Implementation, efficacy, costs and processes of inpatient equivalent home-treatment in German mental health care (AKtiV): protocol of a mixed-method, participatory, quasi-experimental trial.

BACKGROUND: Over the last decades, many high-income countries have successfully implemented assertive outreach mental health services for acute care. Despite evidence that these services entail several benefits for service users, Germany has lagged behind and has been slow in implementing outreach services. In 2018, a new law enabled national mental health care providers to implement team-based crisis intervention services on a regular basis, allowing for different forms of Inpatient Equivalent Home Treatment (IEHT). IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity. METHODS/DESIGN: The presented naturalistic, quasi-experimental cohort study will evaluate IEHT in ten hospitals running IEHT services in different German regions. Within a multi-method research approach, it will evaluate stakeholders' experiences of care, service use, efficacy, costs, treatment processes and implementation processes of IEHT from different perspectives. Quantitative surveys will be used to recruit 360 service users. Subsequently, 180 service users receiving IEHT will be compared with 180 matched statistical 'twins' receiving standard inpatient treatment. Assessments will take place at baseline as well as after 6 and 12 months. The primary outcome is the hospital re-admission rate within 12 months. Secondary outcomes include the combined readmission rate, total number of inpatient hospital days, treatment discontinuation rate, quality of life, psycho-social functioning, job integration, recovery, satisfaction with care, shared decision-making, and treatment costs. Additionally, the study will assess the burden of care and satisfaction with care among relatives or informal caregivers. A collaborative research team made up of researchers with and without lived experience of mental distress will conduct qualitative investigations with service users, caregivers and IEHT staff teams to explore critical ingredients and interactions between implementation processes, treatment processes, and outcomes from a stakeholder perspective. DISCUSSION: By integrating outcome, process and implementation research as well as different stakeholder perspectives and experiences in one study, this trial captures the various facets of IEHT as a special form of home treatment. Therefore, it allows for an adequate, comprehensive evaluation on different levels of this complex intervention. TRIAL REGISTRATION: Trial registrations: 1) German Clinical Trials Register (DRKS), DRKS000224769. Registered December 3rd 2020, https://www.drks.de/drks_web/setLocale_EN.do ; 2) ClinicalTrials.gov, Identifier: NCT0474550 . Registered February 9th 2021.

[Importance of Psychiatric Outpatient Clinics in Primary Care of Somatic Disorders]. / Die Bedeutung Psychiatrischer Institutsambulanzen in der somatischen Grundversorgung.

OBJECTIVE OF THE STUDY: General practitioners are mainly responsible for primary health care. Patients with mental disorders, in particular patients with complex or multiple needs, use these services infrequently in case of somatic complaints. Psychiatric outpatient clinics have to deal with these patients and have perhaps an additional role in diagnosing and treating somatic co-morbidities. This should be evaluated. METHODS: Physicians in outpatient clinics of the Centre of Psychiatry Suedwuerttemberg were asked about their attitude towards somatic co-morbidities, somatic co-treatment and prescribing somatic drugs. In addition, data of the outpatient clinic documentation were evaluated with respect to the treatment by general practitioners and somatic diagnosis. RESULTS: 72% of all patients said that they have a general practitioner. Physicians in outpatient clinics said that they had a high responsibility for somatic co-treatment especially for those patients who did not have a general practitioner. The frequency and type of a somatic co-morbidity was different in patients from general psychiatric, geriatric psychiatry and addiction outpatient clinics. CONCLUSIONS: Our results demonstrate that psychiatric outpatient clinics play a crucial role in diagnosing and treating somatic disorders. Their extent depends on the type of the psychiatric and the somatic disorder but also on the financing of the outpatient clinic.

Psychosomatische Institutsambulanzen (PsIA) ­ und (k)ein Ende. Ein guter Anfang, der nun weiterentwickelt werden will.

