[Day hospital treatment in psychiatry]. / Tagesklinische Behandlung in der Psychiatrie.

Day hospitals provide an organizational framework for complex psychiatric and psychotherapeutic treatments. They have been developed regarding treatment and in number, perhaps surprisingly, to fit existing standards in almost all domains of psychiatry. Similarities exist in the emphasis on acute treatment, in the orientation towards social inclusion, and particularly in the ability to connect with previous treatment settings. Day treatment guidelines exist only in basic form. In general the complex outpatient treatment is led by psychiatrists; the treatment is planned and pre-defined regarding time and goal orientation. It is directed exclusively at patients with severe mental health disorders and practiced by a multi-professional team. A structured treatment milieu is likely to be the main ingredient which includes all somatic-biological and many psychotherapeutic methods. Special options that for the most part have been empirically validated are available for the treatment of post-acute patients, prevention of social exclusion from families and work, detoxification of addicts and psychotherapy of personality disorders. The rapid increase of facilities is expected to persist for some time. Scientific evidence is relatively strong. Given proper indication, financial resources are used with a high degree of efficiency.

[Malignant neuroleptic syndrome associated with amisulpride]. / Malignes neuroleptisches Syndrom durch Amisulprid.

Malignant neuroleptic syndrome (MNS) is a rare side effect of antipsychotic medications but means a serious and life-threatening complication. The risk of MNS seems to be lower for second generation antipsychotics (SGA). We report the 9-month history of a 42-year-old female patient whose antipsychotic medication was switched to 800 mg per day of amisulpride. Two weeks after discharge she suffered muscular pain, stiffness, weakness of the legs, rigor, and fever. After attending our outpatient department and being diagnosed, she was transferred to the neurological intensive unit, where the creatine kinase (CK) level was measured at 160,000 U/l. Furthermore extensive rhabdomyolysis accompanied by a compartment syndrome was seen. Surgical intervention was necessary for the latter. The patient was then retransferred to the psychiatric department after treatment with lorazepam and withdrawal of antipsychotic medications. In addition a therapy with valproate sodium was conducted. Long-term high levels of CK and abnormalities in the electromyogram led to the hypothesis of myopathy as a possible risk factor, but a final diagnostic classification was not feasible. This report describes the appearance of a MNS as a consequence of SGA therapy, discusses risk factors and therapy options, and shows the 9-month course.

[Work, income, intimate relationships: social exclusion of the mentally ill]. / Arbeit, Einkommen, Partnerschaft: Die soziale Exklusion psychisch kranker Menschen.

OBJECTIVES: There are no valid data on the social exclusion of mentally ill people in Germany. This study analyses the social exclusion of the mentally ill. METHODS: With a Scientific Use File on early retirement in 2003, we found a nationally representative database for chronically ill persons. The inclusion in the working market, the work income and the exclusion of intimate relationships of chronically mentally ill people are compared to those of physically disabled people. RESULTS: Mentally ill persons are more excluded than physically ill persons on all three indicators. This is especially true for persons with schizophrenia and alcohol addiction. CONCLUSIONS: Scientifically sound instruments such as Supported Employment need to be implemented in Germany, too.

[Social exclusion of the mentally ill -- a critical review and outlook of community psychiatry at the beginning of the 21st century]. / Zur sozialen Exklusion psychisch Kranker -- Kritische Bilanz und Ausblick der Gemeindepsychiatrie zu Beginn des 21. Jahrhunderts.

The social implications and disabilities of long-term mental disorders have been well described and are known for a long time. The classical paradigm of social psychiatry postulating that dehospitalization automatically generates social integration has proven to be wrong. Along that line the view that living in the community supported by different services aiming at integration has also failed to be successful. Without explicitly labelling it: community-based psychiatry has yielded a psychiatry-based community. It never served the majority of the non-chronically mentally ill with disordered social skills who also need specific support or are as well bound for unemployment and social disadvantages. Without doubt, the progress made by community psychiatry in the past was eminently linked to the ideology and implementation of deinstitutionalization. Defining and dealing with social exclusion means a turning point for social and community psychiatry - a new paradigm that could generate a different view upon therapeutical outcomes and the way that therapy and rehabilitation have to be organised and implemented. Especially the example of vocational rehabilitation could mark a stepping stone by initiating further investigations and progress for new approaches in community support. Supported employment programmes have shown the superiority of "place and train" instead of first train in institutions or services and then place on the spot. Thus a so-called inclusion therapy could arise that takes place "in vivo et actu" and near to the individual's real world of tasks and demands. Progress in any part of multidimensional therapy is legitimized only by empirical validation of functional outcome and social inclusion measures. Such an evaluation of complex programmes taking social inclusion into account is sophisticated but seems to be necessary in the field of general psychiatric therapies as well as for the legitimation of financial resources needed. Foreseeing the perspective of social psychiatry a next substantial step could be the identification of social and functional outcome variables.

