[Internet-based approaches in the therapy of eating disorders]. / Internetbasierte Ansätze in der Therapie von Essstörungen.

Recent technological developments of communication media offer new approaches to diagnostic and therapeutic interactions with patients. One major development is Internet-based primary prevention in vulnerable individuals not yet suffering as well as the development of new therapeutic approaches for affected individuals based on the experiences of guided self-help through CD, DVD or bibliotherapy. The eating disorder literature shows several interesting, partly controlled and randomized, studies on bulimia nervosa, a few studies on binge eating disorder and no studies on anorexia nervosa. As part of the German Eating Disorder Network on Psychotherapy (EDNET) a 9-month Internet-based relapse prevention program for patients with anorexia nervosa after inpatient treatment was evaluated. Conception, first experiences and first results of the Internet-based relapse prevention program for anorexia nervosa are reported.

Twenty-five-year course and outcome in anxiety and depression in the Upper Bavarian Longitudinal Community Study.

OBJECTIVE: Assessment of 25-year course of pure and mixed anxiety and depression in a community sample. METHOD: Participants were grouped into pure anxiety, pure depression, mixed anxiety and depression, and no anxiety or depressive syndrome at baseline. Assessments consisted of a: i) baseline survey, ii) 5-year follow-up, iii) 25-year follow-up. Self-rating scales as well as expert-rating interviews yielded data on social and psychopathological risk factors and outcome measures. RESULTS: Baseline prevalence for mixed anxiety and depressive syndrome was 8.7%. Subjects with combined anxiety and depressive syndrome were more predisposed towards later adverse mental health outcomes and reduced functionality. The transition from anxiety syndrome (pure and mixed) to depressive syndrome over the 25-year study is more likely than the reverse. Logistic regression analysis emphasized the impact of early anxiety syndromes on later depression. CONCLUSION: Results underscore the long-term risks of suffering from a combined anxiety and depressive syndrome.

Binge eating disorder: treatment outcome over a 6-year course.

Little is known about the long-term course of binge eating disorder (BED). The aim of the study was to assess the 3- and 6-year course and outcome of 68 consecutively treated females with BED. Their mean age was 29.3 years and they were assessed longitudinally at four timepoints: (1) beginning of therapy; (2) end of therapy; (3) 3-year follow-up; and (4) 6-year follow-up. Self rating as well as expert ratings were used for assessment. Symptoms of specific eating disorder as well as general psychopathology were measured. The general pattern of results over time was as follows: substantial improvement during therapy; slight (in most cases nonsignificant) decline during the first 3 years after the end of treatment, and further improvement and stabilization in years 4, 5, and 6 after the end of treatment. At the 6-year follow-up, the majority showed no major DSM-IV eating disorder, 5.9% had BED, 7.4% had shifted to bulimia nervosa (purging type) (DSM-IV), 7.4% were classified as ED-NOS, and one patient died. Based on an operationalized global outcome score for the complete sample, 57.4% had good outcome, 35.3% intermediate outcome, 5.9% poor outcome, and one person (1.4%) died. BED and BNP patients showed very similar intermediate and long-term course in self ratings as well as expert ratings.

The structured interview for anorexic and bulimic disorders for DSM-IV and ICD-10 (SIAB-EX): reliability and validity.

OBJECTIVE: For reliable and valid assessment and diagnostic categorization of eating disorders, self-report measures have considerable limitations. A semi-structured interview - the SIAB-EX - was developed for a more reliable and valid assessment of eating disorders. METHODS: One study (videotapes of 31 inpatients, seven raters) was made to establish inter-rater reliability; in another study with 80 patients the SIAB-EX was compared to another semi-structured interview designed for comparable purposes (EDE). In a third study data was obtained on 377 eating disorder patients seeking treatment to explore discriminant and convergent (construct) validity using the following self-rating scales: EDI, TFEQ, SCL-90, BDI, and the PERI Demoralization Scale. RESULTS: Inter-rater reliability of dichotomous ratings was good with mean kappa values of.81 (current) and.85 (past). Comparison of the SIAB-EX with the EDE generally showed quite similar results and higher intercorrelation of the total scale (.77). There are, however, a number of differences between the two scales, which are discussed in detail. Construct validity of the SIAB-EX was established. CONCLUSION: Inter-rater reliability was good. Convergent and discriminant (construct) validity of the SIAB-EX was demonstrated. The constructs assessed by the SIAB and its subscales and items are discussed in the context of their correlations with other well-known scales.

