[Social inequality and mental health]

Social inequality refers to the inequitable distribution of social prosperity including the resource of health. The relationship between social inequality and mental health can be established by means of indicators of social inequality throughout all age groups in Germany. There are social gradients of mental health on the population level, i.e. the linear relationship between social classes or status and state of health. Fundamental determinants of health disparity are cultural, social, political, and geographical conditions, which interact with the genetic make-up and epigenetic processes. These determinants also influence the management of developmental tasks during the life course and are of utmost importance for the development of mental disorders. The maladaptation to chronic stress is at the core of health disparity. Interventions at the individual behavioral level should comprise the development of stress management and coping strategies.

[Treatment pathways in the care of patients with schizophrenia and depression]

BACKGROUND

In mental healthcare the concept of pathways addresses diverse issues and problem areas, such as heterogeneous health service offers, the regional variability of treatment concepts and clear-cut guidelines on how and where to obtain treatment for a particular mental disorder. The ambiguous aspects of the concept require international and national definitions and consensus which must also cover quality criteria.

METHODS

This article gives an overview of currently available evidence for the analysis of clinical pathways and pathways to care in international mental healthcare, covering studies on schizophrenia and depression from 2010 to 2014.

RESULTS AND DISCUSSION

The ambiguity of the concept impedes the overview and does not provide unequivocal results. The development, implementation and analyses of guidelines or clear-cut clinical and pathways to care must consider individual, clinical and care system aspects as well as the interplay of these factors. Results suggest that system aspects tend to dominate over clinical factors of schizophrenia and depression. As a consequence, the definition, implementation and evaluation of clinical pathways or pathways to mental healthcare is first and foremost a responsibility of the respective national mental healthcare system and must be understood on that level, before findings are summarized internationally and models of best practice are debated.

Illness perceptions and personality traits of patients with mental disorders: the impact of ethnicity

OBJECTIVE

To identify differences and similarities between immigrants of Turkish origin and native German patients in therapeutically relevant dimensions such as subjective illness perceptions and personality traits.

METHOD

Turkish and native German mentally disordered in-patients were interviewed in three psychiatric clinics in Hessen, Germany. The Revised Illness Perception Questionnaire (IPQ-Revised) and the Neuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI) were used. Differences of scales and similarities by k-means cluster analyses were estimated.

RESULTS

Of the 362 total patients, 227 (123 immigrants and 104 native Germans) were included. Neither demographic nor clinical differences were detected. Socioeconomic gradients and differences on IPQ-R scales were identified. For each ethnicity, the cluster analysis identified four different patient types based on NEO-FFI and IPQ-R scales. The patient types of each ethnicity appeared to be very similar in their structure, but they differed solely in the magnitude of the cluster means on included subscales according to ethnicity.

CONCLUSION

When subjective illness perceptions and personality traits are considered together, basic patient types emerge independent of the ethnicity. Thus, the ethnical impact on patient types diminishes and a convergence was detected.

Treatment with antipsychotics: The impact on the patient in the community

The assessment of new treatment strategies such as the atypical antipsychotic agents goes far beyond the assessment of psychopathology, and includes evaluation of their effects on a variety of needs associated with living in the community. This article provides some empirical data for such a multidimensional perspective in analysing drug treatment with conventional antipsychotics. We focus on two groups of schizophrenic patients discharged from a psychiatric hospital, who were followed up for one year. One group was treated with oral and the other with depot medication. The two groups were assessed on their needs for care, quality of life, and rehospitalisation rates. We found few significant differences between depot- and orally-medicated patients. However, patients treated with depot antipsychotics were receiving higher mean daily doses. Patients taking oral medication had a lower rate of adverse effects but were more non-compliant, which resulted in a higher rehospitalisation rate, confirming our assumpt on that patients take different risk-to-benefit decisions. Orally-medicated patients did not have a better functional status than depot-medicated patients.

[Methods of health economic evaluation for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

Drohende Wohnungslosigkeit und psychische Gefährdung

BACKGROUND

This study aims to assess the psychiatric morbidity of persons at risk of homelessness and to analyze correlations and risk factors between homelessness and mental disorders.

METHODS

The sample included 101 citizens of Mannheim, Germany, who were immediately threatened by eviction. Mental disorders were diagnosed using a standardized test, and other factors were also assessed. Data from August 2000 to June 2002 were collected.

RESULTS

Acute mental disorders requiring treatment were determined in 79.3% of the study sample. Addiction disorders (alcoholism) played a major role. Personality, anxiety, and affective disorders were even more frequent than in a control group of homeless people in the same region, whereas schizophrenia and other mental disorders were similarly prevalent. Regression analyses confirmed unemployment, alcoholism, and male gender as the most important risk factors for homelessness among people threatened by eviction.

