Patient characteristics and symptoms associated with perceived coercion during hospital treatment.

OBJECTIVE: Large numbers of psychiatric patients either are involuntarily admitted to hospital treatment or feel coerced despite a legally voluntary admission. For ethical and clinical reasons, their perceived coercion should be reduced as far as possible. There is however limited evidence on patient characteristics associated with perceived coercion during hospital treatment. This study aimed to identify i) sociodemographic and clinical characteristics associated with perceived coercion at admission and ii) changes in symptoms and global functioning associated with changes in perceived coercion over time. METHOD: Three thousand and ninety three in-patients who were involuntarily admitted or felt coerced to hospital treatment despite a legally voluntary admission were recruited in the European evaluation of coercion in psychiatry and harmonization of best clinical practice - EUNOMIA project in 11 European countries. Perceived coercion, global functioning and symptoms were assessed after admission and at a 3-month follow-up. RESULTS: Involuntary admission, female gender, poorer global functioning and more positive symptoms were associated with higher levels of perceived coercion at admission. Perceived coercion significantly decreased over time, and the improvements in global functioning and positive symptoms were associated with reduction in perceived coercion. CONCLUSION: Female patients perceive more coercion in psychiatric hospital treatment. Effective treatment for positive symptoms and improving patients' global functioning may lead to a reduction in perceived coercion.

Patients' subjective initial response and the outcome of inpatient and day hospital treatment.

OBJECTIVE: This study aimed to establish whether psychiatric patients' subjective initial response (SIR) to hospital and day hospital treatment predicts outcomes over a one-year follow-up period. METHOD: We analysed data from 765 patients who were randomised to acute psychiatric treatment in a hospital or day hospital. SIR was assessed on day 3 after admission. Outcomes were psychiatric symptom levels and social disability at discharge, and at 3 and 12 months after discharge. RESULTS: After controlling for socio-demographic and clinical characteristics, a more positive SIR was significantly associated with lower symptom levels at discharge and 3 months after discharge and lower social disability at 3 months and 12 months after discharge. CONCLUSION: SIR can predict outcomes of complex interventions over a one-year period. Patients' initial views of acute hospital and day treatment should be elicited and considered as important.

How to improve clinical practice on involuntary hospital admissions of psychiatric patients: suggestions from the EUNOMIA study.

Number and procedures of involuntary hospital admissions vary in Europe according to the different socio-cultural contexts. The European Commission has funded the EUNOMIA study in 12 European countries in order to develop European recommendations for good clinical practice in involuntary hospital admissions. The recommendations have been developed with the direct and active involvement of national leaders and key professionals, who worked out national recommendations, subsequently summarized into a European document, through the use of specific categories. The need for standardizing the involuntary hospital admission has been highlighted by all centers. In the final recommendations, it has been stressed the need to: providing information to patients about the reasons for hospitalization and its presumable duration; protecting patients' rights during hospitalization; encouraging the involvement of family members; improving the communication between community and hospital teams; organizing meetings, seminars and focus-groups with users; developing training courses for involved professionals on the management of aggressive behaviors, clinical aspects of major mental disorders, the legal and administrative aspects of involuntary hospital admissions, on communication skills. The results showed the huge variation of involuntary hospital admissions in Europe and the importance of developing guidelines on this procedure.

Social disability in different mental disorders.

OBJECTIVE: To assess the social disability of people with different psychiatric disorders. METHODS: Cross-site survey in five psychiatric hospitals (Dresden, Wroclaw, London, Michalovce and Prague). Working-aged patients diagnosed (ICD-10) with schizophrenia and related disorders (F2), affective disorders (F3), anxiety disorders (F4), eating disorders (F5) and personality disorders (F6), were assessed at admission (n=969) and 3 months after discharge (n=753) using the Brief Psychiatric Rating Scale and the Groningen Social Disability Schedule. The main outcome measure was Interviewer-rated social disability. RESULTS: During acute episodes patients with personality, eating and schizophrenic disorders functioned less effectively than those with affective or anxiety disorders. After controlling for age and severity of psychopathology, there was no significant effect of the diagnosis (during remission), sex, education and history of disorder on disability. Site, employment and partnership were significant factors for the level of social disability in both measure points. CONCLUSION: Severity of psychopathological symptoms, not the diagnosis of a mental disorder, was the most significant factor in determining the level of social functioning, particularly during the remission period. Site, employment and partnership appeared as significant factors influencing the level of social disability.

