[Recommendations for psychotherapy in psychiatric inpatient treatment : Results of the PAKT Study Part I]. / Psychotherapieempfehlungen in der stationären psychiatrisch-psychotherapeutischen Behandlung : Ergebnisse der PAKT-Studie Teil I.

BACKROUND: In the S3 treatment guidelines psychotherapy is recommended in all psychological disorders. Therefore, outpatient or inpatient psychotherapy should be recommended by therapists in most cases. On the other hand, it is well known that waiting periods for psychotherapeutic treatment are considerable, which raises the question how the recommendation for psychotherapy is presented in psychiatric hospitals in Germany. OBJECTIVES: The article deals with the question of how frequent the recommendation of psychotherapeutic treatment is made after psychiatric inpatient stay or day care, and if there are differences between hospitals and patient groups. METHOD: In four psychiatric hospitals in southern Germany the frequency of recommendation for psychotherapy in psychiatric patients was registered and compared to the number of all patients treated in the equivalent time. For this purpose, we analyzed data of the basic documentation in the four participating hospitals. RESULTS: Overall, 9.6 % of the patients received a recommendation of psychotherapeutic treatment. In the psychiatric university hospital a subsequent psychotherapeutic treatment was recommended somewhat more often. Differences between hospitals were present but marginal. Over all participating hospitals, psychotherapy was recommended markedly less frequently in patients with an F2 diagnosis in comparison with patients with F3 or F4 diagnoses. CONCLUSION: Psychotherapeutic treatment after psychiatric inpatient stay is recommended cautiously. Probably therapists anticipate the fact that the growing demand for psychotherapeutic treatment in general reduces the chances for persons after psychiatric inpatient treatment.

[Implementation of the recommendations for psychotherapy after psychiatric inpatient treatment : Results of the PAKT study Part II]. / Realisierung von Psychotherapieempfehlungen nach psychiatrischem Aufenthalt : Ergebnisse der PAKT-Studie Teil II.

BACKGROUND: Waiting periods for inpatient or outpatient psychotherapeutic treatment are generally considerable. For patients treated in a psychiatric day-clinic or hospital, implementation of a recommended subsequent psychotherapeutic treatment might be difficult. OBJECTIVES: In part II of the psychotherapy after hospital or day clinic (PAKT) study, we examined how the recommendation for psychotherapy can be implemented after psychiatric treatment. MATERIALS AND METHODS: Three months after discharge from one of four psychiatric hospitals in southern Germany, we interviewed 306 patients who received a recommendation for psychotherapeutic treatment after their hospital stays if the recommendation was implemented successfully. RESULTS: Only about 12 % of the patients in the follow-up group were unable to implement the general recommendation for psychotherapy after psychiatric stay despite motivation for psychotherapeutic treatment. In the case of recommendation for outpatient psychotherapy, 20 % were unsuccessful. Predictors for successful implementation were education and employment, whereas variables like age, gender, diagnosis, or severity of disorder did not play a significant role. CONCLUSIONS: The relatively small percentage of unimplemented psychotherapeutic treatment is surprising at a first glance. However, the proportion recommended for psychotherapy after psychiatric stay was less than 10 %, as shown in the first part of the study (see PAKT Study Part I, doi:s00115-016-0107-z).

[Involuntary psychiatric hospital admissions: a comparison between five hospitals in three German federal states]. / Psychiatrische Unterbringungspraxis : Ein Vergleich von fünf Kliniken in drei Bundesländern.

