RESUMO
BACKGROUND: Home treatment for severely mentally ill persons is becoming increasingly popular. This research aims to identify structures and processes in home treatment that impact on patient-related outcomes. METHODS: We analysed 17 networks that provide home treatment to severely mentally ill persons using a naturalistic approach. The networks were similar with regard to central components of home treatment such as case management, 24 h crisis hotline and home visits, but differed in all other aspects such as the multidisciplinary teams, time spent with patients, etc. To determine treatment outcome, patients' psychosocial functioning was measured using the Health of the Nation Outcome Scales (HoNOS). Structures and processes were assessed using claims data and questionnaires answered by the different networks. Primary outcome was highlighted by the change in HoNOS scores from the start of home treatment compared with 6 months later. We sought to explain this outcome through patient and network characteristics using regression analysis. Data on 3,567 patients was available. RESULTS: On average, psychosocial functioning improved by 0.84 across networks between t0 and t1. There were more similarities than differences between the networks with regard to the structures and processes that we tested. A univariate regression analysis found staff's prior experience in mental health care and the effort that they invested in their work correlated positively with patient outcome. This needs to be interpreted under considering that univariate analysis does not show causal relationship. A high case load per case manager, increased and longer patient contact and more family intervention were correlated with worse patient outcome, probably indicating that sicker patients receive more care and intervention. CONCLUSION: Home treatment networks succeed in delivering care tailored to the needs of patients. In order to improve the quality of care in home treatment, this study suggests employing experienced staff who is ready to invest more effort in their patients. Further research needs to consider a longer follow-up time.
Assuntos
Serviços de Assistência Domiciliar/estatística & dados numéricos , Transtornos Mentais/terapia , Pessoas Mentalmente Doentes/psicologia , Avaliação de Programas e Projetos de Saúde , Adulto , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Resultado do TratamentoRESUMO
Since the turn of the century, quality assurance (QA) programs are increasingly being implemented; both generally in health systems and specifically for mental health services. These QA programs can be implemented on a mandatory basis as well as voluntarily. Benefits of mandatory QA programs are a reliable, country-wide dataflow, as well as their long-term sustainability and comparability. Shortcomings relate to the limitations imposed by legal requirements. Benefits of voluntary QA programs are their freedom and flexibility in terms of methods and data sources. Shortcomings relate to the impossibility of country-wide implementation and a lack of sustainability, as well as to the data quality. Examples for QA in mental health care from different European countries show that mandatory and voluntary QA initiatives could complement each other. Specialist medical societies play an important role in the development of voluntary QA and the promotion of high quality care. An example is the accreditation to mental health services offered by the Royal College of Psychiatrists in the United Kingdom.
Assuntos
Atenção à Saúde/normas , Fidelidade a Diretrizes , Transtornos Mentais/terapia , Serviços de Saúde Mental/normas , Guias de Prática Clínica como Assunto , Garantia da Qualidade dos Cuidados de Saúde/normas , Europa (Continente) , Humanos , Transtornos Mentais/diagnósticoRESUMO
BACKGROUND: This study assesses exemplarily the regional structure of mental health services and the practice of cooperation of mental health service providers. The aim is to identify starting points for improving mental health care. METHOD: (1) Mapping of mental health services in four exemplary regions (urban/rural, East/West Germany) using the European Service Mapping Schedule. (2) Analysis of the practice of cooperation in mental health care using focus groups and a postal survey of psychiatrists and psychotherapists working in private practice. RESULTS: All surveyed regions have a well-developed and complex service system available. Cooperation in mental health care takes place in flexible networks rather than in fixed relationships. An explicit concept of cooperation does not exist. Time and resources promote cooperation. Psychiatrists and psychotherapists working in outpatient care mainly cooperate among themselves and rarely on an interdisciplinary basis. In particular psychotherapists are usually not part of cooperation networks. CONCLUSIONS: Improvements in mental health care are more likely to be achieved through improving cooperation rather than just developing additional services. Starting points for improvements include-beyond the increase of resources for cooperation - the training of medical students and psychiatrists in cooperation practice, reimbursement of cooperation and coordination and the implementation of systematic coordination of service networks.
