[Assertive community treatment of psychoses]. / Opsøgende psykoseteam.

Long-term institutionalization is no longer the preferred treatment for the severely mentally ill. Several models for outpatient treatment of the severely mentally ill have been developed, among them Assertive Community Treatment (ACT). The literature on this model is reviewed in a Cochrane review and in randomized trials comparing ACT with hospital admission. ACT is a clinically effective approach to managing the care of severely ill people in the community. ACT, if correctly targeted on high users of in-patient-care, can substantially reduce costs of hospital care whilst improving outcome and patient and relatives satisfaction. Setting up ACT teams should be supported by politicians, professionals and consumers.

[Community psychiatry in Copenhagen. Adaptation to increased needs]. / Distriktspsykiatri i København. Tilpasning til et øget optagelsesområde.

The purpose was to show the changes taking place in a community mental health centre where the need for treatment definitely increased compared to the available resources. The reason for this was an increase in size of the district covered. Data was recorded in a database. All patients in treatment and received during the years 1994 and 1995 were registered. The years 1990-92 were used for comparison. The necessary changes in organisation are described. The number of patients received decreased and the percentage with serious mental illness increased. After visitation the population which received treatment at the centre was dominated by patients with chronic psychosis. More consultations were given in the patients' homes. The retention of patients decreased. It is concluded that only half of the people in the district with serious mental illness were receiving treatment and only by increasing the amount of staff would it be possible to get the rest into treatment. The intake of other diagnostic groups should only be discussed after these steps are taken.

[A method for quality assurance in a community mental health center. Community psychiatry in Copenhagen]. / Metode til kvalitetssikring i et distriktspsykiatrisk center. Distriktspsykiatri i København.

The purpose was to describe a method for quality assurance in community mental health centres. Three psychiatrists and a multiprofessional treatment team conceived the method. The community mental health center--which was the basis for the work--was the Copenhagen centre for the sectors Vesterbro and Kongens Enghave. The target group for the centre is people with serious mental illness. The work is done according to the principles for clinical case managers. Data are registered in a national database in combination with the centre's own registration system. Eleven indicators for process quality and eight for outcome quality were selected. Measurement parameters for there indicators were defined. Criteria and standard were defined according to existing knowledge and the author's clinical experience. The necessary programs for calculating the value of the chosen standards are constructed. With the use of existing data and a limited extra registration it was possible to evolve a method for quality assurance in a community mental health centre.

[Community psychiatry in Copenhagen. Services and resource utilization]. / Distriktspsykiatri i København. Ydelser og ressourceanvendelse.

The purpose was to estimate the number and nature of contacts in a newly-established community psychiatry centre and their distribution according to diagnostic category, registered on computer. The number of contacts and day-patient days were about 6000 each per year. Two professionals participated in 20% of the contacts and 20% were in the patient's home (psychotic patients). Fifty percent of the contacts had a psychotherapeutic content, 10% were about medicine and 30% had a mixed content. The chronic patients made 20-25 contacts/year and other patients 6-10 per treatment episode. Forty-five percent of the resources were used on out-patients/hometreatment, 30% on activities, 10% on intake, 10% on secretarial work and 5% on administration. Seventy percent of resources were used on chronic patients and 20% on patients with minor disorders. Fifty-five percent of time spent was used for direct patient contact (40% for psychiatrists). Time for contacts was 45-60 minutes/patient/2 weeks (6 minutes for psychiatrists). In accordance with the politically defined goal the main part of the resources were used for psychotic patients. The patients valued the contacts as seen by a low rate of non attendance. The amount of time for contact seems reasonable although it was low for psychiatrists.

[Psychiatric admissions, continued hospital stay and community psychiatric treatment. Quality assurance of admission practice]. / Psykiatrisk indlaeggelse, fortsat hospitalsophold og distriktspsykiatrisk behandling. Kvalitetssikring af indlaeggelsespraksis.

