shifting – the transfer of responsibility for the
reinsertion into communities and rehabilitation);
age of increased risk for depressive disorders. Some
increase of the numbers of people who survive into the
e) in some low income countries the selection of
problems such as those related to quaternary syphilis
“priority conditions” disorders such as schizo
(progressive paresis) and vitamin B deficiency have
phrenia and epilepsy which will be given priority
practically vanished.
(concerning funding of care, education about their
nodeficiency syndrome while others previously major
treatment, etc.). Recent years have clearly demonstrated that the above
It is possible, although it has not been demonstrated,
principles will have to be amended, adjusted to the
that the incidence of mental disorders has also in
current and future situation concerning care and
creased. The uncertainty about the changes of inci
treatment.
dence of mental disorders is to a large extent due to the
SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY
lack of evidence about the incidence of mental dis
2016;167(4):108–113
Incidence of mental illness: has it changed?
112
Closure of mental hospitals
that would have followed treatment and recognition
The consequences of the abrupt closure of mental
that they are in treatment for mental illness in their
hospitals have not been as beneficial as it was hoped.
own setting.
The services which were supposed to take on the care
The insistence on community care as the main form
of people who were interned in mental hospitals have
of mental health service provision hit two other prob
only rarely been sufficiently strengthened to take on
lems as well. First, in many places the communities of
their new task. In some instances the closure of mental
the type that the originators of the community care
hospitals resulted in a major increase of numbers of
strategy had in mind when composing the strategy
mentally ill people admitted to prisons. This trans
have vanished from many countries and are likely to
-
dwelling meant that neighbours do not know each
changes were that the judicial system now bore the
other and are unlikely to offer help or accept a person
cost that was previously paid by the health system and
with mental illness as one of their community. The
that the people with mental illness received even less
diminution of the size of families, with a predomi
medical care than before. In other instances the men
nance of nuclear families in which both adults are out
tally ill ejected from hospitals became vagrants and it
to work and the children are in school, further reduced
is likely – although the evidence about their fate is
the creation of ties and connections among people
scarce – that their mortality was heightened and that
living on the same territory. The second problem was
their life was one of misery. The diminution of number
that of staff attitudes. Most of those employed in
of patients treated in mental hospitals did not neces
mental health services entered the profession with
sarily lead to a better service, more human contact and
the expectation of working in an institution, possibly
more competent care: in some places the buildings
and probably next to departments of other specialties.
previously used to house the patients were left to decay
The notion that the service will be outside of institu
making the mental hospital even more frightening
tions and far from colleagues who could offer help and
than it was. Where the reduction of size of mental
advice if necessary is not particularly attractive to staff
hospitals went hand in hand with better service the
who therefore often tried to slow down the move out of
patients experienced clear benefits and in instances
the facilities to areas – sometimes slums – presenting
in which they were located in the community which
danger to those working there or just being far from
was well prepared to receive them they reported an
other medical services and colleagues.
-
vanish from others. Rapid urbanisation and high rise
not decrease the cost of care as was expected: the main
institutionalisation did not benefit patients and did
REVIEW ARTICLE
improvement of quality of life. Regrettably, in many countries the reduction of the size of mental hospitals
Task shifting
did not go hand in hand with an increase of funding
The strategy of task shifting is not a recent invention.
for outpatient and community care nor with a develop
The notion that general practitioners should be invited
ment of services in the community.
to participate in the treatment of mental illness or to take full responsibility for it was voiced in the late 19th 20th century demonstrated that general practitioners
structure of general health care in the community
are often the first point of contact for mental disorders
worked well in some places but not in others. In some
such as depression and a variety of studies showed that
instances the communities were strongly opposed
they can provide treatment to those patients if given
to having a mental health facility next door, near to
some additional training. Even personnel with shorter
them. It was clear that time and money should have
education such as nurses and medical assistants, who
been invested to make members of the community
carry most of the primary health care in many coun
learn more about mental illness and to take other
tries, can adequately deal with many mental disorders
measures that can reduce the stigma of mental illness,
if properly trained. It therefore seemed logical that
yet it was rare that the budget of the institutions
the lack of psychiatrists should be compensated for by
that were to be placed in the community included
shifting many of the tasks involved in the treatment of
funds that could be used to prepare for the move of
mental illness to primary care agents. There are, how
service into the new setting. Stigma of mental illness
ever, problems with this strategy. Many general health
also affected the use of services in the community:
care agents do not wish to be responsible for the treat
people with a mental illness often avoided going to
ment of mental illness. Sometimes this is because they
a psychiatric service in their neighbourhood and
have not been adequately trained to do so during their
sought help far away, so as to avoid stigmatisation
medical or nursing training. Sometimes the stigma of
2016;167(4):108–113
SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY
century by Ray, Griesinger and others. Research in the
The placement of mental health services in the
Placing mental health care into the community
113
mental illness makes them feel that they cannot make
of mental illness among the routine tasks of the health
the mentally ill better and that, in addition, when
system rather than attempt destigmatisation by occa
treating them they might be exposed to aggression.
