[Community mental health approaches for avoidance of patient placement in closed psychiatric facilities-a positioning]. / Gemeindepsychiatrische Ansätze zur Vermeidung der Unterbringung in geschlossenen Heimen ­ eine Positionsbestimmung.

BACKGROUND: In many cases the placement of people with mental disorders in closed residential homes is an expression of the lack of alternative care options. In the area of tension between the need for security in the case of chronically self-endangering behavior, recurrent acute psychiatric crisis interventions and a lack of perspective to establish a permanent therapy, in many places a placement in a closed facility approved under care law is carried out. OBJECTIVE: What alternatives are there to closed institutional care in the psychiatric care system in Germany? METHODS: A trialogical discussion process was carried out in an expert panel taking the relevant literature into consideration and with the participation of organizations of those affected and their relatives. RESULTS: The community psychiatric care system in Germany is extremely heterogeneous. The fragmented sociolegal and financing systems makes cross-sectoral and continuous care planning and service provision difficult. Precisely tailored and individualized services that could prevent the persons concerned from being placed in a closed home exist in Germany only at a few locations and in the form of individual model projects. CONCLUSION: The structural and sociolegal deficits addressed require a reform of the institutional framework and a redirection of all actors involved, including the clinics. Alternative approaches to the care of people with severe mental disorders are outlined. These include the Wedding model, binding community psychiatric structures, the basic functional model and assistance services under the German Social Code IX following the revision of the Federal Participation Act.

[The German Association for Psychiatry, Psychotherapy and Psychosomatics participation compass II : Implementation of social participation for people with mental illnesses]. / Der DGPPN-Teilhabekompass II : Umsetzung sozialer Teilhabe für Menschen mit psychischen Erkrankungen.

For most people living with mental illnesses, participating in society is of existential importance; however, psychosocial care often fails to recognize its significance and therefore rarely includes the patient's interaction with society in the course of treatment. The reasons for this are both substantial and organizational in nature. The endless opportunities for participating in society, current areas as well as ways of taking part in social life even beyond the terms of the social legislative definition are, in addition to institutional variety and regional differences, all too often barriers to providing the very urgently needed support. Further aspects are insufficient knowledge of therapists about established options of rehabilitative treatment and about responsibilities related to participation in specialized training and further education for professional caregivers. The presented compass of participation for social integration of persons with mental illnesses starts at this point: it provides guidelines for psychiatric and psychotherapeutic practitioners, general practitioners as well as for physicians working in residential or day care institutions with a psychiatric and psychotherapeutic background. Both this article and planned online versions should help professionals to timely and successfully assist people, particularly those with severe mental illnesses, to navigate the broad spectrum of services for social and vocational integration in Germany.

[DGPPN compass of participation for vocational integration of persons with mental illnesses]. / DGPPN-Teilhabekompass zu beruflichen Integrationsmaßnahmen für Menschen mit psychischen Erkrankungen.

Working and living for persons with mental illnesses are a major concern of rehabilitative psychiatry. In Germany the definition of rehabilitation for persons with mental illnesses is closely linked to different sectors of social welfare and to the strongly organized supply chain of prevention, acute treatment, rehabilitation and care. In successfully supporting people with mental health problems in terms of vocational integration, professionals face various obstacles. Besides finding the correct content, structural and organizational difficulties can also arise. The welfare system with its specific institutions and settings is complicated which often leads to delays in the onset of rehabilitation. Some essential reasons are insufficient knowledge about established options of rehabilitative treatment and about responsibilities related to participation in specialized training and further education for professional caregivers. Also information and (positive) experiences from pilot projects working in an inclusive, cross-sectional way and across different settings are practically unavailable in Germany. The presented compass of participation from the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) for vocational integration of persons with mental illnesses starts at this point: it provides guidelines for psychiatric and psychotherapeutic practitioners, general practitioners as well as for physicians working in residential or day care institutions with a psychiatric and psychotherapeutic background. Both the paper and planned online versions should help professionals to help people, particularly those with severe mental illnesses to navigate the system of services for vocational integration in Germany.

