Effectiveness and cost-effectiveness of an integrated care program for schizophrenia: an analysis of routine data.

In Germany, a regional social health insurance fund provides an integrated care program for patients with schizophrenia (IVS). Based on routine data of the social health insurance, this evaluation examined the effectiveness and cost-effectiveness of the IVS compared to the standard care (control group, CG). The primary outcome was the reduction of psychiatric inpatient treatment (days in hospital), and secondary outcomes were schizophrenia-related inpatient treatment, readmission rates, and costs. To reduce selection bias, a propensity score matching was performed. The matched sample included 752 patients. Mean number of psychiatric and schizophrenia-related hospital days of patients receiving IVS (2.3 ± 6.5, 1.7 ± 5.0) per quarter was reduced, but did not differ statistically significantly from CG (2.7 ± 7.6, 1.9 ± 6.2; p = 0.772, p = 0.352). Statistically significant between-group differences were found in costs per quarter per person caused by outpatient treatment by office-based psychiatrists (IVS: €74.18 ± 42.30, CG: €53.20 ± 47.96; p < 0.001), by psychiatric institutional outpatient departments (IVS: €4.83 ± 29.57, CG: €27.35 ± 76.48; p < 0.001), by medication (IVS: €471.75 ± 493.09, CG: €429.45 ± 532.73; p = 0.015), and by psychiatric outpatient nursing (IVS: €3.52 ± 23.83, CG: €12.67 ± 57.86, p = 0.045). Mean total psychiatric costs per quarter per person in IVS (€1117.49 ± 1662.73) were not significantly lower than in CG (€1180.09 ± 1948.24; p = 0.150). No statistically significant differences in total schizophrenia-related costs per quarter per person were detected between IVS (€979.46 ± 1358.79) and CG (€989.45 ± 1611.47; p = 0.084). The cost-effectiveness analysis showed cost savings of €148.59 per reduced psychiatric and €305.40 per reduced schizophrenia-related hospital day. However, limitations, especially non-inclusion of costs related to management of the IVS and additional home treatment within the IVS, restrict the interpretation of the results. Therefore, the long-term impact of this IVS deserves further evaluation.

[What do Interpreters Cost? - A Retrospective Analysis of the Costs for Interpreters in Treatment of Refugees in a Psychiatric Outpatient Clinic in Berlin]. / Was kosten uns Dolmetscher? ­ Eine retrospektive Analyse der Dolmetscherkosten in der Behandlung von Flüchtlingen in einer Psychiatrischen Institutsambulanz in Berlin.

Clinical diagnostics of mental disorders especially among refugees and asylum seekers come with unique difficulties: language barriers, different forms of expression and concepts of the understanding of mental illness as well as a different cultural background. Therefore professional interpreters are needed but associated with a higher effort related to costs and time. We conducted a retrospective analysis of costs, which incurred by the use of professional interpreters in our outpatient clinic in Berlin, Germany, in the first quarter 2016 for the treatment of refugees and asylum seekers. The sample consisted of 110 refugees and asylum seekers; the highest costs in the use of interpreters incurred among Neurotic, stress-related and somatoform disorders (53.04%), especially Posttraumatic Stress Disorder (39.04%), as well as affective disorders (38.47%), especially major depressive episodes (25.23%). Our data point out the crucial need of a regulation of costs with regard to the service of professional interpreters in Germany.

Reorganization of mental health services: from institutional to community-based models of care.

Mental health services in the Eastern Mediterranean Region are predominantly centralized and institutionalized, relying on scarce specialist manpower. This creates a major treatment gap for patients with common and disabling mental disorders and places an unnecessary burden on the individual, their family and society. Six steps for reorganization of mental health services in the Region can be outlined: (1) integrate delivery of interventions for priority mental disorders into primary health care and existing priority programmes; (2) systematically strengthen the capacity of non-specialized health personnel for providing mental health care; (3) scale up community-based services (community outreach teams for defined catchment, supported residential facilities, supported employment and family support); (4) establish mental health services in general hospitals for outpatient and acute inpatient care; (5) progressively reduce the number of long-stay beds in mental hospitals through restricting new admissions; and (6) provide transitional/bridge funding over a period of time to scale up community-based services and downsize mental institutions in parallel.

