Highly varying concepts and capacities of forensic mental health services across the European Union.

Introduction: There is wide variation in the processes, structures and treatment models for dealing with mentally disordered offenders across the European Union. There is a serious lack of data on population levels of need, national service capacities, or treatment outcome. This prevents us from comparing the different management and treatment approaches internationally and from identifying models of good practice and indeed what represents financial efficiency, in a sector that is universally needed. Methods: From March 2019 till January 2020 we surveyed forensic psychiatric experts from each European Union Member State on basic concepts, service capacities and indicators for the prevalence and incidence of various forensic psychiatric system components. Each expert completed a detailed questionnaire for their respective country using the best available data. Results: Finally, 22 EU Member States and Switzerland participated in the survey. Due to the frequent lack of a clear definition of what represented a forensic psychiatric bed, exact numbers on bed availability across specialized forensic hospitals or wards, general psychiatric hospitals or prison medical wards were often unknown or could only be estimated in a number of countries. Population-based rates calculated from the survey data suggested a highly variable pattern of forensic psychiatric provision across Europe, ranging from 0.9 forensic psychiatric beds per 100,000 population in Italy to 23.3 in Belgium. Other key service characteristics were similarly heterogeneous. Discussion: Our results show that systems for detaining and treating mentally disordered offenders are highly diverse across European Union Member States. Systems appear to have been designed and reformed with insufficient evidence. Service designers, managers and health care planners in this field lack the most basic of information to describe their systems and analyse their outcomes. As a basic, minimum standardized national reporting systems must be implemented to inform regular EU wide forensic psychiatry reports as a prerequisite to allow the evaluation and comparison of the various systems to identify models of best practice, effectiveness and efficiency.

Impact of new country, discrimination, and acculturation-related factors on depression and anxiety among ex-Soviet Jewish migrants: data from a population-based cross-national comparison study.

Migration, displacement, and flight are major worldwide phenomena and typically pose challenges to mental health. Therefore, migrants' mental health, and the factors which may predict it, have become an important research subject. The present population-based cross-national comparison study explores symptoms of depression, anxiety, and somatization, as well as quality-of-life in samples of ex-Soviet Jewish migrants settling in three new countries: Germany, Austria and Israel, as well as in a sample of non-migrant ex-Soviet Jews in their country of origin, Russia. In the current study, we investigate the relationship of perceived xenophobiа and antisemitism, acculturation attitudes, ethnic and national identity, as well as affiliation with Jewish religion and culture to the psychological well-being of these migrants. Furthermore, we consider xenophobic and antisemitic attitudes as well as the acculturation orientation of the new countries' societies, assessed in the native control samples. Our data suggest that attitudes of the new country's society matter for the mental health of this migrant group. We conclude that the level of distress among ex-Soviet Jewish migrants seems to depend, among other factors, on the characteristics of the new country and/or specific interactions of the migrant population with the society they are settling in.

Religiosity, perceived anti-Semitism, xenophobia and mental health: Experiences of Jewish immigrants from the former Soviet Union in Austria and Germany.

Research about the relation between migration and mental health as well as factors influencing the mental health of migrants has been growing because challenges of migration can constitute a significant mental health burden. However, its divergent findings seem to reflect group-specific differences, e.g., regarding country of origin and receiving country. Almost no empirical studies about individual migrant groups in different receiving countries have been undertaken so far. The present population-based study explores symptoms of depression, anxiety, and somatization as well as quality of life in an Austrian and a German sample of ex-Soviet Jewish migrants. We mainly investigate the relationship of religiosity and perceived xenophobic and anti-Semitic discrimination to the psychological condition of the migrants. Standardized self-report scales, specifically the Beck-Depression-Inventory-II (BDI), State-Trait-Anxiety-Inventory (STAI), Brief Symptom Inventory (BSI), and WHO Quality of Life Questionnaire (WHOQOL-BREF), were used to measure mental health. Ex-Soviet Jewish migrants in Austria showed significantly more symptoms of depression than those in Germany. Regression analyses support a protective effect of religiosity on mental health in the sample in Germany and an adverse effect of perceived discrimination in the sample in Austria. The present study reveals a less favorable situation for ex-Soviet Jewish migrants in Austria, in terms of income, residence status, and xenophobic attitudes in the local population, compared to the group in Germany. Furthermore, our data suggest that the receiving country matters for the mental health of this migrant group. However, further research is needed to support these conclusions.