Assuntos
Serviços Comunitários de Saúde Mental/organização & administração , Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Relações Interinstitucionais , Transtornos Mentais/diagnóstico , Transtornos Mentais/terapia , Modelos Organizacionais , Alemanha/epidemiologia , Humanos , Transtornos Mentais/epidemiologia , PrevalênciaRESUMO
BACKGROUND: Strategies are needed to effectively improve the management of depression in Germany. Can telephone case management (TCM) be a promising strategy to improve depression care in the German health-care system? METHODS: A systematic literature review in PubMed, Cochrane Library, ISI Web of Science, PsycINFO and PSYNEXplus for randomised controlled trials (RCT) that evaluate TCM was carried out. RESULTS: Ten RCTs that compared TCM to treatment as usual were found. TCM was more effective in reducing depressive symptoms and in increasing satisfaction with care than treatment as usual. Whether TCM was capable of significantly improving pharmacotherapy compliance remained controversial. DISCUSSION: The effectiveness of TCM seemed to be related to the health-care system structure in which it was implemented. Most studies on TCM were conducted in US-American Health Maintenance Organizations. Thus, it is unclear to what extent these results can be transferred to the German health system. However, in the light of the promising results of these studies it seems to be worthwhile to test TCM also under conditions of the German health-care system.
Assuntos
Administração de Caso/organização & administração , Depressão/diagnóstico , Depressão/terapia , Encaminhamento e Consulta/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Telefone/estatística & dados numéricos , Depressão/epidemiologia , Alemanha/epidemiologia , HumanosRESUMO
OBJECTIVE: Responsiveness is a concept developed by the World Health Organisation (WHO) to evaluate health system performance. It measures how well a health system meets its users' legitimate expectations in non-medical related service aspects. Responsiveness consists of the categories "patient orientation" and "respect for persons". It is operationalised by nine (8+1) domains. This project aims to explore the responsiveness concept as a possibility to evaluate the performance of mental health care. METHOD: Face to face interviews with users of outpatient and hostel mental health services by means of a standardised instrument, developed by WHO were carried out. RESULTS: Overall responsiveness in outpatient care was rated by a lower proportion of users negative than responsiveness in hostel care (15 vs. 20%). Socio-demographic characteristics were related only to responsiveness ratings in hostel care when legal guardianship was considered. Domains indicated as most important (attention, participation) in out-patient care did not perform well there. In hostel care the domains attention and respect were rated as most important. These domains performed well. DISCUSSION AND CONCLUSIONS: The results are in line with the literature and adequately reflect the realities in mental health care. The responsiveness concept offers a systematic approach for considering the categories "patient orientation" and "respect for persons" as quality criteria in mental health care. Evaluating mental health service provision using the concept of responsiveness, indicates where to launch reforms in health care.
Assuntos
Assistência Ambulatorial/normas , Casas para Recuperação/normas , Vida Independente , Serviços de Saúde Mental/normas , Satisfação do Paciente , Relações Profissional-Paciente , Qualidade da Assistência à Saúde/normas , Adulto , Feminino , Alemanha , Humanos , Entrevista Psicológica , Masculino , Pessoa de Meia-Idade , Organização Mundial da SaúdeRESUMO
When considering measures to decrease the burden of disease that is caused by depression, the depressive diseases of adolescents and young adults are of increasing interest. The prevalence in this group is high and an increase in prevalence has to be considered. The prognosis for juvenile depression is particularly bad. This review discusses the potentials to influence the burden of disease through interventions such as therapy, indicated, selective and universal prevention and health promotion for adolescents and young adults. The most impact can thereby be expected from an effective treatment of depression and other mental diseases that have high co-morbidity with depression. There is some evidence for the effectiveness of preventive interventions for depression, however, most approaches currently seem to be unsuitable for wide implementation in the population. However, as open measures, they can offer individual benefit. Health promotion that focuses on political, living and societal conditions should be directed at the family. Policy measures that improve the living conditions of parents also promote the mental health of children. Finally, the discussion about the burden of disease that is caused by depression should be held by considering current societal norms. In this context, it is of special interest as to how much depression and how much loss of function should be still considered as normal and not eligible for intervention.
Assuntos
Efeitos Psicossociais da Doença , Depressão/prevenção & controle , Promoção da Saúde , Saúde Pública , Adolescente , Adulto , Antidepressivos/uso terapêutico , Criança , Ensaios Clínicos como Assunto , Depressão/tratamento farmacológico , Depressão/epidemiologia , Depressão/terapia , Família , Medicina de Família e Comunidade , Alemanha/epidemiologia , Humanos , Relações Pais-Filho , Prevalência , Psicoterapia , Fatores de RiscoRESUMO
The World Health Organisation has defined health service responsiveness as one of the key-objectives of health systems. Health service responsiveness relates to the ability to respond to service users' legitimate expectations on non-medical issues when coming into contact with the services of a healthcare system. It is defined by the areas showing respect for persons and patient orientation. Health service responsiveness is particularly relevant to mental health services, due to the specific vulnerability of mental health patients but also because it matches what mental health patients consider as good quality of care as well as their priorities when seeking healthcare. As (mental) health service responsiveness applies equally to all concerned services it would be suitable as a universal indicator for the quality of services' performance. However, performance monitoring programs in mental healthcare rarely assess health service performance with respect to meeting patient priorities. This is in part due of patient priorities as an outcome being underrepresented in studies that evaluate service provision. The lack of studies using patient priorities as outcomes transmits into evidence based guidelines and subsequently, into underrepresentation of patient priorities in performance monitoring. Possible ways out of this situation include more intervention studies using patient priorities as outcome, considering evidence from qualitative studies in guideline development and developing performance monitoring programs along the patient pathway and on key-points of relevance for service quality from a patient perspective.