[Satisfaction with an integrated care program for outpatients with schizophrenia or depression]. / Patientenzufriedenheit mit einem Programm der Integrierten Versorgung für die Indikationen Schizophrenie und Depression.

OBJECTIVE: To study out-patients' perception of an Integrated Care compliance program. METHODS: Survey of patients enrolled in the Integrated Care program "Münchner Modell" in Munich, Germany. RESULTS: N = 121 patients participated in the survey. Overall patients were very satisfied with the Integrated Care program. They reported improvements in several areas of life. CONCLUSION: The study highlights the aspects of routine patient care that still need to be improved and shows how these deficits can be addressed by Integrated Care programs.

Determinants of psychogeriatric inpatient length of stay and direct medical costs: a 6-year longitudinal study using a national database in Taiwan.

AIMS: This research examined factors related to the average length of hospital stay (LOS) and average direct medical costs (DMC) for 2291 psychogeriatric inpatients (aged 65 and over) admitted for the first time to a psychiatric ward in 2002. METHODS: Hospitalization claim data of these inpatients were traced for the subsequent 6 years (2002-2007) from the dataset of Taiwan's National Health Insurance program. Analysis was carried out using the t-test, χ(2) -test and zero truncated Tobit regression. RESULTS: Mean LOS and mean DMC were significantly different according to sex, psychiatric diagnosis, institution type, ownership type, and number of hospitalizations, but age was the exception. Both LOS and DMC exhibited downward U-shape for the number of hospitalizations. Factors significantly associated with longer LOS and higher DMC were: male sex; schizophrenic and delusional disorders (compared with dementia); and public institution (compared with private hospital). Compared with dementia, organic mental and anxiety disorders had significantly shorter LOS, and affective disorders had shorter LOS but higher DMC. Community and psychiatric hospitals (compared with general hospital) significantly influenced LOS but not DMC. CONCLUSION: Our results can be used as a reference for providers and policymakers to improve psychiatric care efficiency and carry out National Health Insurance financial reform for psychogeriatric inpatients.

History of psychiatry in Sweden during a millennium.

This report covers a millennium, from year 1000 when Sweden had only 0.4 million people until today's 9.4 million. In the 13th century, the first Swedish legal text about the mentally ill and the first hospital to treat them are documented. Control, care and cure of the ill have been shaped by social and cultural changes from time to time, e.g. King Gustav Vasa introduced a paradigm shift of care after the Reformation, when he altered Catholic buildings into state hospitals. He also ordered that medical texts should no longer be written in Latin but in Swedish. The first book dealing with mental illnesses was published in 1578. Laypersons ran the mental hospitals for centuries until the medical perspective and doctors were engaged in the 1800 s. To advance the hospital doctors' competence and skill, a Swedish Psychiatric Association was established in 1905. Severely psychotic patients could not be effectively treated until the introduction of chlorpromazine in the 1950s and there is still no cure available. Following the deinstitutionalization, from more than 35,000 beds 50 years ago down to about 4500 today, the request for outpatient treatment increased. Mandatory training in psychotherapies for all psychiatrists started in the 1970s. A major "psychiatry reform", with the hope of improving the situation for the mentally ill, and to reduce the stigma, was introduced in Sweden in 1995. The historic long-term effect of the reform cannot yet be fully evaluated.

Health care resource utilization and costs in a commercially insured population of patients with bipolar disorder type I and frequent psychiatric interventions.