CONCLUSIONS

The results suggest that prevention strategies should be multidimensional and interdisciplinary.

Forensic psychiatric assessment in European Union member states

OBJECTIVE

To provide a structured description and cross-boundary comparison of legal frameworks and training standards relevant for forensic psychiatric assessment in European Union member states before the extension in May 2004.

METHOD

Information on legislation and practice concerning the assessment of mentally disordered offenders was gathered by means of a detailed, structured questionnaire which was filled in by national experts.

RESULTS

Legal frameworks for the assessment and reassessment of mentally disordered offenders and professional training standards in forensic psychiatry vary markedly across EU member states.

CONCLUSION

Currently a cross-boundary harmonization of legal concepts appears hard to achieve. At least a formal construction and implementation of specialist training standards in forensic psychiatry would appear desirable.

[Cost predictors of depressive inpatient episodes in Germany. The health insurer's point of view]

BACKGROUND

Inpatient treatment is the most costly sector of treatment for depressive disorders in Germany. However, little is known about which patient and hospital characteristics contribute to costs of inpatient episodes.

PATIENTS AND METHODS

To take part in this study, patients had to fullfill criteria for ICD-10 diagnosis of F31.3-F31.5, F32, F33, F34.1, F43.20, or F43.21. Episodes were recorded between September 9 2001 and March 3 2003 in ten hospitals in three German states. Inpatient records of 1,202 persons were analysed. Multiple regression analysis was performed to identify significant patient predictors of cost per inpatient episode, and the predictive function of hospital characteristics was analysed by applying hierarchical linear modeling.

RESULTS

Patient characteristics at admission could not explain a substantial part of the variance in episode costs. Better prediction was possible including variables from the whole treatment process. Also, conditions for admission and patient-related factors did not well explain cost differences between hospitals, but characteristics of the whole treatment were.

CONCLUSION

For predicting costs of inpatient depressive episodes, the complete course treatment has to be considered. As in the physiologic sector, therapeutic and diagnostic procedures have a great effect on cost prediction.

Sind Bonussysteme auf eine leitlinienkonforme haus- und nerven�rztliche Depressionsbehandlung �bertragbar?

In the outpatient treatment of depression, the potential of diagnostic and therapeutic methods is seldom exhausted resulting in variable quality of treatment and partly insufficient cost effectiveness. Implementation of a guideline-oriented reimbursement system seems to be an option to improve quality of treatment. Corresponding incentive systems have been outlined and evaluated for the health care of somatic diseases such as diabetes. Acting on these experiences, an attempt was made to utilize them for the area of psychiatric disorders. Taking depression as an example, a model for a quality-oriented, guideline-based reimbursement system for general and specialist practice is presented.

[Is there an increase in the number of compulsory admissions of mentally ill patients in European Union Member States?]

PURPOSE

In a study subsidized by the European Commission, the course of compulsory admission rates (admissions per 100,000 population) and compulsory admission quotas (proportion of annual compulsory admissions of all admissions to psychiatric inpatient treatment) of mentally ill patients from 15 European member states was analysed.

METHOD

Information was gathered by means of a detailed questionnaire filled in by experts from all EU-Member States.

RESULTS

Compulsory admission rates and compulsory admission quotas differ significantly across the EU member states. Compulsory admission rates range from 6 (Portugal) to 218 (Finland) per 100,000 population and compulsory admission quotas vary from 3.2 % (Portugal) to 30 % (Sweden). In some member states a significant increase of compulsory admission rates was detected without a significant increase of compulsory admission quotas.

CONCLUSION

The relatively steady compulsory admission quotas suggest no real increase of coercion regarding admission to psychiatric inpatient care. Increasing compulsory admission rates rather reflect changing overall patterns of providing psychiatric service, tending towards decreased length of hospital stays, and more frequent readmissions.

[Costs of schizophrenia - what we know (not)?]

Schizophrenia is regarded as one of the most expensive mental illnesses because of its specific symptoms and characteristics. The care of schizophrenic patients consumed approx. 2 % of the total German health care expenditures in 1994, according to the scarce data provided by routine German health reporting. Despite this enormous impact, health-economical research in schizophrenia in Germany is widely neglected. While few empirical studies on direct cost of care for schizophrenic patients suggest that adequate comprehensive community care in Germany during the mid-nineties was about DM 27 000 to DM 28 000 per patient and year, there is a serious lackage of cost-effectiveness-studies, relating cost of care to outcome. Thus, the most basic data for any health care planning in schizophrenia is missing. This paper reviews the studies on cost of schizophrenia in Germany. It identifies the most serious knowledge gaps and describes the obstacles for an adequate research in this field.