Patterns of Substance Abuse in Offenders With Schizophrenia- Illness-Related or Criminal Life-Style?

Objective: The impact of substance abuse on violent behavior in patients suffering from schizophrenia is well-known. However, the association between the pattern of substance abuse and certain aspects of criminal behavior like the severity of offense, the previous history of violence and the age at onset of the criminal career is still unclear. Method: To assess the relationship between substance abuse, schizophrenia and violent behavior we examined healthy non-offenders; healthy offenders; non-offenders suffering from schizophrenia; and offenders suffering from schizophrenia, with respect to different patterns of substance abuse (none, alcohol only, illicit drugs only, and multiple substances). Results: Healthy offenders as well as offenders and non-offenders suffering from schizophrenia are characterized by increased rates of alcohol and illicit drug abuse. Especially multiple substance abuse appears to lower the threshold of aggression and illegal behavior. This effect is more pronounced in subjects suffering from schizophrenia. In both offender groups the abuse of psychoactive substances is associated with an earlier onset of the criminal career, but has no impact on the severity of the offenses. Conclusion: Our results point to the need for a differentiated view on the contribution of substance abuse to the criminality of subjects suffering from schizophrenia.

[Mental health, acculturation and religiosity in Jewish migrants from the former Soviet Union in Austria]. / Psychische Gesundheit, Akkulturation und Religiosität bei jüdischen Migranten aus der ehemaligen Sowjetunion in Österreich.

BACKGROUND: Research on migration provides controversial findings regarding the links between mental health and migration as well as the factors influencing the mental health of migrants. Even though there is evidence for differences between migrant groups from different countries of origin, almost no empirical studies about individual migrant groups in Austria have been undertaken so far. METHODS: In the present population-based study we compared depression and anxiety of 96 ex-Soviet Jews to a sample of 101 Austrians matched by age and sex. Furthermore, we investigated the impact of acculturation attitude and religiosity on the psychological condition of the migrants. Depression and anxiety were measured with Beck-Depression-Inventory (BDI), State-Trait-Anxiety-Inventory (STAI) and Brief Symptom Inventory (BSI). Acculturation attitude was assessed with Vancouver Index of Acculturation (VIA) and religiosity with a self-developed scale. RESULTS: Ex-Soviet Jews were significantly more depressed and more anxious than native Austrians but not more likely to be affected by clinical depression. Integration (i.e. interest in both the original and the receiving society's culture) as an acculturation strategy was associated with the lowest mental health burden. Religiosity had a protective effect against depression but not against anxiety. CONCLUSION: The present study allows initial insights into the mental health of a migrant group which has hardly been subject to research, and it indicates a need for a greater opening of the Austrian majority population to migrants.

[Alcohol- and substance abuse among mentally ill patients with migration background in Austria]. / Alkohol- und Drogenmissbrauch bei psychisch kranken PatientInnen mit Migrationshintergrund in Österreich.

The refugee movements of the recent years are confronting the health care with new challenges. However, it has turned out that in Austria data on the mental health of migrants are nearly not available. Especially data on the frequency and patterns of comorbid substance abuse of migrants with mental disorders do not exist even from international studies. We analyzed data from 1819 patients (1726 first generation, 93 second generation) treated in the outpatient clinic for transcultural psychiatry and migration related disorders at the Vienna General Hospital: In first-generation migrants the cultural and religious background of the region of origin has the greatest impact on the frequency and the patterns of misused substances. In second-generation migrants the consumer habits approximate to those of the majority of the society. The primary diagnosis plays a minor role. Only patients with personality disorders exhibit higher rates of illicit substance compared with other diagnoses.

[Unemployment, suicide- and homicide-rates in the EU countries]. / Arbeitslosigkeit, Suizid- und Tötungsraten in den EU-Staaten.

BACKGROUND: While the link between the unemployment and the national suicide rates is confirmed by various studies, there are few investigations on the impact of unemployment on homicide rates. In particular, it is not known whether suicide and homicide are associated with the same socio-economic factors. METHODS: Using linear regression method, the influence of unemployment rates, per capita incomes and annual alcohol consumption on suicide and homicide rates was examined in the 27 EU states. RESULTS: We found a positive correlation between suicide and homicide rates. Unemployment among men is a strong predictor not only for suicide- but also for homicide rates. Suicide rates in men are also affected by the annual alcohol consumption. The suicide rates in women, however, correlate neither with socio-economic variables nor with alcohol consumption. CONCLUSIONS: Unemployment seems to have a stronger impact on the male than on the female identity. Since the former is still highly dependent on predetermined social roles.