Alcoholism among homeless men in Munich, Germany.

Probably in association with changes in the economic structure and high unemployment rates in western industrialized countries, homelessness is becoming more apparent publicly and receiving increased media attention. More studies on the issue of mental illness and homelessness have been performed in recent years in North America while hardly any representative and reliable data exists concerning Germany and some other European countries. The aim of our study was 1) to assess alcohol abuse and dependency as well as other mental disorders in a representative sample of homeless men in Munich using reliable methods of case identification (Diagnostic Interview Schedule [DIS and DIS/DSM-III diagnoses); 2) to compare homeless alcoholics with homeless non-alcoholics in our sample on relevant variables and issues and 3) to compare our data from the sample of homeless men in Munich with data obtained by others using the same case identification procedure (DIS/DSM-III diagnoses). According to our results, the lifetime prevalence of any DIS/DSM-III Axis I diagnoses was 94.5% and the lifetime prevalence of substance use disorder was 91.8%. The single most prevalent diagnosis among homeless males in Munich was alcohol dependency (lifetime 82.9%), while alcohol abuse (lifetime 8.2%) and drug abuse/dependency were considerably lower (lifetime 17.8%). Data show that alcoholism and its consequences were more severe in the Munich as compared to the Los Angeles homeless sample. Homeless alcoholics showed a high comorbidity with other mental disorders (lifetime) such as affective disorders (44.4%), anxiety disorders (22.6%), drug abuse/dependence (18.8%) and schizophrenia (12.0%); 64% of those with alcoholism at some time during their life had at least one other lifetime mental disorder. Alcohol-related patterns of living and symptoms as well as social or role functioning are described for homeless alcoholics in Munich and compared with data from other relevant studies. Considering the extremely high prevalence of alcohol dependence frequently in combination with other mental disorders, the use of alcohol rehabilitation and other services as well as self-help groups was minimum among Munich homeless alcoholics. New concepts to deal with these problems are needed and if they exist, they need to be implemented.

Intervention effects of supplying homeless individuals with permanent housing: a 3-year prospective study.

OBJECTIVE: To describe the intervention effects of supplying homeless individuals with permanent housing. METHOD: In a prospective study, 109 male and 20 female homeless individuals were assessed at baseline and at 1- and 3-year follow-up concerning mental illness (SCID-I), psychopathology, global assessment of functioning, emotional lability and alcohol consumption. RESULTS: A high proportion (86%) of the individuals was able to maintain or improve stability of housing. Only minor changes were observed concerning mental illness and global functioning. Extensive alcohol consumption and high psychopathology increased the risk of losing the stable housing. CONCLUSION: The placement of homeless individuals in board and care homes or community housing after social counselling seems to be a necessary measure to remedy homelessness. However, supplying more permanent housing is not sufficient to decisively improve mental health status.

Alcoholism in homeless men in the mid-nineties: results from the Bavarian Public Health Study on homelessness.

Parallel to structural economic changes homelessness has become publicly more visible and has received increased media attention in Western industrialized countries. Most studies on mental illness and homelessness in recent years were carried out in North America but only few studies in Europe have dealt with these issues. The goals of the present study were (1) to assess alcohol abuse and dependence as well as other mental disorders in a representative sample of homeless men in Munich using reliable methods of case identification (Structured Clinical Interview for DSM-IV (SCID)), (2) to compare homeless alcoholics with homeless non-alcoholics in our sample on relevant variables, and (3) to compare our data from the Munich sample with data obtained by others. According to our results, the life-time prevalence of any SCID-DSM-IV Axis I diagnoses was 93.2% and the lifetime prevalence of substance use disorder was 79.6%. The single most prevalent diagnosis among homeless males in Munich was alcohol dependence (life-time 72.7%); alcohol abuse (life-time 5.5%) and drug abuse/dependence were considerably lower in prevalence (life-time 19.1%) (weighted data). A higher rate of psychotic disorders was found for non-alcoholic homeless men. Data show that alcoholism and its consequences were more severe in the Munich as compared to North American samples. Homeless alcohol dependent men showed a high comorbidity with other mental disorders (life-time) such as mood disorders (36.4%), anxiety disorders (16.4%), drug abuse/dependence (18.9%) and psychotic disorders (4.5%). Of those with alcohol dependence at some time during their life 59.1% had experienced at least one other life-time mental disorder. Alcohol-related behavioral patterns and symptoms as well as general social functioning are described. Considering the very high prevalence of alcohol dependence (frequently in combination with other mental disorders), the participation in alcohol rehabilitation and other services as well as self-help groups was rather low among Munich homeless alcoholics. Currently homeless men in Germany are adequately supplied with food, clothes, and shelter but psychiatrically (and medically) neglected. Existing concepts and programs for dealing with these problems need to be implemented.

