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

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

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

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

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

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

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

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

[Work--its significance in the therapy and rehabilitation of chronic psychiatric patients]. / Arbeit--ihre Bedeutung in Therapie und Rehabilitation chronisch seelisch Kranker.

More and more chronic mental patients live in the communities and are jobless. Most of them cannot be expected to become gainfully employed in the near future, but the aim of all efforts should always be a permanent working place or at least meaningful activity. Due to the multitude of institutions participating in rehabilitation work the only chance of maximum utilisation of available chances can be achieved only by a local rehabilitation team. The article discusses the available scientific data on evaluation, success prediction, environmental structuralization and organisation of psychiatric working area.

[Complementing and replacing the clinic sensibly--on the management, effectiveness and indications for a complementary psychiatric residence. Results of a 1-year prospective evaluation study]. / Die Klinik sinnvoll ergänzen und ersetzen--zur Versorgung, Effektivität und Indikation des komplementären psychiatrischen Wohnbereichs. Ergebnisse einer einjährigen prospektiven Evaluationsstudie.

The complementary psychiatric (home) area is a relatively new branch of institutional psychiatry, the therapeutic evaluation and integration of which into everyday psychiatric thinking and acting has not yet become a reality. The evaluative study presented here covered 53 inmates and concerned their everyday life, the success of the treatment, predictors and perspectives. A gradual change in the means and aims of psychiatric rehabilitation seems to be materializing: the (re-)integration of the subject into his family of origin or into the psychosocial network will probably become more important than just reinstating the patient into his original place and kind of work. For the future it appears desirable that the inmates and the equipment are financially secured, that the entire setup is integrated into the system of psychiatric institutions, and that the method can be applied to further groups of patients.

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

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

[Results in extramural rehabilitation of chronic mental patients: 5-year follow-up study]. / Ergebnisse der extramuralen Rehabilitation chronisch psychisch Kranker: 5-Jahres-Follow-up.

Presented are the findings of a 5-year prospective study concerning residential rehabilitation of 53 subjects with chronic mental illness living in a differentiated system of complementary facilities and services. The focus had been the chronically ill patients' development and disease course, as reflected in their psychological wellbeing, work status, therapeutic requirements, social contacts, as well as periods of rehospitalization. At the end of the 5-year period, 50% of the subjects were living in sheltered communal groups, and some 25% fully on their own. Only 10 percent had returned to psychiatric hospitals as long-term patients. Vocational integration in the general labour market is only rarely achieved, but the work available in sheltered employment is suitable for 40%. All of the patients were in medical care after 5 years. Given a differentiated system of complementary support and services in the residential and vocational spheres, for medical care and leisure activities, persons with chronic mental illness, too, are able to live outside the psychiatric hospital, above all enjoying greater normality in their lifestyles as well as a higher degree of personal autonomy.

A second labour market? Vocational rehabilitation and work integration of chronically mentally ill people in Germany.

In Germany, the vocational rehabilitation of chronically mentally ill people is concentrated on the sheltered labour market, supplemented by special programmes for the care and reintegration of mentally ill people on the open labour market. Our investigation covered 502 representatively selected patients in sheltered employment (outpatient work therapy, firms for mentally ill people, workshops for the disabled). The sociodemographic, anamnestic and psychopathological data reveal that these are chronically mentally ill people with significant disabilities, making comprehensive social care and psychiatric treatment essential. Most of the subjects intend to remain in sheltered employment; only 20% hope to change to the open labour market. The level of subjective job satisfaction is surprisingly high despite generally inadequate pay, though it has to be pointed out that many long-term patients are presumably resigned to their circumstances. In conclusion, the relationship of the open labour market to sheltered employment is the subject of critical discussion.

[Current practice of psychiatric occupational rehabilitation. Results of a representative study in sheltered environments in the Westfalen area]. / Die gegenwärtige Praxis der psychiatrischen Arbeitsrehabilitation. Ergebnisse einer repräsentativen Untersuchung in beschützten Arbeitsverhältnissen in der Region Westfalen.