Investigations on psychiatric admissions and length of stay at hospitals show great variations that are difficult to explain and many factors, besides relevant clinical ones, have been shown to contribute. Short hospital stays do not, in contrast to common beliefs, seem to increase the rehospitalization rate, more likely the opposite. Several places in the world have established criteria for "good practice" which use few and short intakes in combination with intensive community treatment. The results (symptoms and function) are better, the satisfaction of patients and relatives greater and the cost unchanged or less. The results have been reached by the use of "therapist case managers" in a psychiatric team. The use of coordinating case managers seems to increase hospital use. There is a need for intensive community psychiatry carried out on the patients' terms. Inpatient treatment must be a part of the system. Concurrent quality assurance of the criteria for use is recommended.

[Controlled alcohol intake. Is it possible to predict which alcohol abusers can manage a more controlled drinking?]. / Kontrolleret alkoholindtagelse. Kan man forudsige, hvilke alkolmisbrugere der kan opnå at drikke mere kontrolleret?

The purpose of this investigation was to identify parameters of predictive value as to which alcohol abusers can manage controlled alcohol intake. Of 72 patients admitted during one year with alcohol abuse as a major diagnosis 27 attempted controlled drinking in a total of 64 events. Socio-demographic data and history of alcohol abuse had no predictive value in identifying patients who could achieve a controlled alcohol intake. However, it appears that a desire and hope for an improved psychological well-being can increase alcohol-abusers' control of alcohol intake. We also found a good correlation between the opinion of an experienced clinician as to which patients should attempt controlled drinking and the patients' own estimation of their possibilities, but neither evaluation had predictive value for the outcome of attempts at drinking. We conclude that it is difficult to predict the outcome of attempted controlled alcohol intake during and after treatment for alcohol abuse.

[Young persons sentenced to psychiatric treatment in Copenhagen]. / Unge med behandlingsdom i København.

The material consisted of 87 persons given a sentence in the years 1978 to 1987. Twenty-seven were under 23 years. There was no significant difference in the number of persons sentenced each year in the ten year period. The age of the patients was between 16 and 29 years with the median age being nearly 25 years. Most of the patients had a psychosis. The youngest group (less than 23 years) had a greater proportion of non-psychotic illness. Most of the patients were males. They had committed serious crimes and were sentenced to treatment in psychiatric hospitals with contact to a probation officer during out-patient treatment. Most of the patients were treated with neuroleptics, whereas psychotherapy, education and work-training were rare. The ability to attend out-patient treatment was generally low, and most of the patients were taken in for hospital treatment, according to the requirements of the sentence, because they did not keep their appointments. In order to increase the quality of the treatment offered it is recommended that special forensic psychiatric departments are established. This has taken place in the Copenhagen mental health hospital in 1989.

[Admissions and ambulatory treatment before and after establishment of a community psychiatric center in Copenhagen]. / Indlaeggelse og ambulant behandling før og efter oprettelse af et distriktspsykiatrisk center i København.

The purpose was to measure the use of psychiatric treatment before and after the start of community psychiatry in a part of Copenhagen. The use was measured during the two years before and after starting for the first 45 patients entering the treatment facility. Number of patients taken in for in-patient treatment, of intakes, of in-patient days, of emergencyroom visits and out-patient attendances were measured. Data about treatment with medicine, committed intakes, suicide attempts and the profession of the case manager were recorded. The number of intakes was reduced from 98 in the two years before community psychiatry to 36 in the period with community psychiatry. In-patient days were reduced by 60%. The number of out-patient contacts was increased six-fold and contacts with psychiatrists two-fold during the period with community psychiatry. Two-thirds of the patients came for day treatment. The treatment contact became more stable. Use of medicine per day was the same, but total use increased because of the more stable contact. No difference in in-patient treatment use was seen according to the case manager's professional education. It is concluded that community psychiatry by increased use of outreach, patient contact, and psychological treatments can increase the stability of the contact and reduce the use of in-patient days.

