Needs of forensic psychiatric patients with schizophrenia in five European countries.

AIMS: The purpose was to compare the frequency of needs of patients with schizophrenia in forensic services across five European countries as assessed by both the patients and their care staff. METHODS: Patients with schizophrenia and a history of significant interpersonal violence were recruited from forensic psychiatric services in Austria, Germany, Italy, Poland and England. Participants' needs were assessed using the Camberwell Assessment of Needs-Forensic Version (CANFOR). Multiple linear regression analyses were used to identify predictors of numbers of needs. RESULTS: In this sample, (n = 221) the most commonly reported need according to patients (71.0%) and staff (82.8%) was the management of psychotic symptoms. A need for information was mentioned by about 45% of staff and patients. Staff members reported a significantly higher number of total needs than patients (mean 6.9 vs. 6.2). In contrast, staff members reported a significantly lower number of unmet needs than patients (mean 2.0 vs. 2.5). Numbers of total needs and met needs differed between countries. Unmet needs as reported by patients showed positive associations with the absence of comorbid personality disorder, with higher positive symptom scores and lifetime suicide or self-harm history. Significant predictors of unmet needs according to staff were absence of comorbid personality disorder and higher positive as well as negative symptom scores according to PANSS. CONCLUSIONS: Staff rated a significantly higher number of total needs than patients, while patients rated more unmet needs. This indicates that patients' self-assessments of needs yield important information for providing sufficient help and support.

[Social inequality and mental health]. / Soziale Ungleichheit und psychische Gesundheit.

Social inequality refers to the inequitable distribution of social prosperity including the resource of health. The relationship between social inequality and mental health can be established by means of indicators of social inequality throughout all age groups in Germany. There are social gradients of mental health on the population level, i.e. the linear relationship between social classes or status and state of health. Fundamental determinants of health disparity are cultural, social, political, and geographical conditions, which interact with the genetic make-up and epigenetic processes. These determinants also influence the management of developmental tasks during the life course and are of utmost importance for the development of mental disorders. The maladaptation to chronic stress is at the core of health disparity. Interventions at the individual behavioral level should comprise the development of stress management and coping strategies.

[Determinants of psychotropic medication in adults with mild or moderate intellectual disabilities]. / Bedingungsfaktoren psychopharmakologischer Behandlung bei leichter oder mittelgradiger Intelligenzminderung.

BACKGROUND: During the past years the provision of mental healthcare for adults with intellectual disabilities (ID) has repeatedly been criticized; however, the number of relevant studies is still relatively few. OBJECTIVE: The aim of the present study was to identify determinants for utilization of mental healthcare services and prescription of psychotropic medication in adults with mild to moderate ID. MATERIAL AND METHODS: Analyses were based on data from 417 adults with mild to moderate ID, which had been collected within the cross-sectional MEMENTA study in three different regions of Germany. Logistic regression analyses were conducted to identify clinical and sociodemographic variables as predictors of utilization of mental healthcare services (n = 282) and psychotropic medication (n = 351). RESULTS: Utilization of healthcare services and psychotropic medication were both associated with mental disorders and problem behavior. In addition, the likelihood of being treated with psychotropic medication and antipsychotic drugs was higher in adults living in residential homes. CONCLUSION: The findings indicate a lack of adherence to existing guidelines in the treatment of adults with ID living in residential homes.

[Treatment pathways in the care of patients with schizophrenia and depression]. / Behandlungspfade in der Versorgung von Patienten mit Schizophrenie und Depression.

BACKGROUND: In mental healthcare the concept of pathways addresses diverse issues and problem areas, such as heterogeneous health service offers, the regional variability of treatment concepts and clear-cut guidelines on how and where to obtain treatment for a particular mental disorder. The ambiguous aspects of the concept require international and national definitions and consensus which must also cover quality criteria. METHODS: This article gives an overview of currently available evidence for the analysis of clinical pathways and pathways to care in international mental healthcare, covering studies on schizophrenia and depression from 2010 to 2014. RESULTS AND DISCUSSION: The ambiguity of the concept impedes the overview and does not provide unequivocal results. The development, implementation and analyses of guidelines or clear-cut clinical and pathways to care must consider individual, clinical and care system aspects as well as the interplay of these factors. Results suggest that system aspects tend to dominate over clinical factors of schizophrenia and depression. As a consequence, the definition, implementation and evaluation of clinical pathways or pathways to mental healthcare is first and foremost a responsibility of the respective national mental healthcare system and must be understood on that level, before findings are summarized internationally and models of best practice are debated.