RESUMO
Psycho-oncology addresses the psychological, social, behavioural, and ethical aspects of cancer. Identification and proper management of the patients' psychosocial needs, as well as the needs of their caregivers and family are essential for a person-centred concept of breast cancer care. The aim of this overview is to describe how psychosocial support in breast cancer is incorporated in cancer-related policy documents, such as national cancer plans and breast cancer care certification schemes.
Assuntos
Neoplasias da Mama/psicologia , Política de Saúde , Oncologia/legislação & jurisprudência , Sistemas de Apoio Psicossocial , Certificação , Europa (Continente) , Feminino , HumanosRESUMO
AIMS: To explore the practice of cooperation in mental health care across services and identify conditions that promote and inhibit cooperation. METHODS: Focus groups with relevant service providers were conducted in four exemplary regions in Germany (rural/ urban and East/West). The discussions were content analysed. RESULTS: Seven central categories were deduced: (1) involved service providers, (2) comprehension, (3) reasons, (4) instruments for cooperation, (5) promoting and inhibiting conditions, (6) interdisciplinarity, and (7) regional and personal networks. Cooperation is practiced in networks, rather than defined relations. Who is involved in cooperation depends on patients/clients needs and may vary from case to case. Service providers do not have theoretical concepts of cooperation. Cooperation relies not only on personal contacts and knowledge between services but also on time, financial reimbursement and the social capital of the environment. In particular, cooperation with physicians was considered to be difficult by non-medical professionals. Physician's role models do not seem to include cooperation with other disciplines as a core task. CONCLUSIONS: To improve cooperation, regional and sustainable mental health networks have to be systematically implemented by providing leadership, time and reimbursement for network meetings. Interdisciplinary cooperation practice should be part of the curricula of medical students and residents in psychiatry.
Assuntos
Comportamento Cooperativo , Comunicação Interdisciplinar , Transtornos Mentais/terapia , Serviços de Saúde Mental , Equipe de Assistência ao Paciente , Continuidade da Assistência ao Paciente , Grupos Focais , Alemanha , Humanos , Motivação , Papel do Médico , Garantia da Qualidade dos Cuidados de Saúde , Mecanismo de Reembolso , Meio SocialAssuntos
Neoplasias da Mama , Neoplasias , Psico-Oncologia , Mama , Europa (Continente) , Humanos , OncologiaRESUMO
BACKGROUND: It is not known how characteristics of suicide attempts vary with different forms of alcohol involvement. The aim of this study is to clarify the role of alcohol use disorder and acute alcohol consumption in suicide attempts. METHODS: Data on 1921 suicide attempts was gathered in a major German city over a 5-year period. Suicide attempts were categorised according to a diagnosis of alcohol use disorder and acute alcohol consumption at the time of the attempt. Group comparisons and multinomial logistic regression were used for statistical analysis. RESULTS: In 331 suicide attempts (17%) an alcohol use disorder was diagnosed. Six hundred and twenty-two suicide attempts (32%) were committed with acute alcohol consumption. Suicide attempts by individuals with alcohol use disorder were more often committed by men, older individuals and as a recurrent attempt, independently of alcohol consumption at the time of the attempt. When alcohol was consumed in suicide attempts by individuals with alcohol use disorder, low-risk methods were used most often. CONCLUSIONS: Individuals with a diagnosis of alcohol use disorder are a high-risk group for multiple suicide attempts and should be a target group for suicide prevention. Screening for suicidality should be a regular part of the clinical assessment in individuals with alcohol use disorder.