The objective of this paper is to describe the agreement from the perspective of the authors who, as experts for the Deutsche Krankenhausgesellschaft (DKG - German Hospital Federation), have accompanied the PsIA negotiations since 2013. It traces the development of the PsIA negotiations leading to the "Änderungsvereinbarungen zur Vereinbarung zu den Psychiatrischen Institutsambulanzen gemäß § 118 Abs. 2 SGB V" (amendment agreements to the Agreement concerning the Psychiatric Outpatient Departments according to § 118 Abs. 2 SGB V - German Social Security Statute Book) of October 2019 with its striking difficulties in view of partly diametrally opposed interests of the negotiating partners.

[Health Care Organization - The New German S3-Guideline on Alcohol-Related Disorders and its Relevance for Health Care]. / Versorgungsorganisation ­ Die neue S3-Leitlinie Alkohol und ihre Bedeutung für die Versorgungspraxis.

BACKGROUND: Alcohol dependence is one of the most serious diseases of addiction in Germany. The new S3-guideline "Screening, Diagnostics and Treatment of Alcohol-Related Disorders" has been presented in 2015 and summarizes the present state of knowledge pertaining to the diagnosis and treatment of alcohol abuse and alcohol dependence. METHODS: This guideline was developed over four years within the framework of the Association of the Scientific Medical Societies in Germany (AWMF). The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and the German Society for Research and Therapy in Addiction (DG-Sucht) took the lead in the organization. More than 50 professional societies and associations and health organizations as well as more than 60 acknowledged experts were involved, including networks of self-help groups and relatives. The working group on "health care organization", whose results are presented here, was one out of thirteen working groups, focusing on the task how to implement the guideline under the basic conditions of the German health care system with its sectors and interfaces. RESULTS: For the chapter on "health care organization" 27 recommendations have been consented. Many of these have been prepared by the respective working groups. These recommendations cover areas such as screening, diagnostics and short interventions, detoxification and withdrawal as well as pharmacotherapy, physical complications and psychic comorbidity, medical rehabilitation and other forms of post-acute treatment, primary care by general practitioners, as well as specific target groups such as children and adolescents, (pregnant) women and the elderly, and, in addition, self-help approaches. CONCLUSION: For needs-based diagnostics and treatment of alcohol-related disorders, guideline-based recommendations for health care organization offer a framework for the cooperation and coordination of all health sectors and occupational groups, especially with respect to their interfaces. This includes the cooperation between the medical and the psychosocial system and stretches from harm reduction to social inclusion of people concerned. Particularly the field of rehabilitation with its explicit aims for participation relies heavily on such a cooperation.

Rehospitalization risk of former voluntary and involuntary patients with schizophrenia.

BACKGROUND: The aim of the study was to examine the differences between former involuntary and voluntary patients with a schizophrenic disorder with regard to time to and frequency of rehospitalization. METHODS: In this prospective observational study, 374 patients with a diagnosis of schizophrenia or schizoaffective disorder were included. At the time of inclusion, 290 (77.5 %) were hospitalized voluntarily and 84 (22.5 %) involuntarily. Follow-up assessments were conducted half-yearly over a 2-year period with measures of PANSS, GAF, sociodemographic data and cognitive functioning. These data served as covariates for adjustment in statistical models that included a Cox regression model, a random-effect logit model and a random-effect tobit model. RESULTS: After adjustment for other relevant covariates, the Cox regression showed that involuntary treatment is a significant risk factor of subsequent rehospitalization (HR = 1.53; CI = 1.06, 2.19; p = 0.02). The involuntary group had higher half-year incidence rates of rehospitalization, and in case of rehospitalization the duration of hospital stay was longer. CONCLUSIONS: Involuntary hospitalization seems to be associated with a higher risk of rehospitalization and longer subsequent hospital stays in patients with schizophrenia and schizoaffective disorders. Further studies are needed to examine in detail the processes and interventions that are suitable for interrupting circles of repeated hospitalizations, especially in former involuntary patients.

Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion.

