[Personnel assessment in psychiatry and psychotherapy : Results of a feasibility study on the platform model]. / Personalbemessung in der Psychiatrie und Psychotherapie : Ergebnisse einer Machbarkeitsstudie zum Plattform-Modell.

The topic of personnel assessment in psychiatry, psychotherapy and psychosomatics is currently of great importance in terms of health policy. Sufficient empirical evidence for the development of a comprehensive system for staffing is not yet available. The platform model developed by the psychiatric psychosomatic societies and associations pursues a combined empirical normative approach for a future-oriented assessment instrument for the various professional groups. The concept presented has been proven in the health policy discussion as a sensible system of comprehensive personnel assessment; however, an empirically sound control is still lacking as to whether this system can be used practically for the task described and thus can withstand the task of a resilient and future-proof measurement instrument for the necessary personnel. The task of the present study was to examine the extent to which the assumptions of the platform model are confirmed, whether methodological indications can be identified and whether there are limitations of the study that can be used in the validation and foundation of the model. The study confirmed the feasibility of the model and refers to a number of methodological findings and limitations that can be used for the further development of the model. The developed model allows the necessary staffing to be derived and justified, regardless of diagnoses and settings. It is future-oriented and dynamic.

[After the reform is before the reform : Results of the amendment processes of mental health law in German federal states]. / Nach der Reform ist vor der Reform : Ergebnisse der Novellierungsprozesse der Psychisch-Kranken-Hilfe-Gesetze der Bundesländer.

BACKGROUND: On the basis of mental health law, which differs between the federal states in Germany, courts can order the involuntary commitment of people with severe mental disorders in psychiatric hospitals, if they present a danger to themselves or to others. Due to decisions of the highest courts, these laws have been subject to revision since 2011. The aim of this paper is to analyze and compare the results of the revision processes in order to define the need for action for federal and state legislature. MATERIAL AND METHODS: Research of the current status of the revision processes in the federal states and a comparative analysis. The state laws were compared on the basis of selected particularly relevant areas with respect to human rights and treatment. RESULTS: In spite of the revisions the state laws are extremely heterogeneous and in many states do not fully comply with the requirements of the United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD) or the highest courts' decisions. CONCLUSION: The state laws should be harmonized, particularly where they restrict basic and human rights, e. g. regarding prerequisites and objectives of involuntary commitment and coercive measures.

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

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

[DGPPN recommendations on quality indicators for schizophrenia]. / Aktuelle Empfehlungen der DGPPN für Schizophrenie-Qualitätsindikatoren.

BACKGROUND: In Germany, several quality indicators have been proposed for the measurement of quality of mental healthcare. Some of these quality indicators have been tested in feasibility studies. The German Association for Psychiatry and Psychotherapy (DGPPN) established the "Task Force Quality Indicators (QI)" that, based on previous experience in the development and pilot testing of indicators, considered the further development and practical realization of QI for schizophrenia. AIM: The aim was to select a set of QI for schizophrenia that can also be applied to other diagnoses or used in generic measurements. Another goal was to focus on high feasibility of indicators. METHODS: In a multistage selection process, the DGPPN Task Force selected QI that focus on essential quality aspects from an inventory of 161 existing QI developed by national and international research groups. Indicators were adapted in consultation with the "trialogic forum" of the DGPPN. RESULTS: The DGPPN proposes the following ten indicators for quality measurement in mental healthcare for schizophrenia: QI1 Long-term treatment/Monitoring of side effects, QI2 Seclusion and restraint, QI3 Number of suicides, QI4 Psychoeducational-oriented intervention for significant others, QI5 Timely beginning of outpatient treatment after discharge from inpatient treatment, QI6 Aggression management - inpatient treatment, QI7 Diagnostic procedures/Physical examination, QI8 Antipsychotic polypharmacy, QI9 Rehabilitation/Vocational rehabilitation, QI10 Diagnostic procedures/Psychosocial functioning. DISCUSSION: Most of our proposed QI have to be measured by means of additional data documentation. Based on prior experience in the pilot testing of QI, the DGPPN estimates that the additional efforts in data documentation would be manageable, but have to be refinanced. The indicators will be tested in feasibility studies in different mental healthcare hospitals in Germany.

[Coercive measures in German hospitals for psychiatry and psychotherapy : A pilot study by the DGPPN to evaluate a uniform assessment instrument]. / Zwangsmaßnahmen in deutschen Kliniken für Psychiatrie und Psychotherapie : Eine Pilotstudie der DGPPN zur Erprobung eines einheitlichen Erfassungsinstrumentes.