Prevalence of mental illness in homeless men in Munich, Germany: results from a representative sample.

OBJECTIVE: The aim of the study was a reliable assessment of the prevalence of DSM-IV mental disorders in a representative sample of homeless men in the city of Munich. METHOD: A preliminary survey yielded an estimate of 1,022 single homeless men in Munich divided among three sectors (shelter users, service users and street dwellers). A random sample of 265 single homeless men was surveyed from these three sectors. An age-matched comparison group of 178 men was selected randomly from a community register. The Structured Clinical Interview for DSM-IV (SCID-IV) was used for diagnostic classification. RESULTS: The lifetime prevalence rates of mental disorders were as follows: 72.7% vs. 15.2% for alcohol dependence, 32.8% vs. 7.3% for mood disorders, 15.9% vs. 6.2% for anxiety disorders and 9.8% vs. 0.6% for psychotic disorders. Of the homeless males in Munich, 93.2% had at least one lifetime DSM-IV axis I diagnosis, while this was the case for only 38.2% of the community controls. One-month prevalence for all SCID DSM-IV axis I disorders in homeless males was 73.4%. CONCLUSION: Lifetime DSM-IV axis I mental disorders were 2.4 times more frequent among homeless individuals compared to community control. Implications for health care planning are discussed.

Comparing self- and expert rating: a self-report screening version (SIAB-S) of the structured interview for anorexic and bulimic syndromes for DSM-IV and ICD-10 (SIAB-EX).

OBJECTIVE: Carrying out structured interviews in larger numbers by well-trained interviewers is costly and time consuming. Therefore, we developed parallel to the existing Structured Interview for Anorexic and Bulimic Syndromes (SIAB-EX) a similarily designed questionnaire for symptoms of disordered eating and related areas (SIAB-S). METHOD: 377 treated eating disordered patients were assessed within a two-week time period using both the SIAB-EX and SIAB-S. RESULTS: Generally, self-ratings based on the SIAB-S were quite similar to expert ratings. Cohen's kappa showed good agreement between self- and expert ratings. Factor structure based on principal component analyses of expert ratings or self-ratings led to rather similar results confirming the robustness of the subscales in self- and expert ratings. Using expert rating as a criterion, the self-rating (SIAB-S)--which can more easily be used for screening purposes--had a sensitivity of 0.70, a specificity of 0.80 and a PPV = 0.91 for the DSM-IV diagnoses of AN and/or BN (worst ever condition). Diagnostic sensitivity (79/73%) and specificity (66/63 %) were in an acceptable range (past/current). If we focus on the differences between the two approaches the following was found: self-rating (compared to expert-rating) resulted in lower scores for items inquiring about binges and inappropriate compensatory behaviour, attitudes towards food and eating, and social interaction. On the other hand, self-rating (compared to expert-rating) led to higher scores for items measuring general psychopathology and atypical binging. CONCLUSION: Compared to the "gold standard" of t data obtained with investigator-based standardised or structured interviews, data based on self-rating with items formulated clearly and concisely can lead to reliable and valid results. While complex issues (what is a binge) are difficult to assess in self-ratings, some (very personal) questions may even be better asked in a self-report questionnaire.

Six-year course of bulimia nervosa.

OBJECTIVE: Because little is known about the longer-term course of bulimia nervosa, the 2- and 6-year course and outcome of 196 consecutively treated females with bulimia nervosa-purging type (BN-P) was assessed. METHOD: One hundred ninety-six females with BN-P were assessed longitudinally at four points of time: at the beginning of therapy, at the end of therapy, at 2-year follow-up, and at 6-year follow-up. Self-rating scales as well as expert ratings from interview data were used. Eating disorder specific and general psychopathology was assessed. RESULTS: The general pattern of results over time showed substantial improvement during therapy, a slight (in most cases nonsignificant) decline during the first 2 years after treatment, and further improvement and stabilization from 3 to 6 years posttreatment. At 6-year follow-up, 20.9% had BN-P, 0.5% BN-nonpurging type (BN-NP), 1.1% had shifted from BN to binge-eating disorder, 3.7% had anorexia nervosa, 1.6% were classified as eating disorder not otherwise specified (ED-NOS), and 2 patients had died; obesity with a body mass index (BMI) of > 30 was seen in 6.0%; the majority (71.1%) showed no major DSM-IV eating disorder. CONCLUSIONS: Based on a composite global outcome score at 6 years follow-up, 59.9% achieved a good outcome, 29.4% an intermediate outcome, 9.6% a poor outcome, and 2 (1.1%) persons were deceased. Course and outcome were generally more favorable than in anorexia nervosa.