The number of patients suffering from chronic mental disorders but living outside the psychiatric hospital is undergoing a steady increase, which is reflected in an increasing demand for appropriate vocational and occupational facilities. This demand is met primarily by outpatient work therapy, self-help enterprises and enterprises providing jobs to supplement pensions, and by special departments for the mentally retarded in workshops for the handicapped. Within the framework of a prospective study on vocational rehabilitation of the mentally ill, 502 rehabilitants forming a representative sample for the Westphalia-Lippe region of Germany were examined. This sample comprised 313 male and 189 female probands with an average age of 36, almost two-thirds of them suffering from schizophrenic disorders. Only 12.8% of those questioned are able to cover their living expenses primarily from their earnings. Half of them are living in sheltered accommodation, one quarter with their parents, and only one quarter on their own. Most are resigned to remaining in sheltered employment. Only 16.7% expect to change to the open labour market. The level of subjective job satisfaction is high in general. Together with other complementary facilities, sheltered employment permits chronically ill patients to live outside the psychiatric hospital and offers them positive social and psychological aspects of work. With few exceptions, it does not offer an opportunity to cover living expenses. Our follow-up investigations will provide information on the further course of vocational rehabilitation.

[What are the contributions of social psychiatry services to psychiatric patient management? Results from a mid-size, psychiatrically well supplied city 1988 and 1989]. / Welchen Beitrag liefern sozialpsychiatrische Dienste zur psychiatrischen Krankenversorgung? Ergebnisse aus einer mittleren, psychiatrisch gut versorgten Grossstadt in den Jahren 1988 und 1989.

Every year 10-12.5% of the population are in need of psychiatric treatment. Statistical investigations lead us to believe that indeed only one-third of the mentally ill receive treatment. Above all, alcohol- or drug-induced dependence and geriatric illnesses are becoming increasingly prevalent. Patients of the Social Psychiatric Services of the city of Muenster (FRG) for the years 1988 and 1989 were examined for sociodemographic and diagnostic data, and the case histories documented. In 1988 1,019 in 1989 915 citizens were looked after. The treatment was concentrated on the severely mentally ill (22%), psychic geriatric patients (16%) and above all, chronic alcoholics (33%). The studies show that the patients are frequently lonely, have poor accommodation (app. one-third receive only welfare aid, one-third are pensioners) and exist on state hand-outs. App. one-tenth are either under care or guardianship. The peripatetic home visits (1988: 1,923, 1989: 1,512 home visits) are particularly helpful for persons who are immobile or reluctant to establish contacts, and for their relatives. Crisis intervention was necessary for 10% and commitment to institutional care for 6-8%. The Social Psychiatric Services are assuming an increasingly important function in the care of the chronic mentally ill, who--because of "dehospitalisation"--have no access to regular professional care.

A modern therapeutic approach for chronically mentally ill patients--results of a four-year prospective study.

A 4-year prospective study was carried out on 53 chronically mentally ill patients living in a differentiated complementary residential complex. Our main question was how the lives of these patients develop, as reflected in their psychological wellbeing, working capacity, therapeutic requirements and any necessary periods of rehospitalization. At the end of a 4-year rehabilitation period, 50% of the patients were living in sheltered communities and about 25% on their own. Only 10% had returned to the psychiatric hospital as long-term patients. The psychological findings were characterized by apathetic, depressive and psycho-organic syndromes (AMDP system) and were subject overall to minimum variation. Very few patients succeeded in obtaining work on the general labour market, but the work available on the sheltered labour market was suitable for a large proportion (40%) of them. All patients were undergoing medical care after 4 years. Patients suffering from chronic mental disorders can be cared for in the community even after long-term hospitalization. Special success has been achieved with rehabilitation in the residential sphere. Adequate care implies numerous services to ensure that patients are integrated into the labour market, to help establish contacts and to enable chronically ill patients to take part in social and cultural life. Most patients retain a considerable degree of psychological disturbance and are permanently dependent on psychiatric therapy or psychosocial care. On the other hand, they benefit from the fact that their living circumstances are largely normal and that they have higher degree of personal autonomy.

[The psychiatric day clinic--a review of experience to date and our results]. / Die psychiatrische Tagesklinik--Ubersicht bisheriger Erfahrungen und eigener Ergebnisse.