STUDY OBJECTIVE: A simple instrument to record case-related coercive measures was tested as part of a pilot project of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN). METHODS: To assess coercive measures data were collected for 3 months in 8 German hospitals for psychiatry and psychotherapy. The type of measures used, the main diagnosis and the legal basis for the coercive measures were documented. RESULTS: In the sample studied, coercive measures were applied in 8% of cases. Coercive measures were most commonly used in patients with a schizophrenic disorder. The principle of justifiable necessity according to § 34 of the German Penal Code was used particularly often as the legal basis for justifying the coercive measures. CONCLUSION: Suitable measurement instruments and reliable data that enable the learning of best practices represent the basis for a reduction of coercive measures.

[Structural quality in psychiatric and psychotherapeutic hospitals]. / Strukturqualität in psychiatrischen und psychotherapeutischen Kliniken.

BACKGROUND: The new German flat rate reimbursement system for psychiatry and psychosomatics (PEPP) is primarily based on the diagnostic classification and the costs of therapeutic processes. In 2019 the current normative standard for calculating the therapeutic staff in psychiatric clinics (Psych-PV) will be substituted by a stepwise adaptation process over 5 years. Using regionally calculated remuneration factors, all clinic budgets should eventually converge to comparable values. AIM: Major factors influencing the structural quality of therapy in psychiatric clinics are identified and recommendations are given to support the work of the Federal Joint Committee (G-BA) which has been appointed to develop new recommendations for the minimum setting of personnel requirements. RESULTS: The full reimbursement of the necessary staff and of the costs resulting from outsourcing of day clinics and outpatient departments in the community, including the obligation to treat psychiatric emergency patients is mandatory and currently not sufficiently guaranteed in the new PEPP system. A workflow which opens the possibility to finance therapeutic innovations (e.g. psychotherapy) and helps to overcome the financial sectorial boundaries between inpatient and outpatient treatment is also missing. DISCUSSION: A mandatory recommendation for minimum staff settings needs a guaranteed full financing from the political side. Additionally, important would be an option for financing of therapeutic innovations and increased costs because of changed patient structures with respect to diagnosis and severity. Moreover, a sufficient remuneration for regional treatment responsibilities and for additional financial outlay resulting from structural costs for regionally outsourced departments is needed to avoid supplementary financing by reducing the budget for the therapeutic staff.

[Indicators of patient care in Psychiatric and Psychosomatic Facilities (VIPP project)--a database project]. / Versorgungsindikatoren in der Psychiatrie und Psychosomatik (VIPP)--Ein Datenbank-Projekt.

INTRODUCTION: In Germany a new and unique remuneration system for psychiatric and psychosomatic stationary treatments (PEPP system) was introduced in 2013 on an optional basis. From 2015 it will be mandatory for psychiatric and psychosomatic facilities. The introduction of the PEPP system brings up different questions regarding the possible incentives of the new remuneration system and its effects on the supply of psychiatric and psychosomatic treatments. To conduct these necessary analyses a reliable database is needed. MATERIAL AND METHODS: The goal of the project "Indicators of patient care in Psychiatric and Psychosomatic Facilities" (VIPP project) is to gather a representative database which reflects the situation of day-to-day patient care performed by German psychiatric and psychosomatic facilities. The §â€Š21 data set represents the basis of this database which will be complemented by other data sources (i. e., financial statements and other economic data). A number of more than 100 ,000 cases per year has already been exceeded. These case data were provided by a wide range of psychiatric hospitals, departments and universities that participate in this project. The dataset is anonymised and by pooling the data it is not possible to identify the cases of a specific clinic. Participants receive a web-based access and have the possibility to analyse the data independently. RESULTS: Using the examples of coding accuracy and rehospitalisation rates the variety as well as the enormous potential of this database can be demonstrated. DISCUSSION: On the base of the VIPP database valid patient care indicators can be identified and cross-sectional analyses can be conducted. From such results key data on health economic strategies can be derived and the incentives, strengths and limitations of this constantly changing system can be identified.

[Changes in mental health care by a regional budget--results of a pilot project in schleswig-holstein (Germany)]. / Vom Fall zum Menschen--Erfahrungen aus einem Regionalen Psychiatrie-Budget.

