Ernst Rüdin: Hitler’s Racial Hygiene Mastermind

Ernst Rüdin (1874–1952) was the founder of psychiatric genetics and was also a founder of the German racial hygiene movement. Throughout his long career he played a major role in promoting eugenic ideas and policies in Germany, including helping formulate the 1933 Nazi eugenic sterilization law and other governmental policies directed against the alleged carriers of genetic defects. In the 1940s Rüdin supported the killing of children and mental patients under a Nazi program euphemistically called “Euthanasia.” The authors document these crimes and discuss their implications, and also present translations of two publications Rüdin co-authored in 1938 showing his strong support for Hitler and his policies. The authors also document what they see as revisionist historical accounts by leading psychiatric genetic authors. They outline three categories of contemporary psychiatric genetic accounts of Rüdin and his work: (A) those who write about German psychiatric genetics in the Nazi period, but either fail to mention Rüdin at all, or cast him in a favorable light; (B) those who acknowledge that Rüdin helped promote eugenic sterilization and/or may have worked with the Nazis, but generally paint a positive picture of Rüdin’s research and fail to mention his participation in the “euthanasia” killing program; and (C) those who have written that Rüdin committed and supported unspeakable atrocities. The authors conclude by calling on the leaders of psychiatric genetics to produce a detailed and complete account of their field’s history, including all of the documented crimes committed by Rüdin and his associates.     

Is psychiatric training improving?

All consultants in general psychiatry appointed between 1 October 1975 and 30 September 1978 were sent a questionnaire asking about their training experience in various aspects of psychiatric practice. The results showed that the standard of training in several important areas of psychiatry were generally poor, although psychiatrists who had trained at the Maudsley Hospital or in teaching hospitals had better training than those who had worked in psychiatric hospitals. As compared with the last survey made three years ago there had been some improvement, but it had been least pronounced in psychiatric hospitals. The effects of approval visits made by both the Royal College of Psychiatrists and the Joint Committee of Higher Psychiatric Training would seem to be achieving results, but more attention needs to be paid to the standard of training in psychiatric hospitals and units.     

The Texture of the Real: Experimentation and Experience in Schizophrenia

The dominance of the neurosciences in psychiatric research raises questions about the relationship between research practices and the lived experience of mental illness. Here, I use data from a group of researchers focusing on neurocognition in schizophrenia to explore the problem of representation in psychiatric research and the forms that neuroscientific evidence assumes for those who produce it. These researchers grappled with the complexity of schizophrenia not by narrowing disease concepts to biological facts but by referencing measurement techniques to generate new versions of schizophrenia. By linking experimental findings to inchoate concepts of personhood and social experience, I found that they reframed and reinforced cultural values, including that those with schizophrenia are destined to a debased and deficient existence. I argue that cognition has emerged as an essential feature of schizophrenia not only because of its representational utility but also because of the ontological work the concept performs. In closing, I present some implications for the neurobiological and social sciences.     

ADHD in acute care psychiatric inpatients

Attention-deficit hyperactivity disorder (ADHD) is a neurocognitive disorder characterized by symptoms of inattention, impulsivity and motor hyperactivity. The worldwide prevalence of ADHD, in the general adult population, has been estimated to be 2.8%. Patients with ADHD have a high incidence of comorbidity with other psychiatric disorders. Those with a psychiatric disorder as well as ADHD have more psychosocial difficulties than those without ADHD. Despite knowing that ADHD is often comorbid with other psychiatric diagnoses, there are currently no studies elucidating the prevalence of ADHD in the inpatient psychiatric population, nor is there significant information about its impact. The lack of research into this topic suggests more needs to be done in the field of adult ADHD, especially in the inpatient psychiatric population and with respect to impairment in patient function. Knowing the prevalence of ADHD and its impact on quality of life in adult inpatients will help lay the groundwork for effective screening and management. The purpose of this study was to understand the prevalence rates of ADHD among psychiatric acute care inpatients. Other objectives included comparing the quality of life and functioning between patients with a primary psychiatric diagnosis and ADHD (treated or untreated) versus those with a primary psychiatric diagnosis and no ADHD. Thirty-three (N = 31) psychiatric inpatients were screened using the Adult ADHD Self-Report Scale. Those that screened positive for ADHD received a full diagnostic assessment for ADHD. All patients completed the Weiss Functional Impairment Rating Scale (WFIRS) to assess level of functioning and a Clinical Global Impression of Severity/Improvement Scale (on admission and discharge). Demographic information was also obtained. Of the 31 patients analyzed, 12 had a diagnosis of ADHD (36.4%). The participants diagnosed with ADHD scored significantly higher on the WFIRS, suggesting decreased functioning compared to patients without comorbid ADHD. Patients with ADHD also scored significantly higher in the individual domains of this rating scale, suggesting impairment in family, work and social functioning as well as decreased life-skills, poor self-concept and increased risk-taking behavior. In this sample, the prevalence of ADHD is significantly higher among acute care psychiatric inpatients than in the general population. Patients with concomitant ADHD suffer more functional impairment than those without. These findings merit further investigation into the value of routine screening and patient-specific treatment of ADHD in this patient population.     