sional campaigns or by the organisation of special
Sometimes they just felt that dealing with mental ill
events. Major international studies demonstrated that
ness would hugely increase their workload, which is
it is possible to reduce stigma or prevent it if the action
often heavy. In recent years the notion that all general
against stigma is permanently among the priorities of
practitioners should be trained in psychiatry has been
the health care and educational system.
REVIEW ARTICLE
replaced by a different strategy, characterised by three
The relevance of local conditions
volunteer should be given the training; second, that
All of the above will have to be considered in light of
the training should be provided by a general practi
the realisation that policies and plans that are imposed
tioner experienced in the treatment of mental illness
on all parts of the world or a country will fail. While a
(who is a more credible teacher for GPs) with the psy
few general principles are valid for all health care, the
chiatrist serving as a resource person rather than as
way to success is the adaptation of health care strate
the main teacher; and third, that the training should
gies to the local situation, a wise use and combination
be focused on problems most frequently seen in gen
of elements of service based on evidence and experi
eral health care. It was also stressed that the training
ence in the context of the setting in which care is to be
should be of a duration that is compatible with the
provided.
tenets: first, that only those family physicians who
obligations of general health care agents, and thus take the form of a spaced out series of short training courses lasting no longer than a few hours or an afternoon.
Conclusion and coda Research and experience acquired during the past
Medical training before and after graduation is clearly
effective ways of dealing with them. The vast social,
an important avenue for the introduction of changes
ecological, economic and cultural development of re
of the health system necessary to reflect the revision
cent years confirmed the importance of dealing with
of paradigms mentioned above as well as of the socio
mental health problems and underlined the need to
cultural and technological changes characterising our
update paradigms of mental health care developed in
times. The latter include the use of new technology –
the past.
e.g., Internet and mobile phones that make it possible
The time to act is now and it is of crucial importance
to strengthen the self help arsenal of treatment in
that psychiatrists and others knowledgeable about
psychiatry – as well as the need to recognise that pa
mental health and mental health problems take an
tients and families must be seen and treated as part
active role in shaping new strategies of promoting
ners in the provision of treatment, in rehabilitation
mental health, preventing mental illness and mental
and in planning of health services. Improved medical
health problems and providing care to those who are
education is also of central importance in dealing with
affected by them.
and severity of mental health problems and about
century provided evidence about the huge magnitude
-
The use of new technology and other desirable changes to improve mental health care
problems related to the fast increase of prevalence of – Sartorius N, Emsley RA. (2000) Psychiatry and technological advances: implications for developing countries. The Lancet. 356:2090–2. – Stuart H, Arboleda Florez J, Sartorius N. (2012). Paradigms Lost – Fighting Stigma and the Lessons Learned. Oxford University Press, 304p, (ISBN 978 0 19 979763 9). (also available under Oxford Medicine Online). – Sartorius N. (2014) A new model of community care, Lancet Psychiatry (Aug), 1(3), pp 170 1. doi: 10.1016/S2215 0366(14)70260 3. – Sartorius N, Holt RIG, Maj M. (eds.) (2015). Comorbidity of Mental and Physical Disorders. Karger, Vol. 179, 188 p (ISBN 9 783318 026030). – Sartorius N. Fighting for mental health. Cambridge: Cambridge University Press; 2002.
SWISS ARCHIVES OF NEUROLOGY, PSYCHIATRY AND PSYCHOTHERAPY
2016;167(4):108–113
-
-
-
imperative need to include the fight against the stigma
normansartorius.com
is to be provided to all those who need it is also the
-
sartorius[at]
-
-
-
have to be reviewed and updated if mental health care
CH 1209 Geneva
Among the many other paradigms of care that will
14, chemin Colladon
MD, PhD, FRCPsych.
Norman Sartorius,
Prevention and reduction of stigmatisation and its consequences
Correspondence:
-
century.