[At the border of social psychiatric care systems--a study of "high utilizers" in Mecklenburg-Vorpommern]. / Am Rande sozialpsychiatrischer Versorgungsstrukturen--eine Untersuchung zur "Systemsprengerproblematik" in Mecklenburg-Vorpommern.

Research in social psychiatry has partly neglected the problem of comparatively disturbed persons, who are characterized by a shift from the regular social psychiatric care system into homelessness, closed psychiatric treatment or other desintegrated areas. Against this background in Mecklenburg-Vorpommern, an evaluation of all clinical and complementary institutions engaged in psychiatry was realized. 83.5 % of the institutions took part in the study and 137 (5.21 %) persons were identified as critical. 59.4 % of the institutions, especially therapeutic living groups, remarked that they had treated critical persons during the last year. Sociodemographically, the critical persons could be characterized by comparatively limited interpersonal relationships und a high unemployed status. A factor analysis has resulted in 4 factors characterizing the problematical behaviour: (i) aggression, low social adjustment and impulsivity; (ii) suicidal behaviour; (iii) delinquency and substance use; (iv) manipulative behaviour and pestering. Defining a comparatively high of disturbed behaviour, 51 persons could be identified.

[Follow-up options in institutional protection--"patient careers" in a comprehensive community psychiatric care system]. / Verlaufsmodalitäten institutioneller Protektion--"Patientenkarrieren" in einem gegliederten gemeindepsychiatrischen Versorgungssystem.

The recommendations for the reorganization of German psychiatry were associated with the expectation that institutional protection can be reduced in a comprehensive community care system on the longterm basis and that a stabilization can be achieved during treatment with a minimum share in full and partial hospitalization. To test this assumption we studied the institutional pathways of 136 chronic, mainly schizophrenic patients within the comprehensive care system of the Department of Social Psychiatry over two years. A cluster analysis of sequence and intensity of institutional care showed three major types of use of the system: as a rehabilitation system, as an alternative and flexible care system, and as a traditional "dual-care-system". These patterns of institutional pathways were analyzed regarding predictors from patient's history. Consequences are discussed concerning further development of community mental health, coordination of services and continuity of care.

Prediction of hospitalization within a psychiatric community care system--a five-year study.

Within a comprehensive community care system, we examined which patients became hospitalized during long-term treatment. We studied 60 consecutively admitted, and mainly chronic psychotic patients over 5 years. Full and partial hospitalizations were assessed by means of a hospitalization index. This index was significantly lower in the 2nd to 5th years after admission than in the 1st year. Sociodemographic and clinical characteristics failed to predict hospitalizations during the 1st year. Patients' age, gender and last occupational status were related to hospitalizations in the following 4 years. A better prediction of hospitalizations was allowed by treatment data obtained during the 1st year. It is suggested that long-term prognosis should be based mainly upon experience with a patient in a given care system, rather than on a patient's history and characteristics as known before treatment.

[The work therapy workshop as part of a psychiatric service system--its contribution to the integration of medical, occupational and social rehabilitation]. / Die arbeitstherapeutische Werkstatt als Teil eines psychiatrischen Versorgungssystems--Ihr Beitrag zur Integration medizinischer, beruflicher und sozialer Rehabilitation.

The limitations faced by purely clinical facilities in providing comprehensive rehabilitation for long-term schizophrenic patients having been made increasingly clear by a changing labour market, the Department of Social Psychiatry's community mental health system had already in 1978 been extended to include a work therapy shop, i.e., a printing shop geared to general economic conditions. This effort of integrating various rehabilitative activities "under one roof" within the workshop while maintaining the continuity of medical treatment, is discussed by a synoptical presentation of findings from quantitative und qualitative analysis. It has been possible to show that a wide spectrum of graded rehabilitative activities can be implemented successfully in a well-defined, work life oriented setting. Given close linkages of the workshop with a structured, comprehensive care system, the advantages inherent in integrating medical, vocational, and psychosocial rehabilitation efforts obviously outweigh the disadvantages of insufficient specificity and diversification.