[Psychometric properties of dimensional measures derived from the latest German version of the Schedules for Clinical Assessment in Neuropsychiatry 2.1]. / Dimensionale Diagnostik mit der deutschsprachigen Version der Schedules for Clinical Assessment in Neuropsychiatry 2.1.

BACKGROUND: The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) is a comprehensive set of clinical assessment instruments developed by the World Health Organisation. This is the first study to report psychometric properties of dimensional measures derived from the latest German version SCAN 2.1. METHODS: Within a randomized controlled trial comparing psychiatric day-hospital treatment to inpatient treatment, 202 acute mentally ill patients were interviewed by clinically experienced interviewers. Forty-seven items of Part I of SCAN 2.1 were selected for constructing dimensional measures. Six scales were generated using principal component analyses (PCA). They were compared to five scales constructed according to the items' affiliation to specific sections of SCAN 2.1. RESULTS AND CONCLUSIONS: Cronbach's alpha coefficients qualify the reliability of most scales as moderate (0.500.70). With respect to high correlations between the scales generated using PCA and the section-specific scales, using the latter is recommended. Research into psychotic disorders, however, is missing, given that the present analyses are based on items from Part I of SCAN 2.1 only.

[The process of deinstitutionalization in German State Mental Hospitals. Critical overview of empirical research studies]. / Enthospitalisierungsprozesse in deutschen psychiatrischen Grosskrankenhäusern. Eine kritische Ubersicht zur durchgeführten Begleitforschung.

The process of discharging previously long-term hospitalized patients from German state mental hospitals, and of transferring these patients to other forms of supported housing has meanwhile come to its end. Therefore, this paper presents an overview of the scientific evaluation of this process. By using clearly defined research methodological criteria, eight empirical studies from several German federal states are assessed focusing on the meaningfulness of their results. Because of the heterogeneity of the aims regarding contents of this transformation process, of the research methodological approaches, and of the characteristics of the assessed patient groups, only few general results could be identified. Chronically mentally ill patients (mostly suffering from schizophrenic disorders) who had been successfully discharged to the community were younger, and showed shorter periods of illness and hospitalization than control patients. After discharge they might have experienced positive changes of their objective and subjective quality of life and of their perceived needs of care. Referred to several other outcome domains, no homogeneous tendencies concerning clinically relevant improvement or deterioration were found. In particular, changes related to psychopathological symptoms and social competencies were generally small. However, mortality and re-hospitalization rates of de-hospitalized patients were considerably high, and ranged between 3-24 %, and 4-46 %, respectively. The assessed studies could not identify replicated predictors of successful de-hospitalization. Female sex and long-term last hospitalization seemed to be important for stable placement in forms of supported housing requiring a higher level of autonomy. From the generally unclear procedural quality of the German deinstitutionalization process, the authors deduce implications for the scientific evaluation of future projects of restructuring mental health care services. Besides the clear definition of empirically assessable aims which should be based on theoretical considerations, it is of utmost priority to guarantee high performance quality of research methodological standards.

[Do relatives of patients with different mental disorders also differ in their attitudes towards these disorders?]. / Weisen Angehörige von Patienten mit unterschiedlichen psychischen Erkrankungen auch Unterschiede in ihrer Einstellung zu diesen Erkrankungen auf?

BACKGROUND: Studies on the attitudes of relatives of psychiatric patients have usually focused on views of causes and treatment options for schizophrenic disorders. Comparative surveys, especially those dealing with attitudes on social distance and restrictions, have to date been rather an exception. METHODS: In the present study, 161 relatives and other close reference persons of patients with schizophrenic, recurrent depressive, or bipolar affective disorder were interviewed with the German version of the Questionnaire on the Opinions of the Family between February and July 2003. RESULTS: Relatives of patients with schizophrenic disorder differ from the other two groups especially in attitudes displaying greater social distance toward mental disorders and less hope for social reintegration of these patients. Independently of the form of disorder, natural relatives exhibit the greatest social distance toward mental disorders. Differences in attitudes on the basis of patients' and relatives' socio-demographic and clinical characteristics are rather scarce. CONCLUSIONS: Attitude toward mental disorders is an important trait of relatives supporting mentally ill persons. Differences in the effects of disorder-specific attitudes on relatives' well-being and their perception of burden have to be investigated further to enable the development of supportive strategies suited to the various groups of psychiatric patient relatives.

[Evidence based community psychiatric community health care services in Germany: taking inventory]. / Evidenzbasierung gemeindepsychiatrischer Versorgungsangebote in Deutschland: eine Bestandsaufnahme.