-
must be seen as a major challenge to medicine of our
Further reading
comorbidity of mental and physical disorders which
114
REVIEW ARTICLE
Definitions, epidemiology and outcomes
Severe traumatic brain injury in high-income countries Chiara S. Haller a,b , Bernhard Walder c b c
Department of Psychology, Harvard University, Cambridge, MA, USA Division of Public Psychiatry, Massachusetts Mental Health Center, Boston, USA Division of Anaesthesiology, University Hospitals of Geneva (HUG), Switzerland
In the present review we will summarize the different
Summary
definitions of severe TBI, the estimated incidences in
and economic burden in high-income countries. Different diagnostic ins
Severe traumatic brain injury (TBI) is a silent epidemic, and a medical, social truments are used to define severe TBI; all diagnostic instruments have limitations and may contribute to the heterogeneity in reported severe TBI
high-income countries, and the functional and neuro
a
psychological outcomes. Swiss data will be presented whenever available.
The definition of severe TBI depends on the different
sion. In Switzerland, an incidence of 11/100 000/year was observed using the
17/100 000/year, depending on the diagnostic instruments used for inclu-
Definitions of severe traumatic brain injury
populations. In high-income countries the incidence lies between 4 and
abbreviated injury scale of the head region (HAIS) >3 as inclusion criteria. In
patients ≤65 years the incidence was 8/100 000/year and in patients >65
years the incidence was 22/100 000/year. For severe TBI the mortality lies between 30 and 45% in high-income countries. In Switzerland, the mortality was 30% (25% in patients ≤65 years, 41% in patients >65 years). The
instruments that are used (table 1). The heterogeneity of instruments in use is partially related to the difficulty to classify TBI. But potential treatments are based on diagnostics, thus, it is crucial that diagnostic instruments have proven to be reliable and valid; therefore, first describe the diagnostic scales most
(GOSE) most often is the instrument of choice. In Switzerland median GOSE
commonly used, and further report their reliability
scores were 5 (interquartile range [IQR] 3–7) at 3 months and 6 (IQR 4–8) at
and validity.
otherwise, treatments may be inadequate. We will,
clinical practice; in research the Glasgow Outcome Coma Scale Extended
instruments used to estimate functional outcome differ across studies and
6 months post-injury. Health-related quality of life has rarely been investi-
Glasgow Coma Scale
TBI comparable to functional recovery. Neuropsychological outcome is
The Glasgow Coma Scale (GCS) estimates the conscious
assessed using test batteries that include cognitive, psychiatric and social
states of patients after a TBI [8]. GCS is a predictor of
aspects of functioning. Prolonged cognitive impairments and psychiatric
mortality, together with pupil reaction and age [9, 10].
disturbances, most prevalently affective disorders, were observed after
The scale consists of three domains in which a patient’s
severe TBI. A standardized data collection of patients after TBI may allow
functioning is rated: 1) response to stimuli by eye
interdisciplinary quality improvement initiatives in Switzerland.
opening; 2) verbal response; and 3) motor response.
gated; these rare studies reported on improvement over the first year after
Key words: severe TBI; high-income countries, functional outcome, neurocognitive outcome, quality of life
The sum of scores across domains provides a total score (range from 3–15) that is further often categorized into mild (13–15), moderate (8 or 9–12 [controversial]), ing only the motor component of the GCS in severe TBI
the world. TBI may be considered a “silent epidemic”
patients because of great difficulties to assess all other
due to its high incidence of 4–17/100 000/year, and
components in emergency settings [9, 10].
its high mortality rate of 30–70% in both low- and
Even though the GCS is widely used, inter-rater reli
high-income countries [1–3]. A lifelong disability is
ability has been shown to be moderate among physi-
common among the survivors. In the European Union,
cians [11], marginal among healthcare staff [12, 13], and
approximately 7.7 million people who have experi-
variable across other healthcare providers [12]. Apart
enced a TBI report disabilities [4] of physical, men-
from its inter-rater reliability, its validity has been
tal, and cognitive nature. These reported lifelong disa-
criticized as well, most commonly because of its inabil-
bilities not only cause lower life expectancy compared
ity to accurately record verbal status in intubated and
to the general population [5], but also substantial indi-
aphasic patients [14, 15]. Salottolo et al. further found
rect costs [6, 7].
that the GCS validity to predict severity changes as a
of the Swiss Neurology Society.