Development and current status of partial hospitalization in the Federal Republic of Germany and West Berlin.

Since the opening of the first partial-hospitalization program in 1962, the development of partial hospitalization in the Federal Republic of Germany and West Berlin has markedly accelerated, especially in recent years. As of July 1, 1982, there were at least 60 such programs with approximately 1200 places in the country. A review of the current status is given regarding the individual programs' perceived mission and their integration into the existing network of psychiatric services. Summary statistics are provided regarding patient census, duration of stay, staffing, therapeutic activities, and clientele. Problems such as the low number of direct community referrals, the preponderance of chronic patients, and the underutilization of programs are discussed.

[Status of day care treatment of elderly psychiatric patients in West Germany and West Berlin]. / Zum Stand tagesklinischer Behandlung älterer psychisch Kranker in der Bundesrepublik Deutschland und West-Berlin.

The possibilities as well as the limits of day-hospital treatment for elderly mentally ill patients are described, using as a basis a general survey on the situation of psychiatric day-hospitals in the Federal Republic of Germany and West Berlin. As of July 1, 1982, there were at least seven day-hospitals specializing in psychogeriatric patients, whereas a further eight institutions admitted elderly mentally ill patients as well as the usual patients. For all these day-hospitals a review of the current status is given regarding funds, size of program, integration into the existing network of psychiatric services, referral sources, the individual programs perceived mission, clientele, exclusionary criteria, duration of stay, therapeutic activities and staffing. Finally problems such as indication, clientele and delimitation of other ways of treatment are discussed. Questions are asked with regard to the purpose and the necessity of specialized psycho-geriatric partial hospitalization programs.

[Rehabilitation in a community psychiatric service facility--success and failure during a one year period]. / Rehabilitation in einer gemeindepsychiatrischen Versorgungsstruktur--Erfolg und Misserfolg während eines Jahres.

Rehabilitation outcome was examined within a social psychiatric model institution including several partial hospitalization programmes and various outpatient services. After a one-year period the treatment success was measured by objective criteria in 166 consecutively admitted patients, most of them diagnosed as schizophrenics. 75% showed improvements in terms of reduced institutional protection and a more independent living situation. Vocational rehabilitation was successful in 47%. There was no significant correlation between these outcome measures. A poor outcome was found in a group of patients who had received a comparatively high rate of therapeutic activities and was classified by sociodemographic variables. Consequences concerning the therapeutic approach in community mental health services and its evaluation are shown.

[Treatment conditions and discharge from the viewpoint of the therapist and patient--on the follow-up of former patients of a social psychiatric model institution]. / Behandlungsbeendigung und Entlassung aus der Sicht von Therapeuten und Patienten--Zur Nachbefragung ehemaliger Patienten einer sozial-psychiatrischen Modellinstitution.

An interview conducted with former patients verified whether or not the reasons for being discharged from hospital coincided with those of the therapists. There was only agreement in approximately 50% of the cases according to whether the patients demanded to be released or whether their discharge was ordered by the hospital. Agreement was found to be greater particularly in cases where further treatment was not considered to be necessary by the patients and where patients were assigned to medical treatment elsewhere. There was more agreement in cases where further care was regarded as not necessary by both--therapists and patients. Patients who believed that they themselves had terminated treatment judged the hospital in a more negative light, as was to be expected. Agreement was high between therapists and patient regarding the treatment which was conducted afterwards. In this case medical records transpired to be very reliable. The question why a model setting, which aims at a high consensus among the medical staff and patients, attains only limited agreement on the reasons and necessity for discharge from hospital, is discussed.

[Old people in homes]. / Alte Menschen in Heimen.