["Case manager" in district psychiatry. A review of the concept]. / "Case manageren" i distriktspsykiatrien. En gennemgang af begrebet.

During the past 20 years, the "case manager" has become a central expression in district psychiatry in USA. The case manager is a person who has the main responsibility for coordination and to a varying extent granting of the district psychiatric contributions to persons with prolonged psychoses. This function was introduced because the previous system with many administrative and physically separate offers appeared to be uncoordinated, mutually competitive and ineffective. The case manager acts as a supplementary "ego" for the patient on his own terms and has an active supportive function. Whereas, coordination was previously the central task, it became considered to an increasing extent more suitable that a multidisciplinary team of case managers supply the district psychiatric therapy themselves. Investigations reveal that the results are just as good or even better than those of the previous combination of hospitalization and outpatient treatment and that the patients are more satisfied. Many hospitalizations can be avoided but the employment of resources is probably not reduced on account of expenses for the case manager function and housing. The number of patients per case manager varies between four and 50, depending on the therapeutic needs of the patient group and, in particular, the tasks which the case manager must perform (all over the treatment or coordination of treatment administered by others). On account of the close contact by the case manager and his supportive activity, there are reasons for particular attention to ethical problems concerning personal choice and exchange of information. Utilization of the American experience with case managers is recommended simultaneously with avoidance of administrative practical splitting of district psychiatry which would make the total therapy ineffective.

[Homeless individuals admitted to a psychiatric hospital]. / Hjemløse indlagt i psykiatrisk hospital.

This investigation reveals that 10% of the patients admitted to Sankt Hans Hospital in Roskilde during a period of three months were homeless and that the homeless patients are among the younger patients. Relatively more of the homeless patients are men. Women are represented by just under one third and these are primarily among the youngest. The homeless patients are mainly severely mentally ill. The majority of diagnoses are of psychoses. Compared with the entire group of hospitalized patients in which loneliness and poor social network are also pronounced, the homeless patients are among the most unfortunate. Homeless patients are, on an average, hospitalized for briefer periods that the hospital patients as a whole and the psychiatric hospital has apparently only limited possibilities of helping homeless patients. No therapeutic aftercare is available for half of these patients. The great majority are discharged to homelessness again. It is essential that a reasonable combination of therapeutic and housing possibilities is instituted for these patients e.g. in the form of offers of various forms of housing of more or less collective form, graduated as regards size and staffing and depending upon the needs and wishes of the individual patients.

[Treatment of alcoholics based on the control principle. A prospective study of therapeutic results]. / Alkoholmisbrugere behandlet efter kontrolprincippet. En prospektive beskrivelse af behandlingsresultaterne.

The results of a psychotherapeutic inpatient treatment for alcoholism using the goal of increased control of drinking are reported. The patients participating and the outcome of the first 18 months after treatment are presented. Eighty-six patients participated in the treatment and between 78 and 71 of these could be followed-up. Before the treatment the great majority of the patients drank in accordance with the diagnosis addictive alcoholism. The mean duration of alcohol problems was nine years and the first therapeutic contact had taken place six years ago. The results are compared with the situation on admission and the 12 month period before treatment. After treatment, the mean daily alcohol consumption was nearly halved. About 3/4 of the patients reduced their drinking, half of the patients by more than 50% and 1/4 by more than 75%. Half of the patients drank less than six drinks per day, 1/3 less than four, and 1/4 less than three. The consumption showed a decreasing tendency during the 18 month period mainly due to an increase in non-drinking days. The patients' satisfaction with their mental condition, their relation to family and friends and life in general was greatly increased. The socio-economical problems were restored compared to the situation on commencing treatment but not to a level above the situation in the 12 months period before treatment. It is concluded that severely dependent alcohol abusers can be helped by psychotherapy with their mental or life problems and thereby increase control with their alcohol consumption.