PURPOSE AND METHODS: One of the outcomes of reforming mental health care in Germany has been the establishment of a range of community mental health services. However, current evidence for the effectiveness of these services is slight. Based on a literature search this article provides a systematic overview of empirical research in this sphere. In detail, social psychiatric services, crisis centres, psychosocial contact points, day care centres, and various models of supported housing and work/employment are assessed. Available results on effectiveness are classified according to their level of scientific evidence. RESULTS: The current state of research is characterised by the situation that effectiveness of the care approach provided by social psychiatric services and some types of supported housing and work/employment has been demonstrated at a medium level of scientific evidence. In contrast, the evidence level of mental health care provided in crisis centres, psychosocial contact points, and day care centres is poor. CONCLUSION: The major reasons for this lack of research are: heterogeneity of care models and staffing levels in the different community mental health services, lack of standardised documentation and reporting system in these services, and lack of research culture to utilise routine outcome data. The consequences of aiming at increasing the level of scientific evidence in this sphere would be to intensify funding of research projects and to implement high quality research designs such as randomised controlled trials.

[Assessing deinstitutionalization of the nursing home area of a large state mental hospital from the point of view of patients and staff]. / Der Enthospitalisierungsprozess des psychiatrischen Heimbereichs eines ehemaligen Grosskrankenhauses aus Patienten- und Mitarbeitersicht.

OBJECTIVE: Within the deinstitutionalization process of a large psychiatric hospital, the development of two cohorts of patients with chronic schizophrenia is compared over a two-year period: patients living in the hospital's nursing-home area (n = 50) vs. patients already released to two social therapeutic hostels (n = 51). Results of the cohort study were compared with assessments of nurses working in the nursing home (n = 55), focusing on their subjective views of the deinstitutionalization process and its impact on their working conditions. METHODS: Patients are assessed through yearly home-visits in their place of residence. The instruments used measure several outcome parameters: psychopathology, social disabilities, subjective quality of life, and normative needs for care. Concurrent staff assessments were conducted using standardized survey instruments focusing on current working conditions and quality of teamwork. Nineteen nurses participated in qualitative interviews evaluating the deinstitutionalization process. RESULTS: For all measures, patients living in the nursing home show significantly worse outcomes. Furthermore, during the study period 34 % experienced a change in their living situation with which they were dissatisfied. Needs for care and the number of areas of "unmet" need increased significantly for this subgroup. Patients living in social therapeutic hostels demonstrate stable levels of psychopathological symptoms, social disabilities, and needs for care. Assessments indicating a deterioration in patients' subjective quality of life focus mainly on areas important for social contacts. Regarding "personal concerns" and "insecurity at work", ratings from nursing home staff were significantly worse than those of a reference group from several other health care institutions (n = 224). Staff showed a tendency to give higher ratings for their opportunities to participate in decisions, in contrast with the low ratings for chances to improve their knowledge in the workplace, a result which may indicate a lack of prospects. In general, staff faces the conundrum of being asked to adopt a new mental health care paradigm while organisational structures are being eliminated and insecurity about career opportunities is increasing. CONCLUSION: To adequately manage deinstitutionalization of care, all participating parties must be involved in the process as early as possible to clarify expectations and to demonstrate commitment to future opportunities in the new system.

[Randomised controlled trials in mental health services research: practical problems of implementation]. / Randomisierte kontrollierte Studien in der psychiatrischen Versorgungsforschung: Probleme der Durchführungspraxis.

This article outlines problems of implementation and clinical practice of randomised controlled trials in mental health services. Furthermore, it offers practical solutions taking into account the experiences with a randomisation process in a multi-site EC-funded (EDEN-) study on the evaluation of acute treatment in psychiatric day hospitals. Identification of the problems follows the time-course of a research project: 1. Problems to be solved prior to the study's commencement: Definition of the eligibility criteria, information of clinically working colleagues. 2. Problems referring to the process of randomisation: Influence of clinical experience of the research fellows, precise time-point of implementing the randomisation into the process of admission, assessment of the patient's ability to give informed consent, patient's refusal of randomisation but agreement to study participation, availability of treatment places. 3. Problems which might occur after randomisation: Early break-off of treatment, transfer from one treatment setting to another. General conclusion: Detailed definitions of the randomisation procedure do not guarantee high performance quality and randomisation rates. Continuous precise assessment of the implementation into the clinical routines of every study centre, adaptation according to specific conditions and personal discussions with all participants are obligatory to establish and maintain a high quality of this important research procedure.

[Opinions of staff in the trial phase of standardized documentation of complementary psychiatric services]. / Mitarbeitermeinungen in der Erprobungsphase einer standardisierten Dokumentation für komplementäre psychiatrische Dienste.