[Calculating personnel allocation at 100 % implementation of the Psychiatry Personnel Act. Can it be done on the basis of existing routine data?]. / Berechnung der Personalbemessung bei einer Umsetzung von 100 % Psych-PV. Kann diese auf der Grundlage vorliegender Routinedaten erfolgen?

From 1 January 2019, after completion of the convergence phase, the Psychiatry Personnel Act (Psych-PV) will no longer be the basis of budget negotiations of psychiatric hospitals and departments with the health insurance funds in Germany. Instead, the new compounding remuneration system for psychiatric and psychosomatic inpatient institutions (PEPP) will provide a new framework. The Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) has been given the task of elaborating a directive on the basis of the expiring Psych-PV in order to redefine standards for personnel allocation within this new framework. This task presupposes the existence of reliable data in the psychiatric hospitals and departments for categorizing patients following the Psych-PV. It presupposes further that these data allow an exact calculation of the personnel to which the clinics are entitled. This article shows that the so-called §-21 dataset from the database of the VIPP project (indicators of patient care in psychiatric and psychosomatic facilities) allows this calculation. The VIPP dataset was used as a basis to calculate the personnel requirements. Exemplary analyses illustrate that the information available regarding the Psych-PV can be transformed in minutes per day, minutes per month and full time positions. Therefore, this information would also be available to the Institute for the Hospital Remuneration System (InEK).

Illness perceptions and personality traits of patients with mental disorders: the impact of ethnicity.

OBJECTIVE: To identify differences and similarities between immigrants of Turkish origin and native German patients in therapeutically relevant dimensions such as subjective illness perceptions and personality traits. METHOD: Turkish and native German mentally disordered in-patients were interviewed in three psychiatric clinics in Hessen, Germany. The Revised Illness Perception Questionnaire (IPQ-Revised) and the Neuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI) were used. Differences of scales and similarities by k-means cluster analyses were estimated. RESULTS: Of the 362 total patients, 227 (123 immigrants and 104 native Germans) were included. Neither demographic nor clinical differences were detected. Socioeconomic gradients and differences on IPQ-R scales were identified. For each ethnicity, the cluster analysis identified four different patient types based on NEO-FFI and IPQ-R scales. The patient types of each ethnicity appeared to be very similar in their structure, but they differed solely in the magnitude of the cluster means on included subscales according to ethnicity. CONCLUSION: When subjective illness perceptions and personality traits are considered together, basic patient types emerge independent of the ethnicity. Thus, the ethnical impact on patient types diminishes and a convergence was detected.

[Indicators of patient care in Psychiatric and Psychosomatic Facilities (VIPP project)--a database project]. / Versorgungsindikatoren in der Psychiatrie und Psychosomatik (VIPP)--Ein Datenbank-Projekt.

INTRODUCTION: In Germany a new and unique remuneration system for psychiatric and psychosomatic stationary treatments (PEPP system) was introduced in 2013 on an optional basis. From 2015 it will be mandatory for psychiatric and psychosomatic facilities. The introduction of the PEPP system brings up different questions regarding the possible incentives of the new remuneration system and its effects on the supply of psychiatric and psychosomatic treatments. To conduct these necessary analyses a reliable database is needed. MATERIAL AND METHODS: The goal of the project "Indicators of patient care in Psychiatric and Psychosomatic Facilities" (VIPP project) is to gather a representative database which reflects the situation of day-to-day patient care performed by German psychiatric and psychosomatic facilities. The §â€Š21 data set represents the basis of this database which will be complemented by other data sources (i. e., financial statements and other economic data). A number of more than 100 ,000 cases per year has already been exceeded. These case data were provided by a wide range of psychiatric hospitals, departments and universities that participate in this project. The dataset is anonymised and by pooling the data it is not possible to identify the cases of a specific clinic. Participants receive a web-based access and have the possibility to analyse the data independently. RESULTS: Using the examples of coding accuracy and rehospitalisation rates the variety as well as the enormous potential of this database can be demonstrated. DISCUSSION: On the base of the VIPP database valid patient care indicators can be identified and cross-sectional analyses can be conducted. From such results key data on health economic strategies can be derived and the incentives, strengths and limitations of this constantly changing system can be identified.