Six-year course and outcome of anorexia nervosa.

OBJECTIVE: Since there are discrepant findings in the literature, we studied the longer-term course in a large sample of 103 DSM-IV anorexia nervosa (AN) patients. METHOD: Assessments were made at four points of time: beginning of therapy, end of therapy, 2-year follow-up, and 6-year follow-up. Self-rating scales as well as expert-rating interview data were used. Eating disorder-specific and general psychopathology were assessed. These data were also compared with data on the 6-year course of patients with bulimia nervosa and binge eating disorder, respectively, who were treated at the same institution at about the same time. RESULTS: The participation rate at the two follow-ups was high (97.9% of those alive). The general pattern of results over time of those alive at 6-year follow-up was as follows: substantial improvement during therapy, moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 6 years posttreatment. At the time of the 6-year follow-up, 26.8% had AN, 9. 9% had bulimia nervosa-purging type (BN-P), 2.0% were classified as eating disorder not otherwise specified (ED-NOS), all diagnosed according to DSM-IV criteria; more than one half (55.4%) showed no major DSM-IV eating disorder. Based on an operationalized global outcome score at 6-year follow-up, 34.7% had a good outcome, 38.6% an intermediate outcome, 20.8% a poor outcome, and 6 of 101 persons (5.9%) were deceased. Body mass index was 17.9 +/- 2.8 at the 6-year follow-up; amenorrhea was still found in 23.9%. DISCUSSION: In comparison to samples with bulimia nervosa or binge eating disorder, the 6-year course of anorexia nervosa was less favorable. Mortality was rather high and symptomatic recovery protracted; predictors of unfavorable 6-year course were the presence of binges during 4 weeks before index treatment, psychiatric comorbidity, and low body weight at discharge from index treatment.

Recurrent overeating: an empirical comparison of binge eating disorder, bulimia nervosa, and obesity.

The goal of the study was to contribute empirical data to the discussion of appropriate diagnostic classification of obese and nonobese, binging, and nonbinging eating disordered patients. The study consists of two parts: (1) patients with binge eating disorder (BED) (N = 22) are compared to a matched sample of patients with bulimia nervosa (BN) and to 16 patients with obesity (body mass index [BMI] > 30). These patient groups were cross-sectionally assessed using expert ratings (interview) and self-ratings. (2) A sample of 68 patients with BED were assessed longitudinally on admission and discharge of inpatient treatment and at a 3-year follow-up using the same instruments as in the first study. The study is the first to report longitudinal data on patients with BED. The general pattern of the cross-sectional data was that patients with BN not only had higher scores concerning disturbances of eating behavior and attitude but also for general psychopathology when compared to patients with obesity without marked binges. The scores of patients with BED had an intermediate position between BN and obesity but were closer to BN than to obesity. The BED group (and the obesity group) showed a high degree of body dissatisfaction, which, however, was accounted for by their high body weight. Concerning general psychopathology BED as well as BN had significantly higher scores than the obesity group in the Hopkin's Symptom Checklist (SCL) subscale anger and hostility, in the Complaint List, the PERI Demoralization Scale, and the Beck Depression Inventory. Results of the longitudinal study with BED showed marked improvement in specific and general psychopathology over time. Except for body weight this improvement largely persisted over the 3-year follow-up period. Severity of depression did not predict the course of body weight over time. Data are presented concerning the design of diagnostic criteria for eating disturbed patients not fitting criteria for BN or anorexia nervosa (AN). Arguments pro and contra the introduction of a new BED category in psychiatric diagnostic criteria are discussed. Although there is generally a need for developing or revising the diagnostic criteria for recurrent bingers, our data do not support inclusion of BED (as presently defined) as a separate diagnostic category in DSM-IV.

Course of multi-impulsive bulimia.