A computerised standardised documentation system for non-hospital based psychiatric and psychosocial care is being developed in Saxony. A range of non-hospital based services was involved in the development process. Staff members were interviewed concerning their experience in using the documentation system. Results showed a critical appraisal by staff members, emphasising particularly (a) the investment of time required, and (b) the perceived usefulness of the documentation which was considered to be limited. Besides staff members feared that data protection issues might be disregarded and that data would be used to cut expenditure. Findings are compared with other studies assessing staff attitudes towards data collection in mental health services. It is concluded that the study adds to the existing evidence of staff scepticism towards computerised standardised documentation systems.

Schizophrenic patients' normative needs for community-based psychiatric care: an evaluative study throughout the year following hospital release in the Dresden region.

BACKGROUND: The present study is part of a public health research project that evaluates restructured psychiatric community care for chronic patients in Saxony after the German reunification. It focuses on the analysis of the individual (expert-based) normative needs for mental health care of chronic schizophrenic patients in the Dresden region. METHOD: A cohort of ICD-10 chronic schizophrenic patients (n = 115) was examined at 1, 6 and 12 months after hospital release using the Needs for Care Assessment. RESULTS: Schizophrenics' normative needs for care in the clinical sector are dominated by positive and negative symptoms, psychopharmacological side effects and psychosocial distress. In the social realm, problems dealing with the management of household affairs, recreational activities, household chores, occupation and communication skills are the most frequent areas of need. In the Dresden region, considerable deficits apparently persist in the subsections "recreational activities" and "occupational and communication skills", which can be ascribed to the lack of appropriate institutions of care in the area. Schizophrenic patients' normative needs for care cannot be determined simply on the basis of a few, quickly identifiable markers. Individualized analysis is needed that incorporates variables pertaining to psychopathology, subjective coping, social competence, and the course of the disorder. The development of the needs for care over the period of 1 year can be predicted by trends in the social realm that are already visible within the first months. CONCLUSIONS: Community-based care offers available for schizophrenic patients in the studied region are by no means generally insufficient. Identified deficits in focal fields of social skills and rehabilitation must be minimized to meet international standards. This is of special importance because social impairments/disabilities predominate over the entire spectrum of schizophrenics' normative needs for psychiatric care.

[Deinstitutionalization, housing situation and subjective satisfaction of schizophrenic patients]. / Deinstitutionalisierung, Wohnsituation und subjektive Zufriedenheit schizophrener Patienten.

OBJECTIVE: After the German reunification the deinstitutionalisation of long-term hospitalised psychiatric patients and the restructuring of the complementary psychiatric care has become necessary in the "new" German states. Hereby it became possible to offer alternative residential settings and new community-oriented care programmes for the mentally disabled. METHODS: Ten years after the beginning of this process we analysed the impact of the housing conditions and the subjective satisfaction of 245 chronic schizophrenic patients living in different residential care-settings or with family resp. on their own in the Dresden region. Additionally we asked for the satisfaction with the organisation of the deinstitutionalisation process. RESULTS: The subgroups--defined by the residential setting--differ in sociodemographic variables and in the levels of psychopathology (PANSS) and social disabilities (DAS-M). It is shown how deficiencies and restrictions of the living situation and the deinstitutionalisation process are reflected in the respective judgments of the patients especially referring to autonomy and self-determination. CONCLUSIONS: Requirements for the further development of the complementary psychiatric care system are deduced.

[Rehabilitation concepts of schizophrenic patients treated in community psychiatry]. / Rehabilitationsvorstellungen gemeindepsychiatrisch betreuter schizophrener Patienten.

In a cohort of patients with chronic schizophrenic disorders (n = 115) characterized by many social deficits and a high level of psychopathology, suggestions concerning rehabilitation were examined in an exploratory way and analysed referring to their relevance for community psychiatric care. The schizophrenic patients were followed up 1 and 12 months after discharge from hospital using an extensive array of instruments (among others: Needs for Care Assessment, Berlin Inventory of Care Needs). Included was a guided interview focusing on patients' subjective views relevant for the course of the disorder and for therapeutical procedures. Using a content analysis of the verbal material received at both points of study, the following main defining elements of the term rehabilitation (or reintegration, resp.) could be identified from the patients' perspective: vocational reintegration, independent residential setting, recovery of normality, and acceptance of responsibility. The rate of individualized confirmation in each category established after the first interview was between 75% and 93% 1 year after discharge from hospital.--Results from multiple and logistic regression analyses demonstrate that a higher degree of differentiation concerning individual rehabilitation suggestions exerts influence on the extent of subjective and normative needs for (psychiatric) care at the first point of study and moreover can be identified as a predictor of the decrease in the normative needs for care during the study period. To differentiate schizophrenic patients' suggestions referring to this subject can therefore be declared a therapeutical task. Furthermore it is a must to adjust individualized expert-based and subjective suggestions concentrating especially on the patients' main point of emphasis, i.e. vocational rehabilitation.