BACKGROUND: There is considerable variance in involuntary psychiatric hospital admission rates both in Europe and Germany. In a prospective comparison between five hospitals in three German federal states we assessed and analyzed involuntary psychiatric hospital admissions, including the patient's perspective. MATERIAL AND METHOD: All involuntarily admitted patients were assessed by an independent researcher. Clinical data, patient and psychiatrist views were documented with different instruments including the McArthur admission experience survey. RESULTS: In this study 104 out of 244 involuntarily admitted patients gave informed consent. We found considerable differences between study centres concerning involuntary admission quotas (3.2-25.8% of all hospital admissions) and involuntary admission rates (16.6-97.6 per year per 100,000 inhabitants). Hospitals in the state of Baden-Württemberg had the lowest involuntary admission rates while they were highest in Bavaria. In Baden-Württemberg involuntarily admitted patients were more likely to suffer from chronic schizophrenia, they were more severely ill and experienced the involuntary hospital admission as more strenuous. There were no differences between centres concerning frequency of dangerous behavior or self-harm. CONCLUSION: We found a high variance across regions concerning the reasons for, frequencies and legal basis of involuntary hospital admissions. Regional differences of legal frameworks and service organization can explain this only to a limited amount. Transparency, legal certainty and reflection of stakeholder roles are a future necessity. Furthermore, there is a need for stringent compliance with legal regulations and coherent documentation.

Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment.

OBJECTIVE: Evaluating the effects of different types of psychotropic polypharmacy on clinical outcomes and quality of life (QOL) in 374 patients with schizophrenia and schizoaffective disorder in routine care. METHOD: Psychotropic regimen, clinical outcomes, and QOL were assessed before discharge and after 6, 12, 18, and 24 months. Data were analyzed by mixed-effects regression models for longitudinal data controlling for selection bias by means of propensity scores. RESULTS: At baseline 22% of participants received antipsychotic monotherapy (APM) (quetiapine, olanzapine, or risperidone), 20% more than one antipsychotic drug, 16% received antipsychotics combined with antidepressants, 16% antipsychotics plus benzodiazepines, 11.5% had antipsychotics and mood stabilizers, and 16% psychotropic drugs from three or more subclasses. Patients receiving APM had better clinical characteristics and QOL at baseline. Patients receiving i) antipsychotics plus benzodiazepines or ii) antipsychotics plus drugs from at least two additional psychotropic drug categories improved less than patients with APM. CONCLUSION: Combinations of antipsychotics with other psychotropic drugs seem to be effective in special indications. Nevertheless, combinations with benzodiazepines and with compounds from multiple drug classes should be critically reviewed. It is unclear whether poorer outcomes in patients with such treatment are its result or its cause.

Psychotropic drug treatment, clinical characteristics and cognitive processing speed in patients with schizophrenia: results from the ELAN study.

INTRODUCTION: Psychotropic drug combinations (PDC) are common in the treatment of patients with schizophrenia but there is little research regarding the effects of PDC on cognition. OBJECTIVE: The aim of this study was to analyse the effects of antipsychotic monotherapy and various types of PDC on cognitive processing speed (CPS). METHODS: ELAN is a 24-month multi-site prospective observational controlled trial following up 374 patients with schizophrenia under routine treatment conditions following discharge from inpatient treatment. The propensity score method, multinomial logistic regression analyses and mixed effects regression models were used. RESULTS: CPS correlated significantly with PANSS and GAF scores and improved over time in the monotherapy group. Negative effects of some PDC (antipsychotics + tranquilizers/antipsychotics+at least 2 other psychopharmacological subclasses, sedative/anticholinergic drugs/high adjusted antipsychotic dose) lost significance after controlling for clinical characteristics. DISCUSSION: Indications for PDC should be examined with care although, in the present study, effects on cognition were small.

[Neuroleptics--psychotherapy--psychiatric social work. In schizophrenia help is needed from many sides]. / Neuroleptika--Psychotherapie--sozialpsychiatrische Begleitung. Bei Schizophrenie muss Hilfe von vielen Seiten kommen.

Schizophrenic disorders require a complex, multidimensional treatment strategy. Throughout the entire course of the illness, psychopharmacologic, psychotherapeutic and psychosocial therapeutic measures must be integrated within an overall management plan. Although treatment planning should be orientated to the needs and expectations of the patient, current therapeutic guidelines must also be taken into account. Management decisions are based on such central questions as the patient's ability to cope with the requirements of daily life, or the attitude to the illness of the patient and family members. Inpatient treatment concepts include, in addition to pharmacotherapy, a cognitive-behavioral therapeutic program. In the outpatient setting, the question as to supportive rehabilitation measures and social integration aids needs to be dealt with.