Psychiatric day hospitals are a relatively young therapeutic facility insufficiently known to many psychiatrists. This accounts for the application potential of day treatment not being adequately recognised and utilised despite its many advantages (efficacy, flexibility, versatility). Treatment at a day hospital is not a (more or less) acceptable alternative to hospitalisation but has a specific contribution of its own to make in certain situations. Although the scientific standard of the literature published on day hospitals is relatively good, many questions on theoretical and practical aspects remain unanswered. The aim of this paper is to show the opportunities and limitations of the psychiatric day hospital with reference to a survey of the existing literature and to our own experience.

[Ambulatory occupational therapy. Results of a multicenter, prospective evaluation study]. / Ambulante Arbeitstherapie. Ergebnisse einer multizentrischen, prospektiven Evaluationsstudie.

Work is an indispensable component in the treatment of (chronically) mentally ill patients. In critically scientific terms, however, there is no adequate proof of its therapeutic effectiveness. Efforts at evaluation fail because of the complexity of the clinical reality. Moreover, the differential aspects of the indication have been ignored in research. This is exemplary of the problems confronting research on the provision of psychiatric treatment: the status of what has been put to the test and introduced on the basis of routine experience is such that emperical investigations are not carried out because of lack of interest and methodological problems. Against the background of this dilemma, this study seeks a middle course for measuring success. We carried out a prospective study on a representative sample of 126 outpatients in 7 clinical work therapy departments. The results show that outpatient work therapy can be seen as a useful part of differentiated therapy, in particular for chronically mentally ill patients. Previous experience is summed up in a review of the literature.

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

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

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

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

[Rehabilitation of psychiatrically ill and handicapped patients--historical, conceptual and scientific aspects]. / Rehabilitation psychisch Kranker und Behinderter--Historische, konzeptuelle und wissenschaftliche Aspekte.

Since the early days in the 19th century, psychiatry has been dealing with chronic courses of illness and mental disabilities. The 1975 German "Psychiatry Enquete Report" has played a major role in achieving progress in the care system, allowing mentally ill patients with impending or established handicaps to be rehabilitated or to have long-term care of varying intensity and even at home. In particular, differentiated and graduated systems of sheltered accommodation, a sheltered labour market and leisure-time support have been created. Rehabilitation may induce a response in the disabled patient and improve his skills. It may, however, also be aimed at finding or structuring an adequate living environment to enable the patient to cope. A distinction must also be drawn between early and late rehabilitation: late rehabilitation applies primarily to those patients whose disabilities have become relatively irreversible after protracted illness. The objective in this case is to maintain social integration. Early rehabilitation is desirable today if functional deficits and impairments are found to occur in conjunction with a mental illness. If a substantial disability remains in spite of intensive efforts towards rehabilitation, adequate re-integration of the affected patient may be achieved by adapting the living environment. Although the practical state of development is promising, a large number of theoretical and scientific problems remains unsolved. The topic of psychiatric vocational rehabilitation in particular is raising more and more questions. There is a lack of information on the number of chronically mentally ill patients in the community and their needs, i.e. on the number of potential users. Further studies are needed to investigate the effects, the efficacy and the course of psychiatric rehabilitation.

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

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

Suspension of neuroleptic therapy in acute schizophrenia.

What are the effects of the abrupt discontinuation of neuroleptics (suspension therapy) in acutely schizophrenic patients with unsatisfactory remission under standard neuroleptic therapy? This question was investigated in a prospective study of 159 patients. In addition to the psychopathologic results of the AMDP system, the self rating (VAMS) and nurses' rating (NGI) of psychopathologic parameters were assessed. Indication for suspension of the neuroleptic treatment was established in 21 patients (13%) following definite criteria. Suspension therapy brings about a rapid improvement in psychopathologic results. The paranoid-hallucinatory syndrome also undergoes remission; this is to be understood as an immediate effect of suspension of therapy. In one-third of the cases complete suspension effects, in another third partial suspension effects, and in the remaining third failure occur. Further advantages of suspension therapy are the reduction in neuroleptic drug requirements and a favorable influence on the entire treatment course. The investigation does not permit any statement as regards prediction of the suspension effect or concerning the mechanism underlying the suspension therapy.

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

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