[Limits of deinstitutionalization?--perspective of the specialty clinic]. / Grenzen der Desinstitutionalisierung?--Die Sicht der Fachklinik.

Deinstitutionalization is a complex process that in the past was often misunderstood solely as a run down or even closure of psychiatric hospitals. Although chronically mentally ill patients were prevented from long term hospitalisation some fundamental mistakes were repeated often: patients were simply discharged without any preparations and outpatient care was badly organised. In some cases this led to therapeutic neglect, social disintegration, homelessness, incarceration or other forms of dramatic loss of quality of life. These findings are internationally confirmed although there are remarkable differences between various health care systems. Especially when primarily determined by purely economic interests deinstitutionalization constitutes a severe danger for the whole psychiatric system of care and in particular for chronic patients. Intensive research is required to avoid severe disadvantages for the further development of psychiatry.

ROC analysis of alcoholism markers--100% specificity.

A combination of 4 so-called markers of alcoholism, i.e. methanol, acetone + 2-propanol, gamma-glutamyltransferase and carbohydrate deficient transferrin, was investigated in 341 blood samples from alcoholics and non-alcoholics. From the history of alcohol consumption, four defined subgroups were formed: non-alcoholics divided into (A) 33 persons with no ethanol consumption during the past year and (B) 60 persons with daily consumption less than 40 g ethanol. Alcoholics were divided into (C) 177 persons with no ethanol at the time of admission/first blood sampling (withdrawal therapy) and (D) 71 persons with positive ethanol levels on admission/first blood sampling. All markers showed different extents of overlap between the collectives of alcoholics and non-alcoholics. By logistic regression, a formula was developed combining these markers with different mathematical weights. Thus an "Alc-Index" could be calculated for each individual. The ROC curve connecting all individual values gives an ideal form with 100% specificity and nearly 93% sensitivity. The threshold between the collectives of alcoholics and non-alcoholics was defined by the Alc-Index value 1.7. This was associated with no false positives among the non-alcoholics while nearly 93% of the alcoholics exceeded this index. The ROC-based calculation of the Alc-Index thus seems to be the most effective method for the diagnosis of alcoholism.

Long-term psychiatric patients in vocational rehabilitation programmes: a naturalistic follow-up study over 3 years.

OBJECTIVE: This paper aims at assessing the vocational integration attained after a 3-year period by psychiatric patients who participated in different vocational rehabilitation programmes. METHOD: In the north-western German region of Westphalia-Lippe a naturalistic follow-up study was carried out on 471 patients from three different types of vocational rehabilitation programmes. The sample comprised chronically ill patients with a history of repeated and long-term hospitalization. RESULTS: After 3 years 11% of the patients were in competitive employment, 67% (still) in sheltered employment, 7% in out-patient work therapy programmes and 15% were unemployed. It is important to notice that 74% achieved their subjective rehabilitation goals expressed at baseline. CONCLUSION: Vocational rehabilitation programmes are an essential part in the treatment of people with chronic mental illness. Integration into work varies markedly while patients' satisfaction is comparably good. Competitive employment represents a realistic objective only for patients with high motivation and favourable preconditions.

[Homeless men in inpatient psychiatric treatment--a controlled study. 1: Health status and self assessment at intake]. / Wohnungslose Männer in stationär psychiatrischer Behandlung--Eine kontrollierte Studie. Teil 1: Gesundheitszustand und Selbstwahrnehmung bei Aufnahme.