[Concepts in early planning for vocational rehabilitation in schizophrenia patients during acute care]. / Konzepte beruflicher Rehabilitationsvorbereitung für schizophrene Patienten während der Akutbehandlung.

The particular relevance of employment for financial independence, acquisition of social skills and, hence, an increase in self-confidence is undeniable, and has for several years now been increasingly considered an essential component of care notably in psychiatric disorders. Vice versa, unemployment is deemed a potential risk factor with regard to poorer therapeutic response and social integration as well as a higher incidence of crises in persons with mental illness. Schizophrenia is among the psychiatric disorders very often resulting in unemployment and subsequent early pensioning. Planning for vocational rehabilitation early-on during acute care therefore is considered of greatest importance especially in this patient group. This article gives a brief overview of the main concepts drawn on in preparing the vocational rehabilitation of patients with Schizophrenia, focussing in particular on their relevance for daily practice and the possibilities for evaluating their effectiveness.

Indicators of quality of in-patient psychiatric treatment: the patients' view.

OBJECTIVES: The object of this study was to find out from psychiatric in-patients which aspects of care and treatment they considered important and how satisfied they were with these. DESIGN: One hundred and ninety-four in-patients were asked to rate the importance of, and their satisfaction with, 22 different aspects of in-patient care and treatment. The questionnaire, developed for the purpose of the study after a pilot phase including professional care givers and patients, contained 92 items and was returned by 52% of all discharged patients from the Psychiatric university hospital during a 3-month period. RESULTS: Patients made a clear distinction between aspects of treatment they considered important and aspects they were satisfied with. Ranked of highest importance were various therapeutic relationships, and respect for their rights and privileges. They were satisfied with their relationships with clinical staff but dissatisfied with medication. CONCLUSION: A well differentiated assessment of importance and satisfaction has implications for the evaluation of the quality of psychiatric care, for specific methods of treatment, and for the improvement of in-patient psychiatric care.

Psychiatric commitment: patients' perspectives.

OBJECTIVE: The literature pertaining to patients' perceptions of commitment and its consequences is limited. The object of this study was to learn more about these experiences from the patient's perspective. MATERIAL AND METHODS: 108 court-committed patients (78% of whom were schizophrenic) were identified for inclusion in a retrospective follow-up study. After an interval varying from one to 4.5 years from time of commitment to follow-up, 76 patients could be contacted, of whom 47 were included in the follow-up. RESULTS: The majority of patients felt that their court commitment had not been justified and could have been avoided. Events and circumstances identified as particularly stressful about commitment were confinement in a locked ward, side effects of medication, feelings of helplessness, and certain staffbehaviors. Adverse psychological, somatic, and social consequences were common. Coercive measures during hospitalization were strongly associated with negative feelings about the effect of commitment on mental health and about subsequent treatment. The majority, however, also remained in treatment after commitment was terminated, said they would return to hospital in event of future crisis, and had pertinent comments about how commitment could have been avoided. CONCLUSIONS: Many patients who had been court-committed reported negative feelings about their experiences, but the great majority had continued in treatment, both at the termination of commitment and later. They also had ideas about how to reduce the negative impact of commitment that are worth including in future contingency plans.

Heart-rate variability (HRV) in the ECG trace of routine EEGs: fast monitoring for the anticholinergic effects of clozapine and olanzapine?