[The Cotard syndrome in schizophrenic disorders]. / Das Cotard-Syndrom bei schizophrenen Erkrankungen.

BACKGROUND: The Cotard-Syndrome (CS), the belief of being dead, was described for the first time in 1880. Since then it met the interest not only of psychopathologists but also of philosophers. With a few exceptions, the literature is mainly restricted to case reports of anxious-depressive, demented or paranoid patients. It was the aim of our study to investigate the prevalence and the psychopathological context of the CS. METHODS: We analyzed the Austrian data (N = 346) of the International Study of Psychotic Symptoms in Schizophrenia. RESULTS: A CS could be diagnosed in three cases (0.87%). In all of them, CS developed on the basis of nihilistic-hypochondriac delusions and a progressive loss of energy. Two patients bridged the logical inconsistencies between obviously being alive and the belief of being dead by visual illusions, the third patient, however, by locating himself in an intermediate region between this world and the afterworld. CONCLUSIONS: On the one hand the CS can be considered as a special manifestation of the topic of death in schizophrenic delusions, on the other as a nihilistic delusional identity. Without doubt, this uncommon and bizarre psychotic phenomenon will be an object of interest for general psychopathology as well as for the philosophy of mind also in future.

[The traces of violence: Suicide and homicide rates in the former Bloodlands]. / Die Spuren der Gewalt: Suizid- und Homizidraten in den ehemaligen Bloodlands.

BACKGROUND: Suicide and homicide rates are the ultimate expressions of violence. The rates are globally almost distributed mirror-reverted. Rich, modern democratic countries with a functioning legal system have high suicide and low homicide rates, traditional states with a weak central government high homicide and low suicide rates. Exceptions are some Eastern European countries, in which both, the rates of homicide and suicide are very high. These states are located on the territory of the former Bloodlands (Snyder, Bloodlands: Europa zwischen Hitler und Stalin, 2011), where between 1930 and 1945 14 million people were civilian victims of the Soviets and the National Socialists. We addressed the question of whether these eight countries (Poland, Lithuania, Estonia, Latvia, Moldova, Belarus, Russia and Ukraine) differ from the other European countries of the former East bloc, from the Asian countries of the former USSR and the Western European countries in social, economic and psychosocial factors. METHODS: The data used for analyses were taken of various data sets from the WHO, the UN and the CIA. The statistical comparison of the four regions was carried out by nonparametric tests. RESULTS: The States on the grounds of the former Bloodlands and the other European countries of the former East bloc are comparable concerning important social and economic parameters such as level of modernization, Democracy-index and Rule of Law-Index. Statistically significant differences were found only in the annual alcohol consumption per capita and the divorce rates. CONCLUSIONS: We hypothesize that the high suicide and homicide rates in some Eastern European countries may be the result of the traumatic experience of extreme violence of nearly the entire population between 1930 and 1945. Possible paths of the transgenerational transmission as well as conceivable chains of causality between the trauma in the first generation and suicidal or homicidal behavior in the following generations are presented.

[Religion and suicide - part 1: the attitudes of religions towards suicide]. / Religion und Selbsttötung - teil 1: die Einstellungen der Religionen zum Suizid.

OBJECTIVE: While suicide is known in all human societies, national suicide rates vary to a high degree. Different interacting social, economic and biological factors may explain a part of the variance. Religions are supposed to have a protective effect against suicidal behavior. It is still unexplained, whether or not this holds true for all religions and whether this has an effect on the national suicide rates. For this purpose it is necessary to illustrate the positions of the single religions towards suicide in the context of their idea of a human being as well as their concepts of death and afterworld. METHOD: Our considerations are based upon a research on the religious- and culture-historical literature on this topic. RESULTS: None of the world religions argues for suicide, however, the degree of refusal is varying. Mosaic religions (Judaism, Christianity, Islam), which are based on the idea of a human being as the image of God, have a more pronounced position against suicide than Eastern religions with a concept of transmigration and rebirth. Atheistic positions, which are not attached to transcendent norms, show a broad range of opinions from radical refusal to cautious approval. CONCLUSIONS: The positions of the different religions towards suicide are leading to assumptions of their effect on national suicide rates that have to be tested empirically.