OBJECTIVES: In a region of Schleswig-Holstein, a regional budget was used to investigate which structural changes could be brought about by a financial plan which enables (clinical) treatment that defies rigid financial limits and makes flexible treatment in various settings possible. METHODS: Since 2003 in a region in Schleswig-Holstein (Steinburg) a financing system has been tested in cooperation with all health insurances. It is no longer based on days of treatment or individual treated cases, instead a budget has been made available for the setting of interdisciplinary psychiatric and pyschotherapeutic management. RESULTS: In 5 years, the number of inpatient treatment places in the care region was reduced considerably. The length of stay per patient and year decreased by 25%. Day care and outpatient treatment offers were expanded substantially and new treatment concepts were established. The quality of treatment remained safeguarded. CONCLUSIONS: A regional budget is suitable for bringing about fundamental changes in terms of content and structure in psychiatric care. The result is clearly improved flexibility as compared to previous care structures; incentives for disorders are reduced. The principle "outpatient before inpatient" is strengthened. The financial plan can be transposed onto other regions, whereby modifications according to the structure of the care region may be necessary.

Prognostic value of initial subtype in schizophrenic disorders.

The prognostic value of the subtype diagnosis at the initial episode was investigated in 148 narrowly defined schizophrenic patients. Every initial episode was classified according to multiple criteria: DSM-III-R, ICD-10, the positive/negative dichotomy, and Schneider's first rank symptoms. Patients were followed up on average 23 years later (range 10-50 years). Different aspects of long-term outcome were evaluated (global functioning, social adjustment, negative social consequences). In 93% of the patients persisting alterations were found at the end of the observation time. The influence of the predominant clinical features at the initial episode on various aspects of long-term outcome was found to differ depending on which of the four diagnostic systems was used. The highest power for discrimination was found for the subtypes of DSM-III-R, while the presence of first rank symptoms had no prognostic value. It was found that patients with an initial paranoid or positive episode had a significantly better long-term outcome than patients initially having a disorganised/hebephrenic or catatonic episode. The frequency of negative social consequences was not influenced by the initial subtype, with the exception of permanent hospitalisation.

Validity of the negative/positive dichotomy for schizophrenic disorders under long-term conditions.

A total of 148 patients fulfilling the DSM-III symptomatological criteria of schizophrenia were classified according to Andreasen's criteria of positive, negative and mixed symptomatology. After excluding cases of permanent hospitalisation and patients with monoepisodic course the remaining 100 patients had a total of 458 episodes. Of these episodes, 213 were identified as positive, 134 as negative and 111 as mixed. During the course of illness the proportion of negative episodes increased and the proportion of positive episodes decreased. The great majority of the patients (76%) had a bimorphous course, i.e. one showing both types of schizophrenic symptomatology, positive and negative. Only 6% of the patients had only negative episodes, and only 18% had only positive episodes. The shift from one type of episode to another is dependent on the length of illness. Stability was not greater later during the course of illness than at the beginning.

Functional cortical interaction patterns in visual perception and visuospatial problem solving.

To explore the integration of functional neuronal interactions in human higher cortical functions, we applied multivariate mathematical techniques to regional cerebral blood flow (rCBF) increases induced by mental activity. rCBF was measured using the intravenous xenon-133 clearance technique with 32 bihemispheric detectors in 84 normal volunteers at rest and during both a visuoperceptual accuracy task and a visuospatial problem solving task. Both paradigms activated rCBF in bilateral premotor, motor and postcentral regions. Bilateral prefrontal activation occurred during problem solving but not during the perceptual accuracy task. Partial correlations coefficients and factor analysis identified significant interactions between numerous cortex regions in both tasks. There were highly ordered and integrated patterns of functional interaction patterns between cortex areas subserving elementary subfunctions of complex behavior. Cortical interaction analysis by such techniques is a useful tool to describe the functional anatomy of large-scale neurocognitive networks in the intact human brain. Imaging functional interactions between active cortex areas are complementary to other experimental neurophysiologic methods to explore brain-behavior relationships in health and disease.

Long-term stability of subtypes in schizophrenic disorders: a comparison of four diagnostic systems.

The long-term stability of subtypes of schizophrenic disorders in 148 narrowly defined schizophrenic patients according to four diagnostic systems was compared. The patients were investigated longitudinally for 23 years on average (range 10-50 years). Patients who experienced only one episode and those who were permanently hospitalised were excluded on methodological grounds. Of the remaining 100 patients, a total of 461 episodes were classified into various subtypes according to the criteria of DSM-III-R, ICD-10, the positive/negative dichotomy, and Schneider's first-rank symptoms. It was found that long-term stability of subtype in schizophrenic disorder was not the rule but the exception. The frequency of stable course was found to be depend on the type of the initial episode. In most cases a subtype change occurred within the first few years of the illness with no clear direction. In later stages of the illness the relative frequency of episodes predominated by negative symptomatology increased. The findings were similar for DSM-III-R, ICD-10 and positive/negative dichotomy. Only in patients beginning without first-rank symptoms were more stable than non-stable courses found. The results of this study do not support the assumption that stable subtypes are nosological or etiopathogenetic subentities of schizophrenic disorders.