Fall in admission rate of old people to psychiatric units.

The numbers of the elderly, and particularly the very old, have been increasing and continue to increase rapidly; but admission rates of old people to psychiatric hospitals in England and Wales suddenly started to fall in 1970. They were still generally falling in 1974 (the most recent year for which figures are available). There is no evidence that the incidence of dementia has suddenly fallen, or that expansion of extramural or other non-psychiatric services is everywhere coping with the severely demented. It is probably becoming more difficult for demented people to be admitted to psychiatric hospitals that are often still overcrowded, in view of the greater scrutiny of institutional care that has become established since the Ely Report of 1969. If this is so the cost to the demented and those who care for them of the undoubted improvements in conditions in psychiatric hospitals needs to be counted.     

A Contribution to the Comparative Epidemiology of Schizophrenia in Urban and Rural Places

In psychiatry, epidemiology rests upon statistical studies of mental illness in the population. Much attention was given to this as early as the work of Esquirol, (1) and I. F. Riul' (2) in our country. Zemstvo psychiatrists contributed much in the field of psychiatric morbidity. (3-8) However, as a result of the lack of outpatient psychoneurological institutions in prerevolutionary Russia, these studies, like the majority of those currently being conducted by psychiatrists abroad, resolved fundamentally to isolated unidimensional selective surveys of particular groups in the population. The existence in the Soviet Union of a broad network of outpatient psychiatric institutions permits Soviet psychiatrists to go beyond single-factor selective surveys, to make a systematic study of mental illness in accordance with the data of current dispensary records, and to provide timely therapeutic and social prophylactic assistance to the ill, i.e., to conduct epidemiological research on a higher level of scientific methodology. A number of such studies has been published. (8-23) Therefore the statement by Lin and Standley, (24) who allege — in a monograph, The Role of Epidemiology in Psychiatry, published by the World Health Organization — the absence of epidemiological psychiatric studies in the Soviet Union, must be rejected as unfounded.     

The outcome of targeting community mental health services: evidence from the West Lambeth schizophrenia cohort.

OBJECTIVES--To report outcome of targeting community mental health services to people with schizophrenia in an inner London district who had been shown, one year after discharge, to have high levels of psychotic symptomatology and social disability but very low levels of supported housing and structured day activity. DESIGN--Repeat interview survey of symptoms, disability, and receipt of care four years after index discharge. SETTING--Inner London health district with considerable social deprivation and a mental hospital in the process of closure. SUBJECTS--51 patients originally aged 20-65 years who satisfied the research diagnostic criteria for schizophrenia. MAIN OUTCOME MEASURES--Contact with services during the three months before interview, levels of symptoms (from present state examination), global social disability rating. RESULTS--65% (33/51) of the study group had been readmitted at least once in the three years between surveys. Recent contacts with community psychiatric nurses and rates of hospital admission increased (8 at one year v 24 at four years, p < 0.01; 5 v 13, p < 0.06). Conversely, fewer patients were in contact with social workers (17 v 7, p < 0.03). Proportions in supported housing, day care, or sheltered work did not change. Unemployment rates remained very high. A considerable reduction (almost a halving) in psychiatric symptoms was observed, but there was no significant change in mean levels of social disability. CONCLUSIONS--The policy of targeting the long term mentally ill resulted in significant increases in professional psychiatric input to the cohort but failed to improve access to social workers or suitable accommodation. Improvements in social functioning did not follow from reductions in the proportions of patients with psychotic mental states. Social interventions are likely to be crucial to achieving the Health of the Nation target of improving social functioning for the seriously mentally ill, as improving mental state seems in itself to be insufficient.     

Post-acute anti-NMDAR encephalitis mirrors schizophrenia

The post-acute evolution of the cognitive and psychiatric features of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis has been poorly investigated so far. In recent work published in Lancet Neurology, Guasp et al. report that the neuropsychiatric symptoms of the post-acute phase mirror those observed in schizophrenia, although only patients with anti-NMDAR encephalitis showed improvements of their symptoms.     

Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study

Background:Establishing irremediability of suffering is a central challenge in determining the appropriateness of medical assistance in dying (MAiD) for patients with a psychiatric disorder. We sought to evaluate how experienced psychiatrists define irremediable psychiatric suffering in the context of MAiD and what challenges they face while establishing irremediable psychiatric suffering.Methods:We conducted a qualitative study of psychiatrists in the Netherlands with experience assessing irremediable psychiatric suffering in the context of MAiD. We collected data from in-depth, semistructured interviews focused on the definition of irremediable psychiatric suffering and on the challenges in establishing irremediability. We analyzed themes using a modified grounded theory approach.Results:The study included 11 psychiatrists. Although irremediable psychiatric suffering is a prospective concept, most participants relied on retrospective dimensions to define it, such as a history of failed treatments, and expressed that uncertainty was inevitable in this process. When establishing irremediable psychiatric suffering, participants identified challenges related to diagnosis and treatment. The main diagnostic challenge identified was the frequent co-occurrence of more than 1 psychiatric diagnosis. Important challenges related to treatment included assessing the quality of past treatments, establishing when limits of treatment had been reached and managing “treatment fatigue.”Interpretation:Challenges regarding the definition, diagnosis and treatment of irremediable psychiatric suffering complicate the process of establishing it in the context of MAiD. Development of consensus clinical criteria for irremediable psychiatric suffering in this context and further research to understand “treatment fatigue” among patients with psychiatric disorders may help address these challenges. Registration: This study was preregistered under osf.io/2jrnd.

Medical assistance in dying (MAiD), also known as physician-assisted death, has been legalized in an increasing number of jurisdictions around the world.¹ In 2023, Canada will join a small group of countries that allow MAiD for people with mental illness, more commonly referred to as persons with a psychiatric disorder. ² In the Netherlands, MAiD for irremediable psychiatric suffering has been approved by jurisprudence since the 1990s and it has been regulated by law since 2002. The last decade has seen a marked increase in MAiD for irremediable psychiatric suffering; in 2020, MAiD was performed 88 times for psychiatric suffering (1.3% of all MAiD cases), compared with just 2 instances in 2010.³ The number of requests by patients with a psychiatric disorder is much higher, but 90% of requests do not end in MAiD. Sometimes, they are retracted by patients, but most are denied by psychiatrists.⁴The main legal requirements for MAiD in the Netherlands are that the patient must be able to make a competent request, that the patient’s suffering must be unbearable and irremediable, and that the patient and physician agree that there are no other reasonable treatment options. The process for MAiD requires an assessment by an independent physician and, in the case of psychiatric suffering, a third assessment by an independent psychiatrist, preferably one with specific expertise regarding the patient’s disorder.⁵ The Canadian legal requirements under the amended Bill C-7, which will come into effect in 2023, will be largely similar to the Dutch requirements.⁶ However, Canadian legislation, which does not yet permit MAiD for mental illness, has 1 important difference: patients with decision-making capacity can qualify for MAiD if they refuse treatments that they do not find acceptable. It is as yet unknown whether this approach to refusal of treatment will also be applied to MAiD where mental illness is the sole underlying condition.Although there are concerns about decision-making capacity, the central dilemma of MAiD for patients with a psychiatric disorder appears to revolve around applying the concept of irremediability to psychiatric disorders. The 2018 guideline by the Dutch Psychiatry Association defines irremediable psychiatric suffering in the context of MAiD as follows: “irremediability means that there is no longer any prospect of alleviating, mitigating, enduring or removing suffering. There is no longer a reasonable treatment perspective.”⁷ Elsewhere, the guideline states that reasonable treatment perspective means that “there is a prospect of improvement with adequate treatment, within a foreseeable period, and with a reasonable ratio between the expected results and the burden of the treatment for the patient.”⁷A recent scoping review identified a multitude of conceptual articles addressing irremediability in the context of psychiatric MAiD but few empirical studies.¹ This suggests that the assessment of irremediable psychiatric suffering is particularly difficult relative to suffering arising from other types of conditions.Surveys estimate that 46% of psychiatrists in the Netherlands have received an explicit MAiD request at least once in their career, and 4% actually assisted in the death of a patient with a psychiatric disorder.⁸ The experiences of psychiatrists who have handled MAiD requests can be seen as an important source of knowledge about the challenges of establishing irremediable psychiatric suffering in practice. The aim of this study was to learn how experienced psychiatrists define psychiatric suffering as irremediable in the context of a MAiD request and what challenges they face while establishing irremediable psychiatric suffering.     