Assuntos
Consumo de Bebidas Alcoólicas/psicologia , Alcoolismo/psicologia , Ideação Suicida , Tentativa de Suicídio/psicologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Alemanha , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-IdadeRESUMO
Optimised treatment of depression is important to patients and their families and has important health economic implications in Germany. The optimised treatment of depression can best be achieved with multilevel interventions targeting different groups. The "German Alliance Against Depression" emerged within the framework of the "German Research Network on Depression and Suicidality". This action-oriented programme aims to improve the care of depressed patients through parallel interventions on four levels. These levels are as follows: 1) co-operation with general practitioners, 2) a public relations campaign, 3) training programmes for community facilitators and 4) interventions with high-risk groups. The programme was tested in Nuremberg. Results were promising with a 24% decrease in suicidal behaviour reported. In the meantime, groups in Germany and abroad declared their interest in adapting the programme. Today, close to 40 German regions have implemented similar multilevel interventions. The European Alliance Against Depression (EAAD) formed and now includes 17 countries. The EAAD was mentioned in the 2005 EU green paper on mental health as an "example for best practice". Improving the care of affected persons requires a systematic research approach. The "Mental Health Research Network" contributes to research related to the optimisation of services for persons with mental disorders.
Assuntos
Depressão/terapia , Prevenção do Suicídio , Pesquisa Biomédica , Depressão/psicologia , Europa (Continente) , Medicina de Família e Comunidade , Alemanha , Humanos , Relações Públicas , Fatores de Risco , Suicídio/psicologia , Organização Mundial da SaúdeRESUMO
OBJECTIVE: Vocational rehabilitation is an important component of community-oriented mental health care. How is the situation of supply with vocational rehabilitation facilities in Germany offering their services to mentally challenged persons? METHOD: Search of a Germany-wide rehabilitation database, supplemented by information from the Federal Working Groups on Vocational Rehabilitation. Cartographical classification of the identified facilities. Analysis of the results in a comparison of the situation in the 16 German States (Länder). RESULTS: The Länder of North Rhine Westphalia, Bavaria, Baden-Wuerttemberg and Lower Saxony offer the greatest number of vocational rehabilitation facilities to mentally challenged persons. In all East German and in some of the West German Länder vocational rehabilitation facilities are restricted to some areas and to certain vocational preconditions. Many of the facilities in these areas are structured as centres and situated in rural areas. Hence, they lack community-orientation. Only North-Rhine Westphalia offers country-wide community-oriented vocational rehabilitation facilities to mentally challenged persons, which are not restricted to certain vocational preconditions. DISCUSSION AND CONCLUSIONS: The supply with vocational rehabilitation facilities for mentally challenged persons has improved during recent years. Nevertheless, the situation in many of the German Länder needs to be improved, particularly in respect of the availability of rehabilitation facilities for younger mentally challenged persons without prior working experience. The implementation of decentralised community-oriented facilities should be favoured in centres, especially in larger sparsely populated areas.
Assuntos
Centros Comunitários de Saúde Mental/provisão & distribuição , Pessoas com Deficiência Mental/reabilitação , Pessoas com Deficiência Mental/estatística & dados numéricos , Reabilitação Vocacional/métodos , Reabilitação Vocacional/estatística & dados numéricos , Alemanha Ocidental/epidemiologia , HumanosRESUMO
BACKGROUND: The rising public health relevance of mental health requires increased activities in the field of mental health promotion and prevention. In recent times interest in this sphere increases in Germany. OBJECTIVE: Which kinds of population-based mental health promotion programmes and prevention approaches are internationally available? What can be learned from their example? METHOD: Systematic search of the Internet and literature databases. Analysis and comparison of the available mental health promotion and prevention concepts with regard to targets, sub-targets, target groups, protagonists, settings, outcome indicators and evidence management. RESULTS: Concepts for mental health promotion and prevention programmes exist in England, Australia, the European Union and in Quebec, Canada. The concepts show similarities such as choosing similar settings like work place and schools or similar target groups like caretakers or adults in particular challenging life circumstances. CONCLUSIONS: Concepts for population-based mental health promotion and prevention have been created in some countries. For developing such programmes in Germany one should refer to internationally available experience as well as to own gathered experiences as to own expressions gathered pilot projects and the German Health Target Programme.
Assuntos
Comparação Transcultural , Promoção da Saúde/tendências , Transtornos Mentais/prevenção & controle , Austrália , Estudos Transversais , Europa (Continente) , Previsões , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Transtornos Mentais/epidemiologia , Serviços de Saúde Mental/tendências , Equipe de Assistência ao Paciente/tendências , QuebequeRESUMO
Reversible dementia in geriatric depression is known to be a risk factor for irreversible dementia. Whether just mild cognitive deficits in elderly depressed patients hold a similar risk is not known yet. It may be suggested that elderly depressed patients with mild cognitive deficits, who are prone to develop dementia, show EEG alterations similar to those observed in demented patients. We studied the relationships between cognitive performance, severity of depressive symptoms and quantitative EEG parameters in 31 unmedicated, nondemented, depressed patients aged 60 years or more. Twenty-one of the patients showed a cognitive performance characteristic of mild cognitive impairment. In these patients, the mean delta and theta power was significantly higher than in the patients without cognitive impairment. Total delta power was negatively correlated with cognitive performance. There was no relationship between cognitive performance or EEG parameters and the severity of depression.