Subtypes in schizophrenic disorders: frequencies in long-term course and premorbid features.

The subclassification of schizophrenic disorders according to four diagnostic systems (DSM-III-R, ICD-10, the positive vs. negative dichotomy and Schneider's first rank symptoms) was compared over the long-term course of the disease in 148 narrowly defined schizophrenic patients. A total of 595 episodes were classified over a mean observation period of 23 years (range 10-50 years). Initially, paranoid/positive subtypes predominated, while later in the course episodes fulfilling the symptomatological criteria of residual/negative subtypes became more frequent. Disorganised/hebephrenic and catatonic subtypes were found to be rare. Some premorbid features were investigated as non-symptomatological validators for subclassification. Significant differences were found with regard to age at onset. Patients whose first episode was paranoid or positive had the highest age at onset. Patients with initial disorganised/hebephrenic or "residual" episodes had the most unfavourable premorbid social adjustment, even when the influence of age at onset was discounted. The diagnostic systems investigated showed similarities and differences as a result of the underlying concepts. Methodological implications are discussed.

Predicting the long-term outcome of affective disorders.

Factors influencing the long-term outcome of affective disorders were investigated in 106 patients with an average length of course of 28 years. Univariate statistical analyses, stepwise multiple discriminance analyses and path analysis were applied. A direct unfavourable influence on the frequency of persisting alteration (evaluated according to the Global Assessment Scale) was found to have the low self-confident premorbid personality and a higher number of episodes during course, whereas only the variable "male" had such an influence on the social consequences of the illness. The variable "manic episode" (bipolarity) and "age at onset" had only an indirect influence, in that bipolar patients had more episodes, and younger patients more frequently had a bipolar course and therefore had more episodes. The unfavourable long-term outcome was due in those cases to the higher number of episodes.

[Sex-dependent differences in endogenous psychoses. A comparison between schizophrenic, schizoaffective and affective psychoses]. / Geschlechtsabhängige Unterschiede bei endogenen Psychosen. Ein Vergleich zwischen schizophrenen, schizoaffektiven und affektiven Psychosen.

Sex differences in 355 patients with functional psychoses were investigated longitudinally (mean observation time more than 25 years). Using narrow criteria, 148 patients were diagnosed as having a schizophrenic disorder, 101 as having a schizoaffective and 106 as having an affective disorder. Similarities and differences between male and female patients in these three diagnostic groups were investigated and compared on four levels (premorbid and sociodemographic features, elements of course, symptomatology and the different aspects of outcome) using international standardised instruments of evaluation. A different sex distribution in the three groups was found. Female schizophrenic patients showed a better premorbid social adjustment and a better long-term psychopathological and social outcome than male patients. Differences between male and female schizoaffective patients were found only regarding premorbid personality and polarity, but not regarding symptomatology and outcome. In affective psychoses female patients showed a better social outcome than male patients, but no relevant differences regarding premorbid adjustment were found. Gender differences were found as an important variable for research in functional psychoses, but interactions with other variables have to be considered.

The psychopathology of 'late schizophrenia'.

We investigated the clinical features of schizophrenic syndromes first manifested after the age of 50. By comparison with the schizophrenic syndromes first manifested before the 50th year of life we found: late schizophrenia is characterized by rich psychotic productive syndromes (delusions and hallucinations); disturbances of thought are rare; depression, euphoria and anxiety show no difference between the two groups; females are much more represented than males; social isolation is not more common in late schizophrenia than in non-late schizophrenia.

Validity of the negative/positive dichotomy of schizophrenic disorders under long-term conditions.

Based on the phenomenological distinction of positive and negative symptoms, some authors discuss the existence of two subtypes of schizophrenia (positive vs. negative schizophrenia). Investigating the long-term course of 100 schizophrenic patients (on average 23 years after onset) it was found that only 24% of the patients had a stable monomorphous course (only once type of episode). The results of the presented longitudinal study do not support the assumption of 'purely positive' or 'purely negative' schizophrenic disorders. The relevance of positive and negative onset of illness for the long-term course and outcome is discussed with reference to the literature.