BACKGROUND: Bipolar disorder type I (BP-I) is one of the most expensive behavioral diagnoses in the United States. Characterizing patient populations that consume significant resources would be useful for designing and implementing additional resources and targeted interventions to reduce the costs of BP-I. OBJECTIVE: This analysis compared the characteristics, health care resource utilization, and costs of commercially insured patients with BP-I (indicating a history of manic or mixed episodes) and frequent psychiatric interventions (FPIs) versus those without FPIs. METHODS: This retrospective study used data from commercial insurance claims to identify adults with FPIs (≥2 clinically significant events [CSEs]) or without FPIs during a 12-month identification period (year 1). CSEs included emergency department (ED) visits or hospitalizations with a principal diagnosis of BP-I, the addition of a new medication to the observed treatment regimen, or a ≥50% increase in BP-I medication dose. Demographic and clinical characteristics were evaluated during the identification period, and health care resource utilization and costs were evaluated during a 12-month follow-up period (year 2). RESULTS: Data from 7620 patients with FPIs and 11,571 without FPIs were included (women, 67.1% and 59.9%, respectively; P < 0.001). Of patients with FPIs in the identification period, 22.2% continued to have FPIs in the follow-up period. In the follow-up period, the group with FPIs had a greater proportion of patients with psychiatric-related inpatient hospitalizations (14.6% vs 2.8%) and ED visits (11.6% vs 2.7%) [corrected], a longer mean hospital length of stay (11.74% vs 8.24 days) [corrected], and greater adjusted mean psychiatric-related costs ($6617 vs $3276) and all-cause health care costs ($14,091 vs $9357) compared with the group without FPIs (all, P < 0.001). The risks for a psychiatric-related hospitalization and an ED visit during the follow-up period were significantly greater in the group with FPIs compared with the group without (odds ratios, 4.86 and 3.76, respectively; both, P < 0.01). CONCLUSIONS: In this retrospective analysis, FPIs were associated with a greater number of FPIs during follow-up, ∼2-fold the psychiatric-related costs, and 1.5-fold the all-cause health care costs compared with no FPIs. These data highlight the economic burden of FPIs and the potential for health care cost reductions from improved management options in these patients.

[Ambulatory aftercare of forensic patients after release]. / Ambulante Sicherungsnachsorge.

OBJECTIVE: The efficacy of specific forensic outpatient treatment should be investigated. METHODS: In 2000 the Ministry of Social Affairs of the State of Bavaria, Germany, implemented a model for forensic outpatient treatment. Three forensic hospitals established forensic outpatient clinics. The Department of Forensic Psychiatry of the Psychiatric Hospital of the Ludwig Maximilian University of Munich evaluated the treatment and management programs with financial support from the Ministry. RESULTS: 111 mentally ill offenders were included after release from forensic hospitals. 65 % suffered from schizophrenia. In 4.5 years time of observation a recidivism rate of 0.9 % of severe offences could be found (3.6 % including cases of suspicion). 17 % of the patients needed a rehospitalisation and 12 % a legal intervention. At the end of the observation period 42 patients still needed treatment, but 44 patients continued therapy in the forensic outpatient setting out of own interests. CONCLUSIONS: In accordance to literature very low rates of criminal recidivism under specific forensic outpatient aftercare could be found, and in addition a relatively high compliance with the treatment.

[Who gets how much psychiatric outpatient care and why?]. / Wer erhält wie viel Versorgung in der Institutsambulanz und warum?

AIMS: To elucidate the connections between individual aspects and patients' concerns and the care effort provided in a clinic for the sickest among outpatients. METHODS: Clients of one health insurer were followed for six months (n = 339) in a "Institutsambulanz" or "PIA". All treatment activities, which involved roughly 100,000 working minutes, were recorded. Sociodemographic data, the diagnoses, the individual needs and idiosyncracies, symptoms and case history were noted for multivariate analysis. RESULTS: The linear regression model with the best fit (n = 251, r (2) = 0.512, p < 0.001) included six variables. Lower efforts: living in nursing home (beta = - 0.319; p < 0.001), higher age (beta = - 0.238; p < 0.001), legal incapacity (beta = - 0.165, p = 0.006), own work income (beta = - 0.100; p = 0.044); higher efforts: inpatient stays prior to study treatment (lifetime: beta = 0.181; p = 0.001; number of days in last two years: beta = 0.193; p < 0.001). Treatment aims, functional deficits, and diagnoses did not have a significant influence. CONCLUSIONS: Younger patients who wish for an independent life despite of a grave psychiatric disorder may effectuate higher treatment efforts. Treatments administered to nursing-home inhabitants are far less complex, although these patients are even sicker. The current reimbursement mechanism may serve as a disincentive towards care administration according to individual need.