Thirty-two consecutively admitted females with bulimia nervosa (purging type) according to DSM-IV and additional impulsive behaviours (multi-impulsive bulimia (MIB)) and 32 age-matched female controls with DSM-IV bulimia nervosa (purging type) (uni-impulsive bulimia (UIB)) were assessed longitudinally on admission and at discharge following in-patient therapy and at a 2-year follow-up. Multi-impulsive bulimics were defined as presenting at least three of the six of the following impulsive behaviours in their life-time in addition to their bulimic symptoms at admission: (a) suicidal attempts, (b) severe autoaggression, (c) shop lifting (other than food), (d) alcohol abuse, (e) drug abuse, or (f) sexual promiscuity. Multi-impulsive bulimics were more frequently separated or divorced, had less schooling and held less-skilled jobs. Except for interoceptive awareness (EDI), which was more disturbed in multi-impulsive bulimics, there were no differences concerning scales measuring eating disturbances and related areas. Multi-impulsive bulimics showed more general psychopathology--anxiety, depression, anger and hostility, psychoticism--differed in several personality scales from uni-impulsive bulimics (e.g. increased excitability and anger/hostility) and had overall a less favourable course of illness. Multi-impulsive bulimics also received more in- and out-patient therapy previous to the index treatment and during the follow-up period. The data support the notion that 'multi-impulsive bulimia' or 'multi-impulsive disorder' should be classified as a distinct diagnostic group on axis I or that an 'Impulsive Personality Disorder' should be introduced on axis II. The development of more effective treatment for multi-impulsive bulimia is warranted.

Expressed emotion, family environment, and parental bonding in bulimia nervosa: a 6-year investigation.

As part of a prospective, long-term treatment study, 30 in-patients with bulimia nervosa (BN) were divided into groups with high and low expressed emotion (EE) family backgrounds according to the Camberwell Family Interview, and followed for a period of six years. The high EE group initially showed significantly more psychopathology than the low EE group. No group x time interactions were found, but the high EE group showed a worse outcome on the "conflict" and "organisation" subscales of the Family Environment Scale. They also showed significantly more eating disorder pathology according to the Eating Disorder Inventory (EDI) and the Structured Interview for anorexia nervosa (AN) and BN before treatment at discharge, after two years and, to some degree, even after six years. Depth of depression (Beck Depression Inventory) was significantly higher in the high EE group at admission (moderate depression), discharge and after the 6-year follow-up (still slight depression). The Parental Bonding Instrument (PBI) showed no differences between the high EE and low EE groups, but the individuals with "affectionless control" according to the PBI had more negative scores on three of the subscales of the Family Environment Scale (FES). In brief, the high EE individuals with BN were initially sicker and did not fully catch up over time in comparison with the symptomatic recovery of the low EE individuals. These data suggest that EE status upon admission to in-patient treatment is a relevant predictor of the severity and course of BN and depressive symptoms.

[Utilization of medical and psychosocial services by mentally ill homeless persons. Results of an epidemiological study]. / Die Inanspruchnahme medizinischer und psychosozialer Dienste durch psychisch erkrankte Obdachlose. Ergebnisse einer epidemiologischen Studie.

The aim of this study was to ascertain to what extent homeless, mentally ill subjects in Munich take advantage of available psychosocial services. To obtain a representative picture of the situation, the first step was to ascertain how many people in Munich are actually homeless. The next step was to ascertain what proportion of them are in need of psychotherapy. Using the standardized Diagnostic Interview Schedule (DIS), 146 men and 32 women were interviewed. The results according to the DSM-III demonstrated high lifelong and 6-month prevalence of psychic disturbances. Medical and social services were often enjoyed, but mostly over a short period of time in particularly critical situations. Continued treatment rarely followed. Women were treated more often than men. Elements such as age and level of education hardly influenced patients' seeking help. Despite a high prevalence of addictive disease, alcohol and drug clinics were rarely consulted. The increase in the number of diagnoses was paralleled by an increase in the number of patients seeking help. Most treatments involved schizophrenia and anxiety. By means of logistic regression models, predictors of the extent to which these services were used were analysed. We conclude that new clinical models are needed and that the aversion to the present care system is too great. Continued treatment occurs only rarely.

Structured Interview for Anorexic and Bulimic disorders for DSM-IV and ICD-10: updated (third) revision.