SWISS ARCHIVES OF NEUROLOGY AND PSYCHIATRY
2015;166(4):114–119
at the annual meeting 2014
Based on a lecture
and severe (65 years compared with
across countries is provided in table 4 (in the online
patients ≤65 years (40.9% vs 24.5%). High rates of return
appendix).
similarities: similar cause distribution, similar age
zerland, we observed a low incidence of severe TBI of
The Norwegian and the Swiss cohorts showed further
In our prospective, nation-wide, cohort study in Swit-
Demography in Switzerland
to consciousness were observed at 14 days with no differences between age groups. In earlier studies conducted in three different geographical regions in Swit
zerland, the estimated incidence was 8/100 000/year
Outcomes after traumatic brain injury in high-income countries Main outcomes after severe TBI are mortality, func-
using the combined criteria HAIS >3 and GCS 1 year). We will therefore first describe some
(HAIS 4: 41.1%, HAIS 5: 58.9%), including the amount of
outcome assessment instruments most commonly
multiple trauma (32.2%); the overall death rate was
used (see online appendix: table 5), and further report
almost identical (30.0%). Additionally, there was a sim-
their reliability and validity.
nitive, social, and psychiatric outcomes. Mortality and
A French population-based study in a rural region esti
Demography in selected high-income countries
ilarity in the death rates by HAIS category (HAIS 4: 7.7% The most significant mortality is observed in the acute
for the two studies were collected 10 years apart (1997
period and after severe TBI is between 30 and 45% [21,
in France, 2007 in Switzerland). In the Swiss study a
27, 51]. It has been suspected that mortality after severe
median age of 55 years was observed, which is much
TBI could decrease over the decades; however, in a
higher than in the French study. Since age is one of the
meta-regression no such trend could be observed since
most important risk factors for poor post-TBI outcome
1990 [52]. Based on the international, multicenter study
[31], the mortality rate was similar in both studies
CRASH, a prediction model for mortality at 14 days
but the age distribution was different, one may hypo
was developed: http://www.trialscoordinatingcentre.
Mortality
46.0% in Aquitaine, 40.9% in Switzerland). The data
in Aquitaine, France, 10.4% in Switzerland; HAIS 5:
long term than that of the general population (stan
A recent study in Norway observed an incidence of 4 to
dardized mortality ratio = 2.1; 95% confidence interval
5/100 000/year on the basis of ICD-10 codes and a GCS
= 1.9–2.3). The investigators found age, sex and func-
SWISS ARCHIVES OF NEUROLOGY AND PSYCHIATRY
2015;166(4):114–119
Brooks et al. [53–55] reported poorer survival rates at
mortality.
lshtm.ac.uk/Risk%20calculator/index.html.
Europe, thus counterbalancing the effects of age on
thesize that care has improved over the past years in
117
tional disability to be significant risk factors for mor-
tional outcome improves at least up to 1 year, thus a
tality (p 3; 210 patients), 75 (36%) showed a
gration, self-care, employment, and family burden. Dif-
good recovery, 18 (9%) showed moderate disability, and
ferent scales have been developed such as the Glasgow
6 (3%) severe disability.
Functional disability
Outcome Scale (GOS), the Disability Rating Scale (DRS Health-related quality of life (HRQoL) is a part of
estimation of functional outcome after severe TBI.
the outcome research after medical interventions and
The Glasgow Outcome Scale (GOS) was rapidly inte-
it is important to assess it in all investigation of
grated in clinical outcome research and clinical practice
patients with a complex disorder such as TBI. A pa-
after its creation in 1975 [59]. The short and easily usable
tient’s subjective well-being is related to functional
scale consists of five items: death (one point), vegetative
and neuropsychological outcome and, therefore, may
state (two points), severe disability (three points), mod-
be important in the estimation of the quality of TBI
erate disability (four points) and good recovery (five
care. Even in major scientific investigations, however,
points). The inter-rater reliability and validity have
HRQoL has rarely been assessed (see online appendix:
been moderate; which led to the development of more
table 5). In general, two main types of HRQoL can be
sensitive instruments based on the GOS: the Glasgow
distinguished: generic and disorder-specific HRQoL.