[Religion and suicide - part 2: confessions, religiousness, secularisation and national suicide rates]. / Religion und Selbsttötung - teil 2 Konfessionen, Säkularisierung, Religiosität und die Nationalen Suizidraten.

OBJECTIVE: National suicide rates differ remarkably. The influence of religion on the frequency of suicides was already stressed by Durkheim, however, character and dimension of this influence are still unclear. Our study claims to assess the association between (a) the distribution of believers of different religions, (b) the secularization, (c) the religiousness and the national suicide rates by gender. METHOD: Data of the distribution of religious confessions and of the religiousness of the inhabitants of the single countries were correlated with the national suicide rates and illustrated by means of Scatter/Dot-Plots. RESULTS: Independent of gender, low suicide rates were found in Islamic countries. Buddhist countries showed high suicide rates in women, and countries with a high percentage of inhabitants without confession high suicide rates in men. Only catholic countries showed an association between secularisation and suicide rates. In countries with a high proportion of religious inhabitants we found low suicide rates. CONCLUSIONS: Although none of the World religions support the human right of suicide, the mosaic religions of resurrection refuse suicide more strictly than the Eastern religions of reincarnation. All in all our study supports the hypothesis that religiousness can be seen as a protective factor against suicide.

[Psychopharmocotherapy of schizophrenia in forensic and general psychiatry]. / Psychopharmakatherapie der Schizophrenie in der forensischen und in der Allgemeinpsychiatrie.

OBJECTIVE: In general psychiatry, the treatment of schizophrenic psychoses is focused on the reduction of symptoms, the improvement of quality of life and the recovery of the capacity to work. In forensic psychiatry, a further major targets is the reduction of aggressive behavior - not least by the establishment of a stable adherence to medication. It is unclear until now, whether this leads to different psychopharmacological treatment strategies. METHOD: The study includes 91 patients from the Psychiatric University Clinic Vienna (PUC) and 116 patients from the Justizanstalt Göllersdorf (JAGÖ), Austrian's central institution for the treatment of mentally disordered offenders not guilty by reason of insanity. We compared dosage, way of administration (oral, depot) and additional other medication. For both groups the chlorpromazine-equivalents were calculated. Additionally, combinations of different antipsychotic drugs and those of antipsychotics with medication of other substance classes (antidepressants, mood-stabilizers, benzodiazepines, anticholinergics) were compared. RESULTS: Forensic patients were statistically significantly more often treated with intramuscular long-acting antipsychotics (LAI). Surprisingly, the total chlorpromazine-equivalents did not differ between the groups. Combinations of two or more antipsychotics were common in both groups, in the JAGÖ frequently as a combination of a first generation depot antipsychotic drug (FGA) with oral second genera tion antipsychotics (SGA), in the PUC more as often a combination of two or more oral SGA. Antidepressants and benzodiazepines were more frequently prescribed in the PUC, anticholinergics in the JAGÖ. CONCLUSION: Patients suffering from schizophrenia are often non-compliant to medication. As nonadherence is a strong predictor for criminal offences, LAI-formulations are an important treatment tool in forensic psychiatry. This does not result in higher dosages. The high rates of polypharmacy in both groups emphasizes the well known problem that therapeutic guidelines based on studies in highly selected samples are often not transferable into everyday clinical practice.

Culture and the prevalence of hallucinations in schizophrenia.

OBJECTIVE: Besides demographic, clinical, familial, and biographical factors, culture and ethnicity may plausibly influence the manifestation of hallucinations. The purpose of this study was to investigate the influence of culture on the frequency of different kinds of hallucinations in schizophrenia. METHOD: Patients with a clinical diagnosis of schizophrenia were diagnosed by means of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Seven independent samples were consecutively recruited in Austria, Lithuania, Poland, Georgia, Ghana, Nigeria, and Pakistan using identical inclusion/exclusion criteria and assessment procedures (N = 1080 patients total). The association of key demographic factors (sex and age), clinical factors (age at onset and duration of illness), and country of origin with hallucinations of different kinds was examined. RESULTS: The prevalence of various kinds of hallucinations was substantially different in the samples; however, the rank order of their occurrence was similar. Auditory hallucinations were relatively infrequent in Austria and Georgia and more prevalent in patients with an early age at onset of disease. Visual hallucinations were more frequently reported by the West African patients compared with subjects from the other 5 countries. Cenesthetic hallucinations were most prevalent in Ghana and in patients with a long duration of illness. CONCLUSION: We hypothesize that the prevalence of the different kinds of hallucinations in schizophrenia is the result of the interaction of a variety of factors like cultural patterns as well as clinical parameters. According to our study, culture seems to play a decisive role and should be taken into account to a greater extent in considerations concerning the pathogenesis of psychotic symptoms.