OBJECTIVE: This study examines the objective and the subjectively reported state of health, the social network and the utilisation of mental health services in a representative group of homeless men (n = 50) at time of admission to a psychiatric hospital and compares these results with a control group (matched by diagnosis) of non-homeless men. METHOD AND PATIENTS: The BPRS, the SF-12 Health Survey and a neglection index were administered. The main psychiatric diagnosis (ICD-10) were alcohol addiction (n = 29), drug addiction (n = 13), schizophrenia (n = 7) or personality disorder (n = 1). RESULTS: No differences were found according to sociodemographic basis data, but the homeless group had a smaller social network and less financial resources. There was a higher rate of involuntary admission in the homeless group, less contact to mental health services in the weeks before admission, more psychopathological symptoms and more physical neglection. Self-rating of mental and physical health, however, did not differ significantly. There was a positive correlation between thought disturbance and positive self-rating of mental health. CONCLUSION: The mental and physical health of the homeless patients was markedly worse. Beneath structural barriers symptoms, the extreme distress of their living situation and the decreased insight and motivation for treatment are characteristics of this group of patients which make them difficult to treat.

[Homeless men in inpatient psychiatric treatment--a controlled study. 2: Effects of treatment]. / Wohnungslose Männer in stationär psychiatrischer Behandlung--Eine kontrollierte Studie. Teil 2: Behandlungseffekte.

OBJECTIVE: This study examines the objective and the subjectively reported state of health in a regional representative sample of homeless men (n = 50) at time of admission into a psychiatric hospital and shortly before discharge and compares the results with a control group (matched by diagnosis) of non-homeless men. METHOD AND PATIENTS: The BPRS and the SF-12 Health survey were administered. The main psychiatric diagnosis (ICD-10) were alcohol or drug addiction (84%), schizophrenic disorders (14%) and personality disorders (2%). RESULTS: The median of hospitalisation was 26 days with no significant differences between the two groups. At discharge outpatient treatment was planned for only 16% of the homeless patients but for 40% of the controls. There was a significant improvement in symptoms and self reported state of health. On admission and discharge thought disturbance and a positive self-rating of mental health were significantly correlated. CONCLUSIONS: Against the wide-spread clinical prejudice that inpatient treatment of homeless mentally ill men is not effective our results show that the objective state of health as well as the self-perceived mental and physical health was improved by a regular psychiatric in-patient treatment. The results furthermore indicate the limitations of inpatient treatment the need for outpatient treatment programmes.

[Predictors of success in supported employment programmes--results of a prospective study]. / Prädiktoren einer erfolgreichen beruflichen Eingliederung. Ergebnisse einer prospektiven Studie.

BACKGROUND: Vocational integration of mentally ill patients is confronted not only with illness-related restrictions but also with the current situation on the labour market and prejudices on the part of potential employers. The Consultancy Centres for Vocational Integration work with a supported employment approach which was adapted to the German situation. It includes prevocational training, assistance in finding appropriate jobs, cooperation with employing companies and long-term job site support. METHODS AND PATIENTS: Within the scope of a major study on vocational rehabilitation in the German region of Westphalia-Lippe, we carried out a prospective study of the further vocational course of 61 patients who had already been placed in competitive employment within the framework of the Consultancy Centres. These patients (30 men, 31 women) had a mean age of 31 years (+/- 6.9); 54% of them were suffering from schizophrenic disorders; mean duration of illness was 8.2 years (+/- 6.8). RESULTS: After two years (and for a subsample of 33 patients also after 3 years) two-thirds of patients were still in competitive employment. Predictors of success proved to be 1) a higher ability to cope with vocational stress on introduction of the measure, 2) an earlier start to rehabilitation, and 3) financial assistance for the company. A close correlation was recorded between course of illness (rehospitalizations) and success of rehabilitation. CONCLUSIONS: Even in the current situation of high unemployment rates vocational integration of mentally ill patients is possible and stable in medium term. Especially highly-motivated patients with favourable preconditions (early start of rehabilitation measures, higher ability to cope with work stress) are successful if intensive long-term support--including efforts involving employers--is provided.

[Homeless and mentally ill. Review of recent research and results on a doubly disadvantaged minority]. / Wohnungslos und psychisch krank. Uberblick über den Forschungsstand und eigene Ergebnisse zu einer doppelt benachteiligten Randgruppe.