OBJECTIVES: Earlier versions of the Structured Interview for Anorexic and Bulimic Disorders (SIAB) were modified in order to include new research findings and to update the expert rating interview to the diagnostic criteria of DSM-IV and ICD-10. The semistandardized interview was developed for reliable and valid assessment of the specific as well as the general psychopathology of eating disorders. METHOD: Data from SIAB-EX interviews (current and past/lifetime symptom expression) were available from three samples: (a) 330 eating-disordered patients assessed at the start of treatment, (b) 148 former eating-disordered patients with anorexia nervosa (AN) or bulimia nervosa (BN) assessed at follow-up, and (c) 111 community controls. Sixty-one of the 87 items of the SIAB-EX with a 5-point scale were factor analyzed. RESULTS: Principal components analyses with varimax rotation produced the following six components of the SIAB-EX (lifetime): (I) Body Image and Slimness Ideal; (II) General Psychopathology; (III) Sexuality and Social Integration; (IV) Bulimic Symptoms; (V) Measures to Counteract Weight Gain, Fasting, and Substance Abuse; and (VI) Atypical Binges. The factor solution for the current symptom expression was very similar to that based on lifetime symptom expression. Average item and factor scores are given for six groups of eating-disordered patients and controls. High interrater reliability was established for both current and the past symptom expression. Cronbach's alpha coefficients indicated good internal consistency for five of the six components of the SIAB-EX. DSM-IV and ICD-10 diagnoses for eating disorders can be derived directly or by using a computer algorithm from the SIAB-EX. A detailed 90-page manual facilitates the training of interviewers. CONCLUSION: The 87-item SIAB-EX was originally developed for detailed assessment of eating disorders cross-sectionally and longitudinally. The updated version which allows for diagnosis according to DSM-IV and ICD-10 is described here.

Mental illness in a representative sample of homeless men in Munich, Germany.

The aim of the study was to reliably assess the 6-month and lifetime prevalence of mental illness according to DSM-III criteria in a representative sample of homeless individuals in the city of Munich, Germany. Because the characteristics of the homeless population were unknown, we first conducted a pre-sampling survey to determine a proportionate allocation of the main interviews in three nested sampling strata. For the pre-sampling we approached 300 males, who appeared to be homeless, for a brief interview; of these, 271 were homeless according to our definition and were allocated to one of three sectors ("shelter", "meal services", "outdoor"). Thereafter, we randomly sampled homeless males in these three strata until the indicated allocations were met. The Diagnostic Interview Schedule (DIS) was used for diagnostic classification according to DSM-III in the main interview. Results from this representative urban sample show that the mean age of the homeless males was 43 years; most were unmarried or divorced, had a relatively low level of school education and a long duration of homelessness. Based on the main interviews with 146 homeless males the following lifetime prevalence rates were obtained: 91.8% for substance use disorder (82.9% alcohol dependence), 41.8% for affective disorders, 22.6% for anxiety disorders and 12.4% for schizophrenia. Of the homeless males in Munich, 94.5% had at least one DIS/DSM-III axis I diagnosis. Six-month prevalence data is also presented. Results are compared with those of a very similar study on homeless individuals in Los Angeles, which also used DIS/DSM-III diagnoses. In comparison with representative community samples in the United States and in Germany, mental illness was much more frequent among homeless individuals in Munich as well as in Los Angeles. Implications for health care planning are discussed.

[Mental illness in homeless men and women in Munich]. / Psychische Erkrankung bei obdachlosen Männern und Frauen in München.

PURPOSE: Mental illness appears to be overrepresented among homeless individuals. The purpose of this study was the standardised assessment of mental illness in a representative sample of homeless men and of homeless women in the city of Munich, Germany. METHODS: In order to get a very good estimate of the population of homeless individuals in Munich, a pre-sampling survey was conducted. On the basis of this pre-sampling survey the size and relevant characteristics of the total population of homeless individuals in Munich were defined. Individuals of the sample were randomly selected from the population. 146 men and 32 women were interviewed using the Diagnostic Interview Schedule (DIS). RESULTS: Homeless men were on the average 43 years of age; most of them unmarried or divorced, had a relatively low degree of school education and a relatively long duration of homelessness. The prevalence of mental illness (lifetime) was very high: 91.8% had a substance abuse disorder (82.9% alcohol dependence), 41.8% had an affective disorder, 22.6% had an anxiety disorder and 12.4% suffered from schizophrenia. Of the homeless men in Munich 94.5% had at least one DIS/DSM-III axis I diagnosis 6-month prevalence data is also presented. CONCLUSIONS: The results confirm the findings of other studies in other countries of high rates of mental illness among homeless individuals. In comparison to a study in Los Angeles using the same methodology, prevalence rates were even higher in Munich. Implications for health care planning are discussed.