WPA guidance on mental health and mental health care in migrants.

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.

Psychosocial background in incarcerated adolescents from Austria, Turkey and former Yugoslavia.

Adolescents with a migration background account for a substantial proportion of juveniles in custody. Psychosocial adversities pose a significant risk for criminal behaviour. So far, the nature of psychosocial adversities experienced by migrant youth is understudied. The aim of this study was to explore differences in psychosocial background in three ethnic groups (Turkish, former-Yugoslavian and Austrian) of detained juveniles in Austria. A semi-structured interview (Multidimensional Clinical Screening Inventory for delinquent juveniles, MCSI) was used to assess psychosocial background (e.g., trauma, family background, forensic and psychiatric family history, school history, psychiatric treatment received and criminal history) in juveniles entering an Austrian pre-trial detention facility. Of the 370 eligible participants, the final study sample consisted of 278 juveniles. The ethnic distribution was as follows: 55.4% Austrian (mean age 16.88 years, S.D.=1.52), 14% Turkish (mean age 16.28 years, S.D.=1.23), 30.6% former-Yugoslavian (mean age 16.47 years, S.D.=1.41). In the Austrian sample, family dysfunction was significantly more prevalent than in the Turkish or former-Yugoslavian samples. Mental health services were significantly less used by juveniles with migration background. Turkish juveniles had a significantly poorer school performance than Austrians. Juveniles from former-Yugoslavia had significantly less often attended schools offering secondary education. The results suggest that detained juveniles with migration background are poorly integrated into the educational and mental health system of the host society. Family systems, even if substantially dysfunctional, seem to be perceived as more stable by migrant youth than by Austrian youth.

[Etiological illness concepts in patients suffering from schizophrenia from Austria and Pakistan with special consideration of the gender aspect]. / Krankheitsmodelle bei PatientInnen mit Schizophrenie in Pakistan und in Österreich unter besonderer Berücksichtigung von Genderaspekten.

OBJECTIVE: Etiological illness concepts of patients with schizophrenia are an important factor for the drug compliance as well as for a successful psychotherapeutic approach. These cognitive representations are influenced by issues like the illness, culture, gender, and age. The aim of this study was the elaboration of the interaction of these factors with special consideration of the gender aspect. METHOD: The notions about the reasons of illness were explored by means of a 41-item standardized self-rating instrument in 240 patients suffering from schizophrenia from Pakistan and Austria. RESULTS: Only in the scale "conflicts" the mean values for Austrian women were statistically significant higher than for their male counterparts. In Pakistani patients we found no significant differences, patients with an early age at onset of illness more frequently reported a magic-religious explanatory model in both cultures. Austrian patients with a longer duration of illness believed more often that the outbreak of the illness was caused by negligent behaviour. CONCLUSION: While gender has important effects on course and outcome of schizophrenia, the influence on etiological illness concepts is rather weak. Two reasons can be postulated: (a) The acquirement of knowledge about the development of mental disorders is culture-specific, but not gender-specific, (b) psychotic disorders are even out originally existing gender differences.

[Increasing criminality in patients with schizophrenia: fiction, logical consequence or avoidable side effect of the mental health reforms?]. / Steigende Kriminalität schizophrener Patienten: Fiktion, logische Konsequenz oder vermeidbare Folge der Psychiatriereformen?