Outcome Scale Extended (GOSE [8, 60, 61]). The GOSE is
Generic HRQoL [64] has the advantage of comparabil-
one of the most frequently used scales to assess func-
ity with the general population. However, generic
tional outcome (see online appendix: table 5) and in-
HRQoL measures such as SF-12 or SF-36 (most fre-
cludes items for lower (three points) and upper severe
quently used [64–66]) may not be sensitive enough to
disability (four points), lower (five points) and upper
capture HRQoL specifically after certain complex dis-
moderate disability (six points), and lower (seven
orders such TBI [67]. In recent years the QOLIBRI (Qual-
points) and upper good recovery (eight points). Patients
ity Of LIfe after BRain Injury) was introduced as a
or relatives (if the patient is not able in the current
HRQoL assessment that has been validated with pa-
state) fill in the questionnaire that assesses daily func-
tients after TBI (http://www.qolibrinet.com/). The
tioning postinjury and compares those questions with
QOLIBRI is a 37-item self-report covering six dimen
preinjury functioning.
sions of HRQoL after TBI [68] with reportedly overall
Different calculators based on large data bases were
good reliability and validity [69, 70]. The questionnaire
developed to predict GOS and GOSE at 6 months:
provides a profile of quality of life together with a total
http://www.tbi-impact.org/?p=impact/calc or http:
score (http://www.qolibrinet.com/).
//www.trialscoordinatingcentre.lshtm.ac.uk/Risk%20
Hawthorne et al. found scores on the SF-36 to be be-
calculator/index.html. All these calculators were es-
tween 13 and 24% worse among patients with TBI than
tablished for prediction of a population with TBI and
their matched counterparts [71], and Andelic et al. [72]
not for individual patients. The cooperative interpreta-
found 46% of patients to report poor physical health,
tion of functional outcome assessments is di cult be-
and 37% poor mental health. Soberg and Røe [73] found
cause of the different starting times in data collection.
no particular pattern of reduction on the QOLIBRI sub-
Some investigators, for example, start data collection
scales 1 year after injury, though fatigue seemed to be
at acute hospital admission (with a high mortality) and
reported across severities, which in turn was linked to
others after acute hospital admission (with a low mor-
change in cognitive capacity, sleep disturbance, and
tality). Average GOSE will be higher in the latter exam-
depression. In Germany, an improvement of HRQoL
ple and is most often referred to as GOSE of survivors.
over the first year after TBI was observed using a Ge-
The average GOSE of survivors in Switzerland (data col-
neric HRQoL instrument [74]. Neither a generic HRQoL
lection start at acute hospital admission) was 5 (IQR
instrument nor the QOLIBRI have been used to assess
3–7) at 3 months and 6 (IQR 4–8) at 6 months [21]. Func-
HRQoL after TBI in Switzerland.
ffi
2015;166(4):114–119
SWISS ARCHIVES OF NEUROLOGY AND PSYCHIATRY
Health-related quality of life
[58]). In this review we will focus on the GOS for the
[57]) and the Functional Independence measure (FIM
118
Neurocognitive functioning
Ponsford and Downing [75] assessed 141 individuals 2, 5,
Ruttan et al. [80] performed a meta-analysis in which
and 10 years postinjury using the Structured Outcome
they investigated 1380 individuals (694 people with
Questionnaire (SOQ). The investigators observed that
moderate to severe TBI and 686 healthy controls) from
70% were able to drive, 40% required more support
16 studies. They stratified cognitive tests into timed
than before the injury, approximately 50% returned to
and untimed tests. Among the untimed measures were
work and/or leisure activities [76], and 30% reported
tests that assess learning and memory (recall), execu-
problems in personal relationships (marital status
tive function (Wisconsin Card Sort Test), and the full
remained stable). Hoofien et al. [77] reported the
Wechsler Adult Intelligence Scale (WAIS). Among the
10–20 year (mean 14.1 years) postinjury outcome of
timed measures were tests that assess verbal fluency,
76 individuals with severe TBI (17% females). Results
psychomotor function, attention including split atten-
showed an employment rate of 60.5%, whereas 73%
tion, and executive function (e.g., Trails B). They found
out of the employed participants worked in low-level
that individuals with moderate to severe TBI showed
professions (sheltered settings or volunteers [39%] or
reliably lower functioning in both timed and untimed
technology [37%]).