There are about 200,000 homeless persons in Germany, 35,000 of them living on the streets. They suffer from unemployment, poverty, social isolation and physical impairments. More than two-thirds of them suffer from mental illness as well. Substance abuse predominates, but also schizophrenic and affective disorders and personality disorders show a higher prevalence than among the general population. Comorbidity is found frequently. However, mental disorders are just one of several factors contributing to the process of becoming homeless. Due to the complex combination of mental, physical, social and economic problems of the homeless mentally ill psychiatric care is not sufficient. Yet recent US studies show that a combination of multimodal clinical measures and a network of outpatient assistance can improve both physical and mental health and the social situation. Having established reliable epidemiological data, future research should concentrate on analysing the influence of homelessness on mental health, and on planning and evaluating specific programmes for the homeless mentally ill.

[What characterizes the problem psychiatric patient? Results of a study of patient descriptions using the Psychiatric Personnel Order]. / Was kennzeichnet den psychiatrischen Problempatienten?

In recent years, economic pressure on extended and repeated psychiatric hospitalisation have increased dramatically. At the same time, diagnostic approaches, e.g., the new concept of the "young adult chronic patient" have improved. The first part of this article summarises reports and experiences on the chronic mentally ill and the so-called "heavy users" of psychiatric hospitalisation. Although the number of studies evaluating this group is small, several characteristics can be identified. Subsequently, a study is presented that deals with psychiatric problem patients in a special way, namely the A2-categorisation according to the German Psychiatric Personnel Regulation (Psychiatrie-Personalverordnung [Psych-PV]). The study is based on 170 consecutive admissions to the Department of General Psychiatry of a large German state hospital, who are characterised as normal (A1) and intensive patients (A2), respectively. The study aimed at describing difficult-to-treat patients or those whose treatment demands large human resources. Medical histories, sociodemographic and psychopathological data as well as subjective health status data of these patients were analysed by standardised and validated instruments (e.g., BPRS, CGI, SF-36, GAF). Results show that the patients under study suffered mainly from schizophrenic psychosis according to ICD-9. Patients categorised into A2 showed a high degree of psychopathology and little insight into their disease. Further it can be demonstrated that they used more therapeutic help from general practitioners rather than from specialists in psychiatry prior to admission. In conclusion, it is suggested to evaluate concepts, e.g., new treatment methods in respect of motivating schizophrenic patients, new typological methods to better diagnosis and to treat psychiatric problem patients via new treatment modalities such as Case Management or inpatient settings for double diagnoses.

[The course of illness and rehabilitation of schizophrenic patients in ambulatory vocational therapy. A prospective study over 3 years]. / Krankheits- und Rehabilitationsverläufe schizophrener Patienten in ambulanter Arbeitstherapie. Eine prospektive Studie über 3 Jahre.

Within the framework of a study on vocational rehabilitation of the mentally ill, we examined 83 schizophrenic outpatients enrolled in a work therapy program. The course of illness and rehabilitation was documented over a 3-year period by means of annual follow-up examinations. The sample comprised 44 men and 39 women with an average age of 35 years (SD +/- 8.5). The majority were chronically ill patients with a history of frequent and long psychiatric hospitalization. After 3 years, 22% of the patients were integrated into the general labor market, 26% had sheltered employment, 23% were still in work therapy, and 29% were unemployed. Besides the patients' subjective expectations, early introduction of rehabilitative measures and a favourable course of illness were found to be predictors of a successful rehabilitation leading to vocational integration. Outpatient work therapy is a contemporary, effective organizational form of sociotherapy. It may contribute to improved vocational competence and integration, reduced psychiatric hospitalization and stabilized psychopathology.

[Occupational rehabilitation of chronic psychiatric patients. Results of a prospective study over 3 years]. / Arbeitsrehabilitation chronisch psychisch Kranker. Ergebnisse einer prospektiven Untersuchung über 3 Jahre.