[Lump sum payment system in psychiatry and psychosomatics: concomitant research - quo vadis?]. / Pauschalierendes Entgeltsystem in der Psychiatrie und Psychosomatik : Begleitforschung - quo vadis?

The new lump sum payment scheme for psychiatric and psychosomatic services is coming into force in 2013. This constitutes another step on the way to performance-based financial compensation of inpatient and day hospital treatment in psychiatric and psychosomatic hospitals in Germany. This fundamental change needs to be accompanied by scientific evaluation with regards to its effects. This article reflects on the legal foundations of such evaluations and the current progress of preparation. Furthermore, own approaches for analysing the effects of the new finance scheme are presented.

[Methods of health economic evaluation for health services research]. / Methoden der gesundheitsökonomischen Evaluation in der Versorgungsforschung.

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

Does community-based care have an effect on public attitudes toward the mentally ill?

In this cross-sectional study we have investigated the attitudes and feelings toward the mentally ill among the residents of two Central European regions which are at considerably different stages of development in moving toward community-based care, to see if we could connect differing patterns of attitudes in the two regions to the varying levels of development of psychiatric care. By using the telephone survey method, representative samples of interviewees were presented with two complexes of questions, measuring the social distance of the interviewee to the mentally ill and his/her feelings toward the mentally ill. Social rejection and feelings of the people toward the mentally ill in both regions were similar in the direction they took, however not so much in the intensity. The population of the community care area showed a slightly stronger rejection. But factor analysis clearly suggests a more rational and sophisticated position toward the patients in this population. The people living in the custodially-oriented catchment area, on the other hand, showed a more vague pattern in their attitudes.

Treatment with antipsychotics: The impact on the patient in the community.

The assessment of new treatment strategies such as the atypical antipsychotic agents goes far beyond the assessment of psychopathology, and includes evaluation of their effects on a variety of needs associated with living in the community. This article provides some empirical data for such a multidimensional perspective in analysing drug treatment with conventional antipsychotics. We focus on two groups of schizophrenic patients discharged from a psychiatric hospital, who were followed up for one year. One group was treated with oral and the other with depot medication. The two groups were assessed on their needs for care, quality of life, and rehospitalisation rates. We found few significant differences between depot- and orally-medicated patients. However, patients treated with depot antipsychotics were receiving higher mean daily doses. Patients taking oral medication had a lower rate of adverse effects but were more non-compliant, which resulted in a higher rehospitalisation rate, confirming our assumpt on that patients take different risk-to-benefit decisions. Orally-medicated patients did not have a better functional status than depot-medicated patients.

[Cost predictors of depressive inpatient episodes in Germany. The health insurer's point of view]. / Ressourcenverbrauch stationärer Episoden bei depressiven Störungen. Eine Analyse aus Sicht der Krankenkassen.

BACKGROUND: Inpatient treatment is the most costly sector of treatment for depressive disorders in Germany. However, little is known about which patient and hospital characteristics contribute to costs of inpatient episodes. PATIENTS AND METHODS: To take part in this study, patients had to fullfill criteria for ICD-10 diagnosis of F31.3-F31.5, F32, F33, F34.1, F43.20, or F43.21. Episodes were recorded between September 9 2001 and March 3 2003 in ten hospitals in three German states. Inpatient records of 1,202 persons were analysed. Multiple regression analysis was performed to identify significant patient predictors of cost per inpatient episode, and the predictive function of hospital characteristics was analysed by applying hierarchical linear modeling. RESULTS: Patient characteristics at admission could not explain a substantial part of the variance in episode costs. Better prediction was possible including variables from the whole treatment process. Also, conditions for admission and patient-related factors did not well explain cost differences between hospitals, but characteristics of the whole treatment were. CONCLUSION: For predicting costs of inpatient depressive episodes, the complete course treatment has to be considered. As in the physiologic sector, therapeutic and diagnostic procedures have a great effect on cost prediction.

Forensic psychiatric assessment in European Union member states.

OBJECTIVE: To provide a structured description and cross-boundary comparison of legal frameworks and training standards relevant for forensic psychiatric assessment in European Union member states before the extension in May 2004. METHOD: Information on legislation and practice concerning the assessment of mentally disordered offenders was gathered by means of a detailed, structured questionnaire which was filled in by national experts. RESULTS: Legal frameworks for the assessment and reassessment of mentally disordered offenders and professional training standards in forensic psychiatry vary markedly across EU member states. CONCLUSION: Currently a cross-boundary harmonization of legal concepts appears hard to achieve. At least a formal construction and implementation of specialist training standards in forensic psychiatry would appear desirable.