Effect of counselling on the psychiatric morbidity associated with mastectomy.

A controlled trial was conducted to determine whether counselling by a specialist nurse prevented the psychiatric morbidity associated with mastectomy and breast cancer. Seventy-five patients were counselled by the nurse and monitored during follow-up, while 77 patients received only the care normally given by the surgical unit. Counselling failed to prevent morbidity, but the nurse''s regular monitoring of the women''s progress led her to recognise and refer 76% of those who needed psychiatric help. Only 15% of the control group whose condition warranted help were recognised and referred. Consequently, 12 to 18 months after mastectomy there was much less psychiatric morbidity in the counselled group (12%) than in the control group (39%). These findings highlight the high degree of psychiatric morbidity in patients who have undergone mastectomy and indicate the need to find ways of reducing this morbidity.     

Cost of counselling women who undergo mastectomy.

The psychiatric morbidity associated with mastectomy and brest cancer was substantially reduced by a specialist nurse who counselled women before and after surgery and monitored their progress. A controlled study was, therefore, carried out to determine what this cost. National Health Service costs were almost wholly covered by savings made because counselled subjects who developed psychiatric problems were recognised and treated much earlier than control patients. Counselled and control subjects suffered considerable financial losses, but these were offset in the counselled group by their relatives'' earlier return to work. Such counselling schemes are necessary and effective and may be implemented at little extra cost.     

Psychiatric morbidity in men one week after first acute myocardial infarction.

One week after a first myocardial infarction 35 out of 100 consecutive men patients aged under 65 were found by standardised clinical interview to have psychiatric morbidity. In 16 the morbidity had been evident before the infarct, and these patients showed a wider range of psychopathology than those whose symptoms had been precipitated by the infarct. The results suggest that psychiatric morbidity in patients with heart disease is not necessarily a result of the disease process. Thus characterising psychiatric morbidity and identifying the patients'' individual needs are important if rehabilitation is to be effective.     

The rise of counselling and the return of alienism.

Current services for those with mental disorders show two trends. Psychiatric services are becoming concentrated on the care of those with "severe mental illness," largely (but unjustifiably) synonymous with chronic psychosis. The retreat of psychiatry from the care of those with non-psychotic mental disorders has helped the growth of counselling services for these patients. However, there is no evidence that non-directive counselling is effective for such disorders, in contrast to the evidence for the effectiveness of other treatments that are usually delivered by psychologists or community psychiatric nurses. By retreating from the concerns of general practice and general medicine, psychiatry is returning to the days of alienism: in Victorian terms, the care of "the mad." Possible consequences include increasing expectations of psychiatric services that cannot be met, a loss of skills within psychiatry, and increased demoralisation in the mental health services.     

Area security unit in a psychiatric hospital.

Since 1974 a psychiatric hospital security unit, designed to serve the whole catchment area, has cared for mentally ill (mostly psychotic) patients with disturbed behaviour that cannot be managed in open wards. There are a few long-term dangerous patients but most stay only briefly. The admission of women to the unit was not followed by the expected reduction in violence. The unit has facilities for occupational therapy, physical recreation, work, and study, which are particularly important for those who are too dangerous to leave it. The unit''s calming influence depends as much on the supportive effect of the high staff ratio as on the use of tranquillisers. This type of unit is not suitable for patients with personality disturbances who "act out" or for mentally abnormal offenders; but it functions well as a crisis centre for the disturbed mentally ill, and there is an increasing demand for its services.     

“THAT’S NOT HIS ONLY PROBLEM...” CLINICAL TEAMWORK IN A PSYCHIATRIC EMERGENCY ROOM

This article is a qualitative study of the social organization of clinical work in a psychiatric emergency room. The research involved observation of emergency room practices and interviews with the clinical staff members. Due to responsibility of ensuring confidentiality, audio taping was not possible. Observations and interviews were recorded by hand, and thus, except in brief instances, I describe talk rather than reproduce it verbatim. Psychiatry, I argue, should not be explored as a singular profession but as the team practice of a team of occupational groups. These groups are often seen as subordinate to psychiatric physicians, but as this paper will demonstrate these groups are often able to call upon their specific claims to expert knowledge to assume clinical authority over a patient’s diagnosis and treatment. The successful pursuit of such a claim puts these clinical occupational groups in a position to challenge psychiatrists over crucial hospital resources such as beds. These groups’ claim to authority emerges from two sources. The first is their specific histories and their clinical knowledge systems that initially developed independently of cosmopolitan medicine. The second is the political economic environment of urban hospital psychiatric departments which largely treat patients with opaque symptoms of unclear origin that defy easy psychiatric classification.     

