Naturalistic pharmacotherapy of acute episodes of schizophrenic disorders in comparison to treatment guidelines.

INTRODUCTION: This study was designed to investigate to what extent guidelines regarding the pharmacological treatment of patients suffering from schizophrenia-like psychosis are adopted in a naturalistic treatment setting. METHODS: Medical records of n=819 patients undergoing inpatient treatment for schizophrenia-like psychosis in 11 psychiatric hospitals in northwestern Germany were retrospectively analyzed and findings were compared to current schizophrenia guideline recommendations. RESULTS: The prescription rate of second generation antipsychotics increased from 47.1% on admission to 62.5% at discharge. Only half the patients (52.3%) received antipsychotic monotherapy while 47.7% took between 2 and 4 antipsychotic substances at a time. Dosage increases occurred most frequently (in 60%) within the first week of inpatient treatment, 16.6% experienced an elevation between days 15 and 29. A change within the atypical medication was found in 19.3%. Clozapine prescriptions increased throughout the treatment but were combined with other antipsychotic substances in the majority of cases. CONCLUSION: Under naturalistic conditions guideline recommendations for treatment of schizophrenia-like psychosis are adhered to only partially. Combination therapy with 2 or more antipsychotic drugs is quite common despite a clear recommendation for monotherapy.

Galantamine: a cholinergic patch in the treatment of alcoholism: a randomized, placebo-controlled trial.

OBJECTIVES: The involvement of the central cholinergic system in alcohol abuse behavior is well known. It is possible that the reinforcing effects of ethanol are partially mediated by nicotinic receptors, which modulate neurotransmitter release. It was demonstrated that the application of a cholinesterase inhibitor reduces alcohol consumption in alcohol-preferring rats. This suggests that galantamine (GAL), a cholinesterase inhibitor, could be effective when seeking to prolong abstinence in recently detoxified alcoholics. This study represents the first reported clinical trial of a cholinergic drug in alcohol-relapse prevention. PATIENTS AND METHODS: We investigated the efficacy and safety of GAL by conducting a 24-week randomized, placebo-controlled, multicentric clinical trial on 149 recently detoxified alcoholics. Survival analyses (Kaplan-Meier) were performed to reveal evidence of prolonged abstinence periods in patients who received GAL. RESULTS: Our findings did not support our hypothesis. GAL did not extend the time to first severe relapse. However, additional post hoc analyses suggest that relapsed patients treated with GAL consume less ethanol per drinking day than patients treated with placebo. CONCLUSIONS: GAL seems to be ineffective when used in relapse prevention of detoxified alcoholics. It is possible that alcohol needs to be "on board" for GAL to be beneficial. This could explain why our post hoc analysis showed that GAL possibly reduces the alcohol consumption of relapsers. If confirmed, GAL could play a role in the reduction of harmful alcohol use and at-risk consumption.

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

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

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

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

[Music therapy evaluated by schizophrenic patients]. / Musiktherapie im Urteil schizophrener Patienten.

Music therapy is presented as an integral part of the therapeutic program of an open reception ward at a state-funded psychiatric hospital. The target group for music therapy comprises schizophrenic patients whose primary psychopathological symptoms are characterized by basic disorders, autistic withdrawal, anergia and limited means of verbal communication. A sample of 30 schizophrenic patients selected for music therapy is described. The subjective evaluation and rating of the music therapy was registered using a specially developed questionnaire. The primary results are: 1. Music therapy has a high level of subjective acceptance among patients. 2. No negative effects are recorded despite the therapy being introduced in the post-acute phase. 3. The positive therapeutic effects quoted are relaxation, activation, reduced anxiety, easier contact-making, and improved opportunities for emotional expression. The duration of the effects is limited. 4. The training-related concept and the clearly structuring behavior of the group leader are given a positive rating by the patients.

[Psychiatric vocational therapy--concepts, practice and scientifically-based results]. / Psychiatrische Arbeitstherapie--Konzepte, Praxis und wissenschaftliche Ergebnisse.

Work therapy is a widespread form of socio-therapy. In contrast to pharmacological and somatic forms of treatment, proof of efficacy is difficult to produce in multimodal therapy of psychiatric patients. Within the framework of an extensive study on vocational rehabilitation of mentally ill patients, we carried out a naturalistic follow-up study of 112 mostly schizophrenic patients attending outpatient work therapy programmes. The courses of illness and rehabilitation were documented prospectively over a three-year period. At the end of the study 23% of the patients were integrated into the open labour market, 25% were working in sheltered employment, 25% remained in work therapy, and 27% were unemployed. Controlled studies with schizophrenic patients show, that work therapy contributes to improved vocational integration, a reduction of rehospitalizations and a stabilisation of the psychopathological status.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Prevalence of psychiatric disorders and outcome of social integration of homeless men]. / Prävalenz psychischer Störungen und Verlauf der sozialen Integration bei wohnungslosen Männern.

All 52 regular users of a shelter in a medium-sized German city underwent a baseline psychiatric examination in 1990. Mental disorders, especially alcohol addiction and schizophrenic disorders, were recorded among 40 (77%). After four years the residential situation and the number and duration of psychiatric hospitalisations was recorded for 42 of these men. 33 of them mentally ill and 9 with no mental disorders. The four-year follow-up revealed that half the mentally ill men were still living in a homeless environment or had died, whereas most users with no mental disorder had a home of their own again. Longer-term hospitalisation or guardianship was found to have a favourable impact on social integration of the homeless mentally ill. Although psychiatric help without the consent of those concerned cannot solve the social problem of homelessness, it can often improve the living situation of homeless mentally ill patients.

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

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

[Perspectives in the vocational rehabilitation of the mentally ill and disabled--an overview of the current status and problems in the region of Westphalia]. / Perspektiven der Arbeitsrehabilitation psychisch Kranker und Behinderter--ein Uberblick über den Stand und die Probleme im Landesteil Westfalen.

The number of persons suffering from chronic mental disease but living outside the psychiatric hospital in the community, is rising, resulting in an increasing demand for facilities for occupation, occupational therapy and rehabilitation and for paid employment. The past few years have seen a distinct increase in the number of sheltered workplaces for the mentally ill. This development has also led to qualitative differentiation in the offers. In the region of Westphalia there are currently some 940 work places in special departments for the mentally handicapped at workshops for the disabled. Self-help enterprises and those offering opportunities for persons living on social benefits or pensions to supplement their income currently offer some 470 workplaces for the mentally ill, ten psychiatric hospitals are giving their former patients an opportunity to take part in occupational therapy as outpatients. Considerable differences are to be registered with regard to the offers of work, the forms of organization, the tasks involved and the types of supervision. Finally, a specialized psychosocial service has been established within the past four years by the head welfare office of the Landschaftsverband Westfalen-Lippe; this service is designed for the care of the mentally ill at their work place. Like many developments in social psychiatry, the differentiation of occupational rehabilitation has resulted from practical experience. Empirical findings on the indication for and efficiency of individual measures are virtually non-existent. A prospective five-year study is planned to investigate further results.