[Threatened homelessness and mental disorders. Prevalence and influencing factors in populations at risk]. / Drohende Wohnungslosigkeit und psychische Gefährdung. Prävalenz und Einflussfaktoren bei Risikopopulationen.

BACKGROUND: This study aims to assess the psychiatric morbidity of persons at risk of homelessness and to analyze correlations and risk factors between homelessness and mental disorders. METHODS: The sample included 101 citizens of Mannheim, Germany, who were immediately threatened by eviction. Mental disorders were diagnosed using a standardized test, and other factors were also assessed. Data from August 2000 to June 2002 were collected. RESULTS: Acute mental disorders requiring treatment were determined in 79.3% of the study sample. Addiction disorders (alcoholism) played a major role. Personality, anxiety, and affective disorders were even more frequent than in a control group of homeless people in the same region, whereas schizophrenia and other mental disorders were similarly prevalent. Regression analyses confirmed unemployment, alcoholism, and male gender as the most important risk factors for homelessness among people threatened by eviction. CONCLUSIONS: The results suggest that prevention strategies should be multidimensional and interdisciplinary.

[Are bonus systems applicable to guideline-oriented depression treatment provided by general practitioners and neurologists?]. / Sind Bonussysteme auf eine leitlinienkonforme haus- und nervenärztliche Depressionsbehandlung übertragbar?

In the outpatient treatment of depression, the potential of diagnostic and therapeutic methods is seldom exhausted resulting in variable quality of treatment and partly insufficient cost effectiveness. Implementation of a guideline-oriented reimbursement system seems to be an option to improve quality of treatment. Corresponding incentive systems have been outlined and evaluated for the health care of somatic diseases such as diabetes. Acting on these experiences, an attempt was made to utilize them for the area of psychiatric disorders. Taking depression as an example, a model for a quality-oriented, guideline-based reimbursement system for general and specialist practice is presented.

[Costs of schizophrenia - what we know (not)?]. / Die Kosten der Schizophrenie - was wissen wir (nicht)?

Schizophrenia is regarded as one of the most expensive mental illnesses because of its specific symptoms and characteristics. The care of schizophrenic patients consumed approx. 2 % of the total German health care expenditures in 1994, according to the scarce data provided by routine German health reporting. Despite this enormous impact, health-economical research in schizophrenia in Germany is widely neglected. While few empirical studies on direct cost of care for schizophrenic patients suggest that adequate comprehensive community care in Germany during the mid-nineties was about DM 27 000 to DM 28 000 per patient and year, there is a serious lackage of cost-effectiveness-studies, relating cost of care to outcome. Thus, the most basic data for any health care planning in schizophrenia is missing. This paper reviews the studies on cost of schizophrenia in Germany. It identifies the most serious knowledge gaps and describes the obstacles for an adequate research in this field.

[Health report data in the management of chronic psychiatric patients]. / Gesundheitsberichterstattung in der Versorgung chronisch psychisch Kranker.

Reforming mental health care in the Federal Republic of Germany was clearly impeded by a lack of health care data which would allow for a precise description of the state of the reorganisational process. Since these deficits are not a specific problem of mental health care, the need for a national health report providing health care statistics from all medical disciplines is widely recognised and has led to appropriate political initiatives. The difficulties in interpreting mental health care statistics of restricted validity and the resulting dangers will be discussed by means of examples, and the need for a special health report in mental health care is justified.

The cost of comprehensive care of people with schizophrenia living in the community. A cost evaluation from a German catchment area.

BACKGROUND: In community mental health care, knowledge about costs of care is very limited. Only few studies have related costs to outcome measures. METHOD: This German study assesses the cost of psychiatric care of 66 schizophrenic patients during one year of living in the community. Predictors of high cost were identified. RESULTS: The average cost of comprehensive community care of one patient of the cohort was US$ 363 per week. This was only 43% of the cost of constant long-term care in a psychiatric hospital. Significant predictors of total cost of community care were the number of rehabilitative problems at the beginning and at the end of the study period, the type of accommodation before index hospitalisation and the gender of patients. CONCLUSIONS: Results must be understood in terms of the characteristics of the special patient group and the catchment area we studied and are of high relevance in planning future care.