PURPOSE: The purpose of the study was to examine the long-term influence of involuntary hospitalization on medication adherence, engagement in out-patient treatment and perceived coercion to treatment participation. METHODS: In a naturalistic observational multi-centre study, 290 voluntarily and 84 involuntarily hospitalized patients with schizophrenia or schizoaffective disorder had been followed up over a period of 2 years with half-yearly assessments. Assessments included self-rated medication adherence, externally judged medication adherence by blood levels, engagement in treatment and perceived coercion. The statistical analyses were based on multilevel hierarchical modelling of longitudinal data. Level and development of the outcome was controlled for involuntariness, for sociodemographic characteristics and clinical history. RESULTS: Involuntariness of the index-hospitalization did not have an effect on the development of treatment engagement or medication adherence judged by blood levels in the course of the follow-up period when the models were controlled for sociodemographic variables and clinical history. It was associated, though, with a continuously lower self-rated medication adherence. Moreover, former involuntarily hospitalized patients more often felt coerced in several treatment aspects at the follow-up assessments. Yet, there was no difference between the voluntary and involuntary group with regard to the development of the levels of adherence or coercion experiences over time. CONCLUSIONS: Involuntary hospitalization does not seem to impair future treatment engagement in patients with schizophrenia, but formerly involuntarily hospitalized patients continue to be more sensitive to subjective or real coercion in their treatment and more vulnerable to medication non-adherence. Hereby, their risk of future involuntary hospitalization might be increased.

[IEHT or inpatient treatment? - First results of the multicenter AKtiV study on inpatient-equivalent home treatment regarding the study population and index treatment]. / StäB oder Station? ­ Erste Ergebnisse zur Studienpopulation und zur Behandlung im Rahmen der multizentrischen AKtiV-Studie zur stationsäquivalenten Behandlung.

AIM: The quasi-experimental AKtiV study investigates the effects inpatient-equivalent home treatment (IEHT). This paper describes the study population based on demographic and clinical parameters at baseline and compares the index treatment. METHODS: Over a period of 12 months 200 IEHT users were included in the intervention group (IG) and 200 inpatients were included in the control group (CG). The comparability of the two groups was ensured by propensity score matching (PSM). RESULTS: In addition to the PSM variables, IG and CG did not differ significantly from each other variables at study inclusion. The duration of the index treatment was significantly longer in the IG (M=37.2 days) compared to the CG (M=27.9 days; p<0.001). CONCLUSION: The similarity of the two groups enables comparisons over 12 months, investigating IEHT effects on long-term outcomes.

Premature termination, satisfaction with care, and shared decision-making during home treatment compared to inpatient treatment: A quasi-experimental trial.

BACKGROUND: Inpatient equivalent home treatment (IEHT), implemented in Germany since 2018, is a specific form of home treatment. Between 2021 and 2022, IEHT was compared to inpatient psychiatric treatment in a 12-months follow-up quasi-experimental study with two propensity score matched cohorts in 10 psychiatric centers in Germany. This article reports results on the treatment during the acute episode and focuses on involvement in decision-making, patient satisfaction, and drop-out rates. METHODS: A total of 200 service users receiving IEHT were compared with 200 matched statistical "twins" in standard inpatient treatment. Premature termination of treatment as well as reasons for this was assessed using routine data and a questionnaire. In addition, we measured patient satisfaction with care with a specific scale. For the evaluation of patient involvement in treatment decisions, we used the 9-item Shared Decision Making Questionnaire (SDM-Q-9). RESULTS: Patients were comparable in both groups with regard to sociodemographic and clinical characteristics. Mean length-of-stay was 37 days for IEHT and 28 days for inpatient treatment. In both groups, a similar proportion of participants stopped treatment prematurely. At the end of the acute episode, patient involvement in decision-making (SDM-Q-9) as well as treatment satisfaction scores were significantly higher for IEHT patients compared to inpatients. CONCLUSIONS: Compared to inpatient care, IEHT treatment for acute psychiatric episodes was associated with higher treatment satisfaction and more involvement in clinical decisions.

[Does Inpatient Equivalent Home Treatment lead to higher satisfaction? Results on satisfaction of persons involved in treatment within the Multi-center AKtiV Study]. / Stößt die Behandlung zu Hause auf größere Zufriedenheit? Ergebnisse zur Zufriedenheit der an der Behandlung beteiligten Personengruppen im Rahmen der multizentrischen AKtiV-Studie.