Vocational rehabilitation of mentally ill patients is now focused outside the psychiatric hospital. Three types of programmes play a major role: outpatient work therapy programmes at psychiatric hospitals, jobs in (partly) sheltered employment facilities as in companies specially adapted for employing mentally ill persons, and workshops for the mentally disabled. In the north-western German region of Westphalia-Lippe (population: 9 million) we carried out a three-year prospective study on a regionally representative sample from such rehabilitation institutions to assess the course and outcome of vocational rehabilitation. The sample comprised 295 men and 176 women with a mean age of 36.1 year (+/- 9.6). The majority were chronically ill patients with a history of frequent long-term hospitalisation. 61% of all probands were suffering from schizophrenic disorders. The outcome of vocational rehabilitation differs substantially among the three programme types, primarily due to varying baseline conditions, subjective expectations or goals, and courses of illness. The programmes are not alternatives but should be seen as supplementary components of a care system which has to meet a wide range of patient requirements. Vocational integration into the open labour market is a desirable and realistic objective for only some of those concerned.

[A program for the rehabilitation of mentally ill students]. / Ein Programm zur Rehabilitation psychisch kranker Studierender.

The rehabilitation of mentally ill undergraduates is a neglected area. The scope and relevance of this problem are confirmed by the epidemiological figures available. A programme aimed at supporting mentally ill undergraduates at Münster university offers such students psychoeducationally oriented group therapy and intensive individual counselling. The report covers 82 students who have expressed interest in this programme since the 1993 summer semester. 57 took part for at least 1 semester, the majority of them (56%) being schizophrenic patients. The main problem is in structuring and coping with required standards of performance, social isolation, excessively high expectations of their own achievement potential, and insecurity with regard to the prospects of success in their degree courses. Experience to date confirms the need for, and the opportunities offered by on-target support of mentally ill undergraduates.

[Risperidone after clozapine in therapy refractory schizoaffective psychosis--a case report]. / Risperidon nach Clozapin bei therapieresistenter schizoaffektiver Psychose-Eine Fallstudie.

Recently, American authors pronounced the hypothesis that Clozapine-response may be considered as a predictor of response to atypical neuroleptic. We report the history of a schizoaffektive patient unresponsive to butyrophenone and phenothiazine neuroleptic who was first treated with Clozapine and then with Risperidone and who reacted very differently to these atypical neuroleptic.

[Prevalence of psychiatric disorders and outcome of social integration of homeless men]. / Prävalenz psychischer Störungen und Verlauf der sozialen Integration bei wohnungslosen Männern.

All 52 regular users of a shelter in a medium-sized German city underwent a baseline psychiatric examination in 1990. Mental disorders, especially alcohol addiction and schizophrenic disorders, were recorded among 40 (77%). After four years the residential situation and the number and duration of psychiatric hospitalisations was recorded for 42 of these men. 33 of them mentally ill and 9 with no mental disorders. The four-year follow-up revealed that half the mentally ill men were still living in a homeless environment or had died, whereas most users with no mental disorder had a home of their own again. Longer-term hospitalisation or guardianship was found to have a favourable impact on social integration of the homeless mentally ill. Although psychiatric help without the consent of those concerned cannot solve the social problem of homelessness, it can often improve the living situation of homeless mentally ill patients.

Work therapy for schizophrenic patients: results of a 3-year prospective study in Germany.

Work therapy is a widespread form of sociotherapy. In contrast to pharmacological and somatic forms of treatment, proof of efficacy is difficult to produce in multimodal therapy of schizophrenic patients on account of the many methodological problems involved. Within the framework of an extensive study on the vocational rehabilitation of mentally ill patients, we carried out a naturalistic follow-up study of 83 schizophrenic patients attending outpatient work therapy. The sample, which comprised 44 men and 38 women with a mean age of 35 years (+/- 8.5 years), can be seen as regionally representative. The courses of illness and rehabilitation were documented prospectively at annual follow-ups over a 3-year period. Most of the probands were chronically mentally ill patients with a history of frequent and long-term hospitalisation. At the end of the 3-year period, 22% of the patients were integrated into the open labour market, 26% were working in sheltered employment, 23% were still in work therapy, and 29% were unemployed. Two-thirds had achieved their stated rehabilitation objectives. The 3-year rehabilitation outcome was strongly dependent on the patients' subjective expectations. Other factors proving to be predictors of successful rehabilitation were less pronounced psychopathological symptoms (ADMP), better social functioning (GAS), a higher level of education and an early introduction to work therapy. Work therapy appears to have a favourable impact on hospitalisation rates.