Drug monitoring in psychiatry usually serves psychoactive drug plasma concentration measurement. Anticholinergic properties offer a faster approach to monitoring pharmacodynamic intraindividual effects of the drug by measuring their effects on heart rate variability (HRV), which is sympathetically and parasympathetically controlled via cholinergic synapses. The plasma concentrations of the atypical antipsychotics clozapine and olanzapine correlated with parameters of HRV in 59 patients suffering from schizophrenia or schizoaffective disorder. HRV during 4 minutes at rest was extracted from the ECG trace of a routine digital EEG registration in addition to blood sampling for plasma concentration measurement (HPLC method). We calculated sympathetically and parasympathetically controlled heart frequency bands (low, medium and high frequency) and other HRV parameters, coefficient of variation (CV), and root mean square of successive differences (RMSSD). All HRV parameters were significantly more impaired in clozapine patients (n = 33, mean clozapine plasma concentration 331 +/- 294 ng/ml) than in olanzapine patients (n = 26, mean olanzapine plasma concentration 42 +/- 32 ng/ml) and demonstrated 1.7 - 4.8 times the cardiac anticholinergic properties of clozapine in vivo. 14 out of 14 patients with a CV beyond 3.2 % had clozapine plasma concentrations below the proposed optimal therapeutic concentration of 350 ng/ml. All HRV parameters were inversely and significantly correlated with the clozapine plasma concentrations (such as lgCV: r = - 0.73, p < 0.001) and, to a lesser extent, with the olanzapine plasma concentrations (lgCV r = - 0.44, p < 0.05). These results underline the potential clinical value of HRV parameter extraction from routine ECGs in predicting plasma concentrations and objective individual neurocardiac effects of drugs with anticholinergic properties.

[Short- and medium-term outcome of outpatient treatment of alcohol dependent patients. A 6-, 18- and 36-month follow-up]. / Kurz- und mittelfristige Erfolgsraten ambulanter Entwöhnungsbehandlungen für alkoholabhängige Patienten. Eine 6-, 18- und 36-Monats-Katamnese.

The aim of this study was to investigate the short- and medium-term outcome of alcohol dependent patients in Germany after a one-year outpatient treatment. For this purpose, a 6-, 18- and 36-month follow-up of 97 socially well adapted alcohol dependent patients treated between 1992 and 1997 at three "psychosocial advice center" run by the Diakonie Württemberg, Germany, was carried out. Based on the time period between treatment and follow-up, all 97 patients could be followed up for 6 months, 71 for 18 months, and 33 for 36 months. 83% of patients could be interviewed at 6 months, 80% at 18 months, and 78% at 36 months. The statistical analyses were based on the "intention to treat" model. All patients treated between 1992 and 1997 were included. Patients for whom no information was available were classified as relapsers. 6 months after the outpatient treatment 59% of patients were abstinent, 4% had lapsed and 37% were relapsers. At the 18- and 36-month follow-ups 61% of patients had been abstinent in the 6 months before the interview. 53% and 39% of patients respectively were continuously abstinent over the entire follow-up period of 18 and 36 months. Prognostic criteria for a relapse were regular completion of treatment (p < 0.001) and no prior detoxification or abstinence oriented treatment (p < 0.01). Patients without a partner showed a tendency towards higher relapse rates (p < 0.10). The results of this study indicate that an outpatient treatment program can be as effective as inpatient or combined inpatient/outpatient treatments, at least for some patients with good social integration.

[Community-based rehabilitation for severely ill psychiatric patients?]. / Gemeindenahe Rehabilitation für schwer psychisch Kranke?

A central aim of reformatory efforts, as a consequence of the "Psychiatrieenquete" 1975 (a fundamental report of the situation of psychiatry in Germany), had been dehospitalisation of patients with chronic mental illness and their reintegration into the community. Despite a meanwhile well-developed range of community-based services, patients with severe mental illness only rarely get adequate care by these services. This holds especially true for patients with an unfavourable course of disease such as schizophrenia, severe personality disorder, skid-row alcoholism with multiple problems or for patients with double diagnosis. The reasons are barriers set up by the various services and their underlying concepts as well as structural problems in the health care system. Adapted to the special needs for help of these patients, we present a model for the community-based care of this group, combining elements of community psychiatry, addiction treatment and help for the homeless.

Chronic psychiatric patients without psychiatric care: a pilot study.