This part of the AKtiV Study focuses on treatment satisfaction of patients and their relatives within Inpatient Equivalent Home Treatment (IEHT) and regular treatment. Stress of relatives and job satisfaction and workload of employees in IEHT is also considered. Relevant Parameters were collected via established as well as newly adapted questionnaires at the end of treatment. Patients and relatives in IEHT are significantly more satisfied. The stress experienced by relatives is reduced in both forms of treatment. Employees in IEHT are generally very satisfied, although there is no correlation with the satisfaction of relatives and patients. Known limitations of satisfaction surveys must be taken into account. In general these results encourage the expansion and continuous development of this new form of treatment in Germany.

Effectiveness of antipsychotic maintenance therapy with quetiapine in comparison with risperidone and olanzapine in routine schizophrenia treatment: results of a prospective observational trial.

Objective of this observational trial is to examine the effects of quetiapine in comparison with olanzapine and risperidone on clinical outcomes and quality of life in patients with schizophrenia and schizoaffective disorder in routine care. 374 adult persons with schizophrenia or schizoaffective disorder prescribed antipsychotic maintenance therapy with quetiapine, olanzapine, or risperidone at discharge from inpatient treatment were included. Clinical and psychosocial outcomes were assessed before discharge and at 6, 12, 18, and 24 months. Statistical analyses were conducted by mixed-effects regression models for longitudinal data. The propensity score method was used to control for selection bias. Patients discharged on olanzapine had significantly lower hospital readmissions than those receiving quetiapine or risperidone. The average chlorpromazine equivalent dose of quetiapine was higher than in patients treated with olanzapine or risperidone. No further significant differences between treatment groups were found. Quetiapine and risperidone are less effective in preventing the need for psychiatric inpatient care than olanzapine, and higher chlorpromazine equivalent doses of quetiapine are needed to obtain clinical effects similar to those of olanzapine and risperidone.

[IET -What's the Evaluation of Patients within this New Form of Treatment?] / StäB ­ Wie bewerten Patientinnen und Patienten die neue Behandlungsform?

First descriptive statistics on satisfaction with Inpatient equivalent treatment (IET), gathered on self report, of 100 patients are presented. Data has been collected at two psychiatric hospitals in Südwürttemberg.In general results suggested high satisfaction. Approval rate on making use of this innovative treatment again, was 88 % (SD = 26.1). Differences between the distribution of satisfaction values, differentiated by clinic location or psychiatric main diagnosis, have been shown.Results indicate high acceptance by the persons concerned. After the establishment of IET within the past 3 years, these results are building a methodological basis and origin for a wide-ranging evaluation of satisfaction with this sort of crisis resolution within the "AKtiV-Studie" of the Innovationsfonds 2020-2023.

[Inpatient-Equivalent Treatment - How does it Work? Implementation Strategies from Eight Specialised Psychiatric Hospitals and Departments in Germany]. / Stationsäquivalente Behandlung ­ Wie geht das? Umsetzungsstrategien aus acht psychiatrischen Fachkliniken und -abteilungen in Deutschland.

To get information about different ways inpatient equivalent treatment (IET) is implemented and organized eight specialized psychiatric hospitals and departments in Germany were asked to report on implementation details. OUTCOME: Organization and treatment processes depend on local conditions and existing structures. Legal barriers complicate the implementation process, however patients as well as team members report very positive experiences.Current data only give first hints but aren't sufficient to draw viable conclusions. Consequential issues will be picked up within the AKtiV-Study of the Innovationsfonds.

[Changes in Tasks and Job Characteristics in Psychiatric-Psychotherapeutic Inpatient Treatment in Germany - Description of Relevant Progresses since the Commencement of the German "Psychiatry Staff Ordinance" in 1990 - Focusing Psychiatric-Psychotherapeutic Inpatient Intensive Care]. / Veränderungen von Aufgaben und Tätigkeitsprofilen in der vollstationären psychiatrisch-psychotherapeutischen Intensivbehandlung in Deutschland.