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Envelhecimento/psicologia , Transtornos Cognitivos/fisiopatologia , Transtornos Cognitivos/psicologia , Depressão/fisiopatologia , Depressão/psicologia , Eletroencefalografia , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Índice de Gravidade de DoençaRESUMO
BACKGROUND: There are few studies evaluating treatment in gerontopsychiatric day-clinics. In this paper, data are presented on the outcome of day-clinic treatment in late-life depression. METHOD: Forty-four depressed elderly patients (mean Hamilton Depression Score: 17.6) were examined at admission and discharge for psychopathology, functioning in daily living, social situation, burden with medical disease and quality of life. RESULTS: At discharge, the patients showed a significant reduction in depressive symptoms, improvements in cognitive performance, social activities and contacts. However, a more detailed analysis revealed that only patients responding to treatment (n=20) improved in the respective parameters. Patients, who did not recover fully from depression (n=24), did not improve in any of these parameters. At admission, responders and nonresponders did not differ concerning quality of life. At discharge, responders were significantly more satisfied in 11 of 20 domains of life quality. A shorter life time duration of depressive disease and male sex were predictive for a remission of depression. Thus, it could be shown that a considerable number of patients suffering from late-life depression may be successfully treated in a gerontopsychiatric day-clinic and 45.5% fully recover from depression. CONCLUSIONS: The day-clinic setting meets the specific needs of patients suffering from late-life depression by maintaining them in the community, supporting their abilities for self-care and promoting social contacts. Treatment in a day-clinic may be recommended for many elderly depressed patients.
Assuntos
Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Transtorno Depressivo/terapia , Atividades Cotidianas , Idade de Início , Idoso , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial , Cuidadores , Transtorno Depressivo/psicologia , Feminino , Psiquiatria Geriátrica , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Qualidade de Vida , Comportamento Social , Apoio Social , Resultado do TratamentoRESUMO
OBJECTIVE: The variety of institutional treatments in psychiatry, as well as financial aspects make it necessary to evaluate these institutions for the quality of their medical care. At the Central Institute of Mental Health in Mannheim, the quality of treatment at the geronto-psychiatric day-clinic is assessed on the level of outcome quality. METHOD: The patients are examined at admission, at discharge, half a year and one year after discharge. Psychopathology, activities of daily living, social situation and quality of life are assessed by means of standardized instruments. RESULTS: Preliminary results show that at discharge, patients are less depressed, have achieved a higher level of social activities and contacts and that their quality of life improved in most domains. In some domains of quality of life improvement is highly correlated with the amelioration of depressive symptoms, in others not. CONCLUSION: Whether these effects of treatment will last, has to be studied in follow-up examinations.
Assuntos
Hospital Dia/normas , Transtornos Mentais/terapia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/normas , Qualidade de Vida/psicologia , Atividades Cotidianas/classificação , Atividades Cotidianas/psicologia , Idoso , Feminino , Seguimentos , Avaliação Geriátrica , Alemanha , Humanos , Masculino , Transtornos Mentais/diagnóstico , Transtornos Mentais/psicologia , Pessoa de Meia-IdadeRESUMO
Anxiety is a symptom frequently encountered in elderly depressed patients. It is supposed to have an unfavourable prognostic impact. We studied the frequency of psychic anxiety and its relationship to demographic, social and clinical variables in a group of 54 elderly depressed patients admitted to a gerontopsychiatric day-clinic. Severity of depression, cognitive performance, functional level, social situation and life satisfaction were studied by means of standardized instruments. In about half of the patients studied, we found significant psychic anxiety. Compared to the other depressed patients, patients with anxiety suffered more frequently from cognitive impairment and were more dissatisfied with the acceptance of their disease by other persons. They more frequently lived together with other persons in one household. When leaving psychic anxiety out of consideration as a depressive symptom, the severity of depression was not different in patients with and without anxiety. Anxious patients were equally responsive to day-clinic treatment as non-anxious patients. However, duration of treatment was considerably increased. Thus, elderly depressed patients with anxiety show particular psychosocial and clinical features and require special attention in diagnostics and treatment.