OBJECTIVE: The reforms of general mental health care aimed at a substantial improvement of the situation of the mentally ill. We examined the question of a possible association between the mental health reforms and the steady increase of the population of forensic mental hospitals becoming apparent since the introduction of community psychiatry. RESULTS: All recent publications report a moderate albeit statistically significantly increased risk of criminality in patients suffering from schizophrenia, which becomes more obvious in severe, violent offences. In homicide it comes up to the 10-fold of that of the general population. Comorbid substance abuse has a substantial impact on the extent of illegal behaviour, however, even under consideration of alcohol abuse the risk of homicide amounts to about the 7-fold of that of the general population. Nearly all European countries give account on a remarkable increase of the incidence and prevalence rates of mentally disordered offenders. Patients suffering from schizophrenia are disproportionately affected by this development. However, the substantially increased risk of homicide in schizophrenic patients, reported already in the pre-reform era, remained stable over time. Accordingly, the rate of patients admitted to forensic-psychiatric treatment because of offences of minor severity is on the rise. CONCLUSION: This development cannot be explained by single details of the mental health reforms, which show remarkable regional differences concerning numbers of mental hospital beds, ways of service provision, legal preconditions and rates of criminality and substance abuse. Rather, national and international data suggest changes of general societal attitudes to be the crucial factor. They have resulted in changes concerning the self-understanding of the representatives of modern mental healthcare. As aggressive behaviour is not integrated in the understanding of schizophrenia of present-day psychiatry, the objective needs of a subgroup of severely and chronically ill psychotic patients with high rates of comorbid substance abuse, lack of insight and compliance are increasingly neglected. The denial of these facts promotes the shift of 'difficult-to-treat patients' into forensic-psychiatric facilities and damages the reputation of psychiatry.

Delusions of persecution and poisoning in patients with schizophrenia: sociocultural and religious background.

This article presents data on the phenomenology of delusions of persecution and poisoning in patients with schizophrenia and determines parallels between sociodemographic status and personal religiosity and this type of delusions. We have studied the content of delusions in patients with schizophrenia looking for persecution and poisoning themes using Fragebogen fuer psychotische Symptome (FPS). A total of 295 patients suffering from schizophrenia participated in this study; 74.7% reported delusions of persecution. The proportion of female patients (81.9%) who felt persecuted was almost one-third higher than the proportion of male patients (66.9%). The prevalence of delusions of persecution was lower in the group of persons for whom their faith was personally important (73.4%) than in the atheistic group (86.7%). Delusions of persecution and poisoning were strongly intercorrelated. Delusions of poisoning were reported by 57.8% of respondents: 54.8% by male and 60.6% by female patients. In multivariate analysis, delusions of persecution were more prevalent in women compared to men; in those with a chronic course of illness compared to those with periodic course; in those with small size of family compared to those with large family. The presence of delusions of being poisoned was related to older age of the patient, higher than secondary education, chronic course of schizophrenia, and younger parental age. Personal importance of the faith was not associated with prevalence of delusions of persecution and poisoning in patients with schizophrenia.

[Is our clinical practice of antipsychotic relapse prevention in schizophrenia really evidence-based]. / Ist unsere Praxis der medikamentösen Rückfallprophylaxe bei Schizophrenen Psychosen wirklich evidenzbasiert?

UNLABELLED: OBJECTIVE, METHODS: Relapse prevention is one of the central issues in the treatment of schizophrenic psychoses. The paper gives an overview of the current literature on medication adherence with special regard to 2nd generation antipsychotics and long-acting agents and describes the practical consequences for clinical routine. Additionally, it examines whether or not everyday practice is consistent with our actual scientific knowledge. RESULTS: Even in shortterm trials, medication adherence in patients with schizophrenia comes up to merely 50%. The negative consequences of medication non-adherence are substantial. This concerns the rates of relapse and readmission, morbidity and mortality, - in particular suicide -, as well as the economic burden of society. Consequent antipsychotic treatment is associated with significantly better outcomes in all dimensions. In this regard, longacting agents are unequivocally superior to oral antipsychotics - even to atypical ones. These facts conflict with clinical routine, where long-acting antipsychotic agents are scarcely used. CONCLUSIONS: Based on current scientific knowledge, the major objections raised against the application of long-acting agents can be refuted: 1) 2nd generation antipsychotics do not improve medication adherence. 2) Concerns that long-acting agents conflict with the autonomy of a patient neglect the loss of autonomy and self-determination in case of a psychotic relapse. 3) The assertion that the patients do not accept depot injections is simply untrue. Rather, it is the psychiatrists who have their (maybe primarily emotionally-based) reservations. In summary, the use of depot antipsychotics has important advantages in facilitating relapse prevention and should be considered for every patient for whom long-term antipsychotic treatment is indicated.