In Germany, mandatory standards in staff job characteristics concerning inpatient (clinic and day clinic) treatment in psychiatry and psychotherapy were established for the very first time in the year 1990. Those job characteristics, concerning the several groups of professionals in German psychiatric-psychotherapeutic hospitals and departments underwent significant changes causing issues of law, professional and socio-cultural development since then. Besides general structurally changes, the present article focuses more particularly on the field of inpatient psychiatric intensive care therapy.

The long-term course of alcoholism, 5, 10 and 16 years after treatment.

AIMS: To discover the long-term stability of drinking behaviour following an in-patient treatment episode. DESIGN: Three follow-up periods were used at 5, 10 and 16 years. The patients were classified as being abstinent, improved or unimproved on the basis of self-reported drinking behaviour. Patients who could not be interviewed at follow-up were classified as unimproved. SETTING: An alcohol dependence treatment programme at the University Hospital Tuebingen, Germany. PARTICIPANTS: We were able to locate all 96 patients at the 16-year follow-up. Seventy were alive and 26 had died. We collected information from 59 of the 70 surviving patients. The remaining 11 patients could be located and were definitely alive. FINDINGS: Thirty-eight of the 70 patients were abstinent, 10 were improved and 22 (including the 11 living patients without further information) were classified as unimproved. Our main finding indicates that the so-called 'improved drinking' is very inconsistent over time. In contrast, the abstinent and unimproved patients were much more stable in their drinking behaviour. CONCLUSIONS: This study extends our knowledge of the drinking trajectory and outcome from only a few years of follow-up to 16 years. Complete abstinence and unimproved drinking behaviour were the most stable drinking patterns observed over the long term, confirming study results obtained primarily from English-speaking countries.

[Psychiatric care between World War II and "Psychiatrie-Enquête": early approaches of reformation in Württemberg]. / Psychiatrische Versorgung zwischen Zweitem Weltkrieg und Psychiatrieenquete: Frühe Reformansätze in Württemberg.

OBJECTIVE: The article describes care in a psychiatric clinic between 1946 and 1975. This happens against the background of the current psychiatry-historical literature in which this phase of psychiatric care is described often summarily with the destructive words of the report of the 'Psychiatrie-Enquête' of 1975. Improvements achieved in this time were hardly examined up to now though they contributed substantially to the later effects of the 'Psychiatrie-Enquête'. METHODS: The medical annual reports of the psychiatric clinic of Zwiefalten, today ZfP Südwürttemberg, refering to the mentioned period were sighted and evaluated concerning their contents. RESULTS: In the called period evident organizational and structural defects are deplored in the annual reports. Nevertheless, from the late 1940 s on, modern care elements appear, as for example the broadening of the range of the therapeutic offers, multiprofessional treatment, diagnosis-specific concepts for the wards, opening of stations and extensive outpatient care. CONCLUSION: It is shown that already before the appearance of the final report of the Enquête commission clear progress concerning psychiatric care was achieved.

Identification of psychopathological course trajectories in schizophrenia.

Course trajectory analyses have been performed primarily for treatment response in acute episodes of schizophrenic disorders. As yet, corresponding data for the long-term course are lacking. Within a multicenter prospective observational study, 268 patients with schizophrenia were assessed at discharge from hospital and followed up after 6, 12, 18, and 24 months. A latent class growth analysis was performed on the scores from the Positive and Negative Syndrome Scale (PANSS). A two-class conditional latent class model showed the best data fit (Entropy: 0.924). The model divided the sample into a group with amelioration in all PANSS subscales (60%) and a group with stable positive/negative and deteriorating general psychopathology symptoms (40%). Global functioning (GAF score), gender, age, living situation and involuntary admission predicted course trajectory class membership. The model was predictive of significant differences between the two groups in health care service costs and quality of life. The results underline the heterogeneous course of the illness, which ranged from amelioration to deterioration over a 2-year period. Statistical models such as trajectory analysis could help to identify more homogenous subtypes in schizophrenia.