Desplazamiento y aislamiento. Alienados mentales en la ciudad de Medellín. 1878-1930 / Displacement and isolation. Mental illness in the city of Medellin. 1878-1930

La observación sobre la ciudad de Medellín en el contexto de la historia urbana, generó un sorprendente cuadro de temas sobre higiene y salud pública, entre los que encontramos el caso de los alienados mentales y los dispositivos de control propuestos por las autoridades civiles y los médicos. De 1880 hasta 1950 Medellín vivió el proceso de modernización, que la convirtió en polo de atracción de los desplazamientos de población al interior de la provincia de Antioquia. El Ferrocarril garantizó desde los pueblos vecinos la movilización masiva de población, entre la que llegaron no pocos alienados mentales. A finales del siglo XIX, las autoridades crearon la Casa de Alienados para dar asilo a estas personas, esta institución se convirtió a comienzos del siglo XX en Manicomio Departamental y a mediados del siglo XX en el Hospital Mental de Antioquia. El aislamiento de los locos da cuenta del comienzo del proceso de constitución e institucionalización del saber psicopatológico, de la autoridad médica y la medicalización de la demencia en Antioquia a comienzos del siglo XX (AU)

The observation in the city of Medellín within the framework of urban history generated a surprising picture of subjects in hygiene and public health, among which we found the case of mental illness and the control systems proposed by civilian authorities and doctors. In Medellín, between 1880 and 1950, the modernization process went on, turning its pole of attraction on population displacements to the interior of the province of Antioch. As a result of Railroad I, there was a massive mobility of population from the neighboring towns, including some mentally ill people. At the end of the 19th century, the authorities created a house of asylum for these people, which became the Mental Hospital in the middle of the 20th century. The isolation of the mentally ill people reports both medical authority and the beginning of the constitution process and institutionalization of the psychopathology and medicalization of mental diseases in Antioquia at the beginning of the 20th century (AU)

Do socio-economic factors, elderly population size and service development factors influence the development of specialist mental health programs for older people?

BACKGROUND: Despite the increase in the proportion of older people in the population, little is known about factors that facilitate the development of specialist mental health services for older people. METHODS: The relationship between the presence of specialist mental health programs for older people and elderly population size, proportion of older people in the population, gross national domestic product (GDP), and various parameters of health funding, mental health funding and mental health service provision was examined in an ecological study using data from the World Health Organization. RESULTS: The presence of specialist mental health programs for older people was significantly associated with higher GDP, higher expenditure on healthcare and mental healthcare, the presence of a national mental health policy and a national mental health program, the availability of mental health care in primary care and the community, and higher density of psychiatric beds, psychiatrists, psychiatric nurses, psychologists and social workers. CONCLUSION: The challenge will be to persuade policy-makers in low and medium income countries, where the increase in the elderly population is most rapid, to develop specialist mental health services for older people.

[Displacement and isolation. Mental illness in the city of Medellín. 1878-1930]. / Desplazamiento y aislamiento. Alienados mentales en la cuidad de Medellín. 1878-1930.

The observation in the city of Medellín within the framework of urban history generated a surprising picture of subjects in hygiene and public health, among which we found the case of mental illness and the control systems proposed by civilian authorities and doctors. In Medellín, between 1880 and 1950, the modernization process went on, turning its pole of attraction on population displacements to the interior of the province of Antioch. As a result of Railroad I, there was a massive mobility of population from the neighboring towns, including some mentally ill people. At the end of the 19th century, the authorities created a house of asylum for these people, which became the Mental Hospital in the middle of the 20th century. The isolation of the mentally ill people reports both medical authority and the beginning of the constitution process and institutionalization of the psychopathology and medicalization of mental disease in Antioquia at the beginning of the 20th century.