BACKGROUND: The study is based on the hypothesis that in any catchment area there are patients with chronic mental illness who are unknown to a comprehensive psychiatric/psychosocial care system. METHOD: A standardized questionnaire was sent to all general practitioners in a circumscribed catchment area in southwestern Germany in an attempt to identify such a group, to ascertain what the practitioners considered to be the needs of these patients, and to find out why the patients were not receiving specialized psychiatric care. RESULTS: Of 97 general practitioners contacted, 62 returned the questionnaire. Within a study period of 3 months, 89 patients were identified as having a significant psychiatric disorder, of whom 53% were older than 60 years and 15% were schizophrenic. General practitioners most frequently said that provision of specialized psychiatric care was the most pressing need of these patients, followed by a need for psychosocial services. They also said that the major reason patients did not participate in the mental health system was patient refusal of such services. CONCLUSIONS: Having identified the existence of a group of chronic psychiatric patients who are not receiving specialized psychiatric care, further in-depth field studies to pursue some of the issues raised in this pilot study will be necessary to determine whether further efforts to reach psychiatric patients without defined psychiatric care would be worthwhile. These issues include estimates of the prevalence of such patients in a defined population, patients' more specific reasons for refusal of psychiatric care, and the quality of psychiatric care they receive from general practitioners in comparison with patients who receive more conventional psychiatric care.

[Community psychiatric management of severely ill schizophrenic patients. An exemplary case study]. / Die gemeindepsychiatrische Versorgung schwerstkranker Schizophrener. Eine exemplarische Fallstudie.

Psychiatric care for chronic schizophrenic patients has improved in recent years, but for severely ill patients, often with multiple comorbid psychiatric conditions and in great need of care, the situation remains unsatisfactory. Community-based psychiatric care is limited and psychiatric hospitals are now cutting back on inpatient care. The quality of care that chronically mentally ill patients receive at independent psychiatric nursing homes removed from population centers is undetermined, and many patients end up in asylums or homeless shelters unable to provide for their psychiatric needs. Neither a reliable way to assess the needs of these complicated patients nor a scientific basis for therapeutic intervention exists yet. The case study presented here illustrates an interdisciplinary approach to the care and treatment of a chronic schizophrenic patient with several comorbid conditions. Based on the individual needs of the patient and developed over the last 4 years, this approach had positive effects on the course and outcome of treatment and resulted in an impressive reduction of costs. The average annual number of days of hospitalization over a 3-year period was reduced from 206 to two and the total cost of care was reduced from US$70,000 annually to $8000. The results from this single case study are promising. Further investigation of the development and evaluation of highly individualized treatment plans for severely disturbed schizophrenic patients is warranted.

[Role of sports in treatment and rehabilitation of schizophrenic patients]. / Die Rolle des Sports in der Behandlung und Rehabilitation schizophrener Patienten.

The literature on the role of sports in the treatment and rehabilitation of schizophrenic patients is meagre and no systematic interdisciplinary review of the subject exists. This article reviews the existing literature and summarizes the relevant research findings. It also discusses practical experiences derived from a model project designed to study the role of sports in the management of chronically ill psychiatric patients, which showed that social interaction as well as the ability to organize time and leisure activities improved as did self-esteem, body awareness, and overall physical activity. Sports activities as part of the care of chronically ill psychiatric patients are effective as well as cost-effective and should receive more attention in both practice and research.

[Does modification of documentation result in a reduction of medication to involuntary patients?]. / Führt eine veränderte Dokumentation zur Reduktion von Zwangsmedikationen?

OBJECTIVE: The effects of modification of documentation on the administration of psychotropic medication to involuntary patients in hospital were investigated. METHODS: The charts of 414 inpatients on the acute-ward were reviewed two months before and two months after a new form for documentation of rationales for medication administration to involuntary patients was instituted. A follow-up was carried out for a two-month period a year later. RESULTS: The percentage of patients who received medication involuntarily, 70% of whom were schizophrenic, fell by over half, from 12% to 5%, after additional standardized documentation for the use of such medications was instituted. The number of medications administered to involuntary patients fell from 80 to 21, a reduction of 74%. The effects were stable over the course of one year. CONCLUSIONS: Modification of documentation seems to reduce the use of medication with involuntary patients.