tests 18+ months postinjury, with larger effect sizes
Back to work and leisure activities
REVIEW ARTICLE
when comparing timed tests. Thus, cognitive impairNeuropsychological outcome estimation includes
collected data on 2995 individuals with TBI out of
cognitive, psychiatric and social functioning. Clinical
whom 549 were followed-up; patients with severe TBI
neuropsychological testing is an integrative part of
(GCS 3–8, 45 individuals) reported significant cognitive
clinical practice and an important part of the outcome
impairment (decision making, memory, concentra-
research after brain disorders. Neuropsychological
tion) compared with individuals with both mild TBI
ment depends on severity of TBI. Thornhill et al. [81]
Neuropsychological outcome
Most researchers detect an improvement in neuro- and
such as TBI. However, neuropsychological assessments
social cognitive functioning across time. Sigurdardottir
are difficult in individuals with severe TBI, and are
et al. [62] for example reported improvement up to
therefore often missing in scientific contributions
1 year postinjury (3–12 months) on three factors (found
(see online appendix: table 5). Cognitive dysfunction
by principal component analysis) among the 41 individ-
(especially working memory and processing speed)
uals with a severe TBI (total number: 115): memory/
contribute to the (in)ability to go back to work [32],
speed, verbal/reasoning, and visual/perception. Persis-
which in turn explains some of the variance in satis-
tent cognitive dysfunction predicted functional out-
faction with life [78], and may contribute to self-esteem
come even when injury severity, demographics, and
[79]. Patients with severe TBI suffer from extensive
trauma variables were controlled for. Wood et al. [82]
disability compared with healthy controls. A limita-
administered 15 neuropsychological tests (to test atten-
tion of neuropsychological testing in research settings
tion, language, memory, visuoperception and construc-
is the heterogeneity of specific tests in use (see online
tion, psychomotor speed, and problem solving) to
appendix: table 5). For instance, different language
141–182 individuals with TBI (analyses not stratified by
regions will use different instruments, which de-
severity) at 1 year and at 5 years postinjury. They
creases comparability. Furthermore, with more and
observed that individuals with moderate and severe TBI
more geriatric patients, tests may have to be adapted
exhibited statistically significant improvement on 6 of
to this newer phenomenon. Studies that perform
15 neuropsychological tests: i.e., on Digits Forward
extensive and time-intensive neuropsychological test
(working memory, attention), Logical Memory I and II
batteries are often limited by their small cohorts.
(verbal memory), Controlled Oral Word Association Test
This reduces statistical power, increases bias and
(verbal fluency), Symbol Digit, Block Design (visuo
thus decreases generalizability. In studies involving
construction) of the Wechsler Adult Intelligence Scale
patients with TBI, preinjury neuropsychological test-
(WAIS), Wisconsin Card Sorting Test (problem solving),
ing is often not available but may be an important
and Trails B (split attention). However, statistical sig
confounding factor to be assessed. In the Swiss cohort,
nificance does not necessarily imply clinical relevance
for example, 13% of the patients had had a psychiatric
and the analysis concept of minimal clinically impor-
diagnosis before the injury and 25% had consumed
tant difference may be more relevant [83]. Recovery in
alcohol [21].
new learning and memory was not consistent across
and moderate TBI.
and should be assessed after a complex disorder
data is crucial to link functional to structural deficits,
tests; some patients declined (i.e., 15 patients declined,
SWISS ARCHIVES OF NEUROLOGY AND PSYCHIATRY
22 improved, and 62 exhibited no change).
2015;166(4):114–119
119
the degree of impairment is associated with the severity of TBI and cognitive functioning improves at least in the first year after TBI. A Swiss single center study showed that after rehabilitation three quarters of the patients had at least one neuropsychological deficit, even patients with favorable functional outcome measured with GOS [103].
Agenda of further investigations National professional societies together with national authorities should invest into the possibility to create a standardized, minimal data set, which is openly accessible to clinicians and researchers, and to which
Cognitive functioning is impaired after TBI [84–102],
all contribute their data. The dataset should include potential predictors for severe TBI, preinjury variables, patient characteristics including risk factors, and rele-
rates between studies (e.g., incidence of depression = 15.3% to 33%, prevalence for depression from 18.5% to 77%; [104]). Psychiatric disorders can emerge in the acute stages [105, 106], and findings concerning
development of the disorder thereafter have been
patients with severe TBI will be associated with process-oriented interventions based on such a data base. It is crucial to integrate data from prehospital care to the end of rehabilitation. The high costs related to about 900 patients with severe TBI per year in Switzerland justify a national surveillance program
mixed [107–117].
It is highly probable that improvement in care of
Studies report different incidence and prevalence
vant outcomes after severe TBI up to 1 year after TBI.
Social cognitive and psychiatric functioning
individuals with severe TBI at 3, 6, and 12 months postinfi
jury. The 12-months postinjury rate was signi cantly different (p-values