Against the grain? A reasoned argument for not closing a state hospital.

In the face of the Massachusetts Governor's attempts to close one of the state's four remaining state hospitals, Massachusetts legislators overrode the Governor's veto of funding for the hospital, but required the state's Mental Health Authority to author a study of the implications of further loss of public sector inpatient beds. The Center for Mental Health Services Research of the University of Massachusetts Medical School conducted its own study concluding that maintaining a longer-term inpatient capacity in the public sector in central Massachusetts was both necessary and accrued a significant number of benefits. This article can serve as a model for the reasoned position that a state hospital in 21st century psychiatry can be looked at as a multiservice center that fulfills a key role in a public sector, integrated system of treatment, care, training and research.

Cost-effectiveness of clozapine compared with conventional antipsychotic medication for patients in state hospitals.

BACKGROUND: An open-label, randomized controlled trial compared clozapine with physicians'-choice medications among long-term state hospital inpatients in Connecticut. The goal was to examine clozapine's cost-effectiveness in routine practice for people experiencing lengthy hospitalizations. METHODS: Long-stay patients with schizophrenia in a state hospital were randomly assigned to begin open-label clozapine (n = 138) or to continue receiving conventional antipsychotic medications (n = 89). We interviewed study participants every 4 months for 2 years to assess psychiatric symptoms and functional status, and we collected continuous measures of prescribed medications, service utilization, and other costs. We used both parametric and nonparametric techniques to examine changes in cost and parametric analyses to examine changes in effectiveness. We used bootstrap techniques to estimate incremental cost-effectiveness ratios and create cost-effectiveness acceptability curves. RESULTS: Both groups incurred similar costs during the 2-year study period, with a trend for clozapine to be less costly than usual care in the second study year. Clozapine was more effective than usual care on many but not all measures. With the use of effectiveness measures that favored clozapine (extrapyramidal side effects, disruptiveness), bootstrap techniques indicated that, even when a payer is unwilling to incur any additional cost for gains in effectiveness, the probability that clozapine is more cost-effective than usual care is at least 0.80. These findings were not as evident when outcomes where clozapine was not clearly superior (psychotic symptoms, weight gain) were examined. CONCLUSION: Clozapine demonstrated cost-effectiveness on some but not all measures of effectiveness when the alternative was a range of conventional antipsychotic medications.

Economic reforms and the acute inpatient care of patients with schizophrenia: the Chinese experience.

OBJECTIVE: This study compared insured and uninsured schizophrenic inpatients in China and examined changes in the acute inpatient care of schizophrenic patients during China's economic reform era. METHOD: Detailed chart reviews of 50 randomly selected inpatients discharged from a hospital in central China each year from 1984 through 1993 identified 321 patients with schizophrenia. Demographic, insurance, treatment, and cost data of these patients were collected from the charts. RESULTS: With logistic regression models to control for confounding variables, the analyses showed that the 129 insured patients were significantly more likely than the 192 uninsured patients to be urban residents, to be older, to have had 7 or more years of schooling, and to have had more psychiatric hospitalizations; moreover, their index admissions were longer and were more likely to include use of traditional Chinese medications. The estimated 19% of schizophrenic individuals in the community with health insurance receive inpatient treatment 2.8 times more frequently than the 81% without insurance. Compared to admissions in 1984-1988, admissions in 1989-1993 were significantly shorter and involved longer periods of polypharmacy with multiple antipsychotic medications but included lower mean chlorpromazine-equivalent doses of medication. The relative cost of inpatient care for an acute episode of schizophrenia increased 3.5-fold over the 10-year period, from 11% of mean annual household income in 1984 to 37% in 1993. CONCLUSIONS: Changes in the incentive system for care providers and rapid increases in the cost of care during the economic reform era have resulted in increasingly restricted availability of services for the many schizophrenic patients without health insurance.