[Normative needs for care of schizophrenics: a useful concept for community psychiatric planning?]. / Gemeindepsychiatrischer Versorgungsbedarf schizophren Erkrankter: Ein brauchbares Konzept für die regionale Psychiatrieplanung?

One step in a public health research project focuses on the analysis of the individual (expert-based) normative needs for mental health care of chronic schizophrenic patients (n = 115) in the Dresden Region during the first year post hospital release and the extent to which this can be met by the current established level of complementary care. It is an exemplary contribution to the evaluation of community psychiatry as restructured in the Free State of Saxony following German reunification. The results of the study can be condensed to the following interpreting essential statements. Schizophrenics' normative needs for care are not a statistical issue. The single case analysis corroborates a high rate of relevant fluctuations, above all within the clinical sector (e.g. concerning "dyskinesias and other side effects"), that pose a particular challenge to the flexibility of a system of community psychiatry. This includes that the consequence for the practice of care implies then that when diagnosing course, attention must be paid to shifts in the content of the needs for mental health care (e.g. increasing importance of factors, which contain impairments of basic social competences) in order to orient to them any health care measures already initiated.--With the aid of the used research instrument (Needs for Care Assessment) deficits in meeting the needs for care can be identified. In the Dresden Region considerable deficits persist apparently in the subsections recreational activities and occupational and communication skills, which can be ascribed to the lack of appropriate institutions of care in the area.--The normative needs for care of schizophrenic patients cannot be determined simply on the basis of a few, quickly identifiable markers. Rather it demands individualized analysis incorporating variables pertaining to psychopathology, subjective coping, social competence and the course of the disorder. The development of the needs for care over the period of one year can apparently be predicted by trends in the social sector that are already visible within the first months. With regard to aspects of care planning this finding illustrates the limited ability of cross-section surveys to make definitive statements, as well as the predominance of social disabilities over the entire spectrum of the normative needs for psychiatric care.

[Subjective needs for care during the first year following hospital release by schizophrenic patients in the Dresden region]. / Betreuungsbedürfnisse schizophrener Patienten im Jahr nach Klinikentlassung in der Versorgungsregion Dresden.

An initial cohort of 115 patients with chronic schizophrenia was studied during the period of care provided by community psychiatry programmes in the Dresden region one month and 12 months post hospital release using, among other instruments, the Berliner Bedürfnisinventar (Berlin Inventory of Care Needs). Thus a subjective need structure was identified over a one-year period, which is related primarily to autonomic basic social competence, a qualitatively sophisticated level of competence with regard to bonding and relationships, as well as (at least threatening) elements of social disintegration. Features characteristic of the course of disease (e.g. length of illness, changes in the psychopathological symptoms) and a factor of self-perceived disorder-related personal changes are the decisive predictors of how the extent of care needed will develop during the study period. Conclusions result from perceived deficits of care (e.g. with regard to employment/occupation). They pertain to a further content and institutionalized establishment of care-providing elements, which are not yet (currently) offered in a system of care that is being restructured along the lines of community psychiatry following German reunification. These conclusions fortify results of an analysis of normative needs for care and the current structure of community-based psychiatric care in the Dresden region.

[Standardized documentation system for the complementary sector of psychiatric care. Development and trial in Saxony]. / Dokumentationssystem für den komplementären psychiatrischen Versorgungsbereich. Entwicklung und Erprobung im Freistaat Sachsen.

The necessity for a standardized documentation system for the complementary sector of psychiatric care is pointed out, and the goals and requirements to be met are debated. The test-version of such a documentation system (abbrev. BADO-K) is shown. It consists of modules for the assessment of client-centered data, and for the documentation of the treatment process in various facilities. Furthermore, a module of questionnaires and instruments for assessing outcome variables (e.g. quality of life) is integrated. The principles for using the paper-pencil-version and the EDP-version are outlined and discussed with regard to the legal regulations concerning the protection of personal data. Finally, possibilities and limitations of the presented documentation system are discussed. It is argued that the BADO-K is an useful instrument for evaluating the process and outcome of community psychiatric care.