[Role of the clinic in follow-up of schizophrenic illnesses]. / Die Rolle der Klinik im Verlauf schizophrener Erkrankungen.

Schizophrenics have the longest hospital stays and incur the greatest costs with respect to psychosocial care compared to other psychiatric patients. The present study focuses on the relevance of inpatient treatment during the course of schizophrenia with regard to specific symptom characteristics. In addition, the role of the hospital in partnership with local community health care facilities for the care of schizophrenic patients is described. Central aspects of hospitalisation, such as the circumstances of first admission, involuntary treatment, discharge planning, and provision for readmission are analysed and linked to our own data. Schizophrenic patients comprised the largest group of involuntarily treated patients and only 50% said they would return voluntarily to hospital if their symptoms recurred. On discharge from hospital, schizophrenic patients did not differ from other psychiatric patients with regard to their attitudes to hospitalisation. Improvement in both work and interpersonal skills was evident after first inpatient treatment. To provide better care for this group of patients, patient-oriented health provision services with individual attention, treatment and care planning are needed, in contrast to the more traditional hospital-oriented approaches that have been tending to give priority to institutional needs.

[Trial employment: a provisional work setting for psychiatric patients]. / Der therapeutische Arbeitsversuch- Eine Annäherung an die Arbeitswelt für Psychiatriepatienten.

OBJECTIVE: This study investigates the effects of probationary work for psychiatric patients in community-based small businesses during their inpatient or day care. METHODS: Patients were evaluated for working capacity, psychopathology, motivation for work and patient satisfaction (n = 69). RESULTS: The results confirm a high degree of acceptance of this approach as well as significant improvements on various clinical scales such as the Brief Psychiatric Rating Scale (BPRS), the Beck Depression Inventory (BDI), the Global Assessment of Functioning Scale (GAF), choice reaction time (Wiener Determinationsgerät, WDG), attention (Revisionstest) and self-rating of work-relevant skills. CONCLUSIONS: This approach, with its complex demand characteristics, may be an effective alternative to occupational therapy, at least for small therapeutic units.

[Effects of regional obligatory health care exemplified by a university clinic]. / Auswirkungen der regionalen Versorgungsverpflichtung am Beispiel einer Universitätsklinik.

OBJECTIVE: Local care provision for the chronically mentally ill entails responsibility to be taken by all institutions involved in the care system of their respective area. In the clinical sphere regional responsibility is implement-ed to a large extent apart from a few university clinics. The University Psychiatry and Psychotherapy Clinic Tuebingen look after an area with obligatory provision of care consisting of 140,000 inhabitants in 1995. RESULTS: The comparative evaluation of the basic documentation showed minimal overall changes but an increase of older patients, of patients who are frequently hospitalised, and of addicts. The number of emergencies remained unchanged. The concomitant questioning of colleagues indicated delayed acceptance of the change. According to experiences made to date, the conditions for research and teaching have improved in certain areas thanks to the obligatory provision of care.

[The Community Psychiatry Organization in Baden-Württemberg]. / Der gemeindepsychiatrische Verbund in Baden-Württemberg.

While as a result of the report of the German Federal Government's Inquiry Commission a nationwide programme for further development of the provision of care to the mentally ill was launched, Baden-Wuerttemberg went it's own ways with its "Programme for the Development of Outpatient Psychiatric Care 1982-1986". In 1994 Baden-Wuerttemberg's concept of a "Communal Psychiatric Combine" ("Gemeindepsychiatrischer Verbund", GPV) was worked out; this concept increases in some respects the existing differences from other states. Apart from an improvement in coordination and cooperation, the GPV is intended to secure comprehensive local care provision for the chronically mentally ill. Furthermore, care provision appropriate to requirements should be made possible and quality assurance realised on all levels. In the following, Baden-Wuerttemberg's understanding of a "Communal Psychiatric Combine" is contrasted with the combine concept of the expert commission. The potential effects of the reginal care situation as well as the chances of implementation are discussed with reference to earlier experiences.