The role of the psychiatrist in improving patient compliance

Compliance, usually referring to how well the patient takes the medication as prescribed, is an important issue in clinical practice. However, many patients, especially those with a psychiatric illness, stop taking their medications despite physician advice to continue. This cessation can lead to a deterioration in the condition, a relapse, or a recurrence of the illness. In the literature, many different factors contributing to poor compliance have been described, but the doctor's role and responsibilities are hardly mentioned. These factors will be discussed here with special emphasis on what a doctor should do and what a doctor should avoid.     

The Isis Centre: a counselling service within the National Health Service.

A new centre has been established to provide readily accessible counselling, consultation, and mental health information. People may refer themselves or are recommended to attend by general practitioners or other agencies. The counsellors have varied backgrounds in paramedical or counselling services, and they are supported by psychiatrists. Of a sample of 100 clients, four were referred to one of the team''s psychiatrists and 33 visited the centre only once. The centre''s staff aim to adopt a flexible approach to the client and his problems, and formal psychiatric categories have not been found useful. Provision is made for people who want to solve their problems by discussion rather than medication and those for whom the existing psychiatric services may have little time to spare. Consequently, the approach adopted by the Isis Centre, whereby many people benefit from psychotherapy yet the psychiatrist deals directly with only a few selected cases, contributes towards meeting the great need for psychiatric services and using the psychiatrist''s skills more effectively.     

Psychiatric disturbance as a consequence of abnormal periodic cardiac variation

Abstract

The relationship between cardiac rate variation, resting sinus rhythm heart rate in beats per minute, and mental state is reviewed. A small series of 12 psychiatric patients in whom these variables were studied both before and after appropriate psychiatric treatment is reported. Comparison with the periodicity of cardiac rate variation in a normal group of subjects showed that the setting of the biological clock governing cardiac rate variation in psychiatric patients is abnormal, and in these cases running at a slower frequency than that of mental health. Appropriate psychiatric therapy re‐sets this clock in patients responding to treatment, but fails to do so in those patients who remain unimproved. Resting mean sinus rhythm heart rate in beats per minute does not show this relationship.     

Psychiatric and Social Factors in the Abortion Decision

A total of 132 consecutive referrals for psychiatric opinion on termination of pregnancy were examined and followed up at nine months. Of these, 48 (36%) were refused and 44 of the 84 terminated were sterilized. Those recommended for abortion tended to be older, married, and to have children. They had used contraception more often and they showed more clinical psychiatric abnormalities. The group had numerous social problems, but these did not distinguish those terminated from those refused, nor were there differences in religious affiliation or duration of pregnancy. Most of those refused obtained an abortion elsewhere and only 25 of the original 132 had a live child. General practitioners were more likely to disagree with a refusal decision than with termination. Psychiatric, physical, and social sequelae were infrequent in both groups. Contraception before and after was inadequate in most patients.     

Psychiatric Hospital Bed Numbers and Prison Population Sizes in 26 European Countries: A Critical Reconsideration of the Penrose Hypothesis

Background

Recently, there has been a revived interest in the validity of the Penrose hypothesis, which was originally postulated over 75 years ago. It suggests an inverse relationship between the numbers of psychiatric hospital beds and the sizes of prison population. This study aims to investigate the association between psychiatric hospital beds and prison populations in a large sample of 26 European countries between 1993 and 2011.

Methods

The association between prison population sizes and numbers of psychiatric hospital beds was assessed by means of Spearman correlations and modeled by a mixed random coefficient regression model. Socioeconomic variables were considered as covariates. Data were retrieved from Eurostat, the statistical office of the European Union.

Outcomes

Mean Spearman correlation coefficients between psychiatric beds and prison population showed a significant negative association (-0.35; p = <0.01). However, in the mixed regression model including socioeconomic covariates there were no significant fixed parameter estimates. Meanwhile, the covariance estimates for the random coefficients psychiatric beds (σ² = 0.75, p = <0.01) and year (σ² = 0.0007, p = 0.03) yielded significant results.

Interpretation

These findings do not support the general validity of the Penrose hypothesis. Notably, the results of the mixed-model show a significant variation in the magnitude and direction of the association of psychiatric hospital bed numbers and the prison population sizes between countries. In this sense, our results challenge the prevalent opinion that a reduction of psychiatric beds subsequently leads to increasing incarcerations. These findings also work against the potential stigmatization of individuals suffering from mental disorders as criminals, which could be an unintentional byproduct of the Penrose hypothesis.