With regard to gerontological problems (multiple morbidity, insufficient epidemiological knowledge, under-assessment of mental illness, displacement) the results of a total survey of residents over 65 of age in all the geriatric nursing homes and homes for the elderly in the Berlin (W) district of Charlottenburg are presented. Our main interest was in the following items: diagnosis, psychopathology, clinical and personal data, medical and social care, extent of personal contacts with non-residents, and the institutional environment. Results are discussed and inferences for better care, particularly of the mentally ill residents, are indicated.

[Younger psychiatric patients in homes for the aged and nursing homes]. / Jüngere psychisch Kranke in Alten- und Altenpflegeheimen.

All 77 residents aged under 65 in geriatric nursing homes and homes for the elderly in the Berlin (W) district of Charlottenburg were assessed in regard to mental illness and impairment. Additionally, data were collected covering psychopathology, clinical and personal data, medical and social care as well as the extent of contacts to nonresidents and institutional setting. 85% of these younger residents-8% of the total residential population-proved to be mentally ill. Primarily, they suffered from addiction, schizophrenia or mental retardation. Projecting our results to the total residential population of Berlin living in such homes, 728 younger mentally ill or retarded patients or 0,5%o of the population aged under 65 would live in such institutions. These residents had histories of unfavorable living conditions and a long psychiatric case history with frequent hospitalization. Distinct differences in regard to patient data as well as settings were found among public, welfare and private institutions. Results are discussed and arguments for improving care of this population are presented.

[Social workers and physicians--partners in social psychiatry? Assumptions and reality in a social psychiatry model institution]. / Sozialarbeiter und Arzte--Partner in der Sozialpsychiatrie? Anspruch und Wirklichkeit in einer sozialpsychiatrischen Modellinstitution.

With the reform of psychiatric and psychosocial care services, new professional groups, apart from the traditionally medical professions, have increasingly found their way into everyday therapy. Social workers in particular have gained significance in complementary fields of treatment. An empirical survey of the everyday situation in a comprehensive community mental health service system focusing on the therapist-couple "physician" and "social worker" collaborating to guarantee continuity of care for long-term treatment, yielded three results: 1. The dual-therapistsystem was convincingly effective for nearly half of the total number of patients; the other patients were attended generally by one therapist, while the second therapist took an active part in treatment only sporadically. 2. Analysis considering the two professional groups involved showed a significant pre-dominance of the physicians, both on a qualitative basis in their function as being the primary therapist as well as in strictly quantitative terms concerning the relations of all therapeutic activities. 3. A comparison of two extreme groups "doctor-patients" and "social worker-patient" revealed significant differences in features of their respective social and clinical case histories. In the course of treatment we found a rapid focusing on and acceptance of the medical therapeut. These results, which also reflect the conflict between social psychiatric claims and everyday reality, are discussed with regard to the self-perception of the professional groups involved and the practice of our department and the cooperative institutions, as well as the expectations of the patients and their relatives, and finally with reference to the various exclusively medical-oriented treatment models which still dominate contemporary psychiatric praxis.

[Psychiatric disorders in immigrants. I. History, symptoms and diagnostic classification]. / Psychische Störungen bei Ubersiedlern. I. Vorgeschichte, Symptomatik und diagnostische Einordnung.

155 people who had left East-Germany and sought psychiatric help within six weeks after their arrival in West Berlin, were examined. History, living situation and psychopathological symptoms were studied. The disorders were diagnosed according to ICD-9 and DSM-III-R. 85% of the patients reported that they had already suffered from similar complaints in East Germany. 50% stated they have had symptoms before they had made the decision to leave. On average, that decision had been taken 22 months before the actual leaving. Most often patients complained about sleep disturbance, nervousness, and headaches. According to ICD-9, 55% of the disorders were classified as reactive and 39% as neurotic or personality disorders. The most frequent diagnoses according to DSM-III-R were adjustment disorders (41%), major depression (21%), anxiety disorders (16%), and dysthymia (14%). Regardless of diagnosis most patients were found to have symptoms of anxiety and depression associated with vegetative complaints. There were no clear relationships between psychopathological symptoms and data of history or present living situation.