Needs for mental health care and service provision in single homeless people

BACKGROUND

Specific problems in sampling methodology, case-finding strategies and a standardised needs assessment in mentally ill homeless people have contributed to their being neglected as a mental health care clientele.

METHOD

We assessed a representative sample of homeless people (n=102) in the highly industrialised city of Mannheim (Germany) regarding their prevalence of mental disorders (using the SCID) and their needs for mental health care (using the NCA).

RESULTS

We found high prevalences, with 68.6% of all assessed homeless persons having a current mental disorder. Thus, needs for mental health care were very common, with unmet needs predominating in all problem areas, which was supported by a very weak service utilization. Thus, even in a region with a comprehensive community mental health care network, like the study area, mentally ill homeless people are widely under-provided.

CONCLUSIONS

Results suggest that the traditional shelter system for homeless people carries most of the mental health care burden for their clientele and must be supported by adequate interventions from community-based mental health care services. A closer connection of both sectors and a better co-ordination of the care offers seems to be a prerequisite for helping to reduce unmet mental health care needs in this specific high-risk group.

[How do mentally ill homeless persons evaluate their quality of life]

Besides pronounced deficiencies in psychiatric research concerning homeless mentally ill in Germany, studies concerned with the quality of life of homeless mentally ill were missing until now. This study reveals in a representative sample of 102 homeless people from the City of Mannheim, Germany that--compared to the homeless without psychiatric disorders of the sample--the mentally ill homeless (prevalence 68.6%) have significantly different subjective views of their quality of life regarding the items "state of health", "physical capabilities" and "support from others". The differences were even stronger if the homeless mentally ill were compared to a group of non-homeless mentally ill schizophrenic patients (n = 104), cared for in the City's well-equipped community care services. Community care patients reported a significantly better quality of life in respect of 11 items. These results were seen as a success of the concept of community-based mental health care. The consequences for improving care strategies for homeless mentally ill are discussed.

[Quality assurance and documentation for community mental health services cooperative (GPV). A standardized procedure for regional health care documentation and planning]

This paper describes a standardized assessment-procedure for the so-called "Gemeindepsychiatrische Verbünde" in Germany (GPV-Documentation), which are regional combines of community-based mental health care services. It is the first procedure in Germany which puts data on psychiatric care offers, needs for care and service utilization of all sectors and services in community-based mental health care into standardized measures, thus making offers and care of these services comparable. The procedure can be applied to the daily routine of catchment areas. From a methodical point of view the GPV-Documentation keeps a functional approach to community-based mental health care, but additionally it enables services to describe their specific contribution to regional care separately from others. Annual follow-ups make the GPV-Documentation an ideal tool for planning purposes, care management and quality assurance. Cross-regional comparisons of standards of care are possible. The implementation will also enhance the quality of governmental health reports on the care of chronically mentally ill in Germany remarkably.

Needs for care and effectiveness of mental health care provision for schizophrenic patients in two European regions: a comparison between Granada (Spain) and Mannheim (Germany)

OBJECTIVE

The aims of this study were to develop an indicator for comparing the effectiveness of community mental health care across different areas, and to compare the effectiveness of care for schizophrenic patients in two European regions.

METHOD

In a long-term follow-up, service utilization, needs for care and met needs of schizophrenic patients were assessed. An indicator of effectiveness of care was calculated for each region and compared.

RESULTS

Patients in Mannheim received much more intervention in all types of mental health care. Despite differing utilization patterns, the indicator of effectiveness of care revealed no differences in the area of symptoms and behaviour problems between the two regions, while significant differences in the area of skills and abilities of patients were detected.

CONCLUSION

We succeeded in defining a measure that describes effectiveness of mental health care in terms of the long-term relationship between needs and unmet needs of patients. Our results contribute to an evidence-based discussion of the improvement of community mental health care networks.

[Is there a disproportional increase in health care costs for schizophrenic patients?]

Empirical data on costs of care for chronically mentally ill patients in Germany are rare. There is a lack of cross-sectional studies as well as of any analysis of the long-term course of mental health care costs. This study combines data from two cost-studies on patients with schizophrenia, conducted in the same catchment area at an interval of 15 years, to draw conclusions about the long-term course of these costs. The direct costs of comprehensive community based mental health care had increased by 77.0% during 15 years, while the costs of a permanent stay in a long-term ward of a psychiatric hospital had increased by 78.5% in the same period. This increase was 27 and 28.5 per cent higher than the general rise in cost of living in Germany during the interval between the two studies. This higher-than-average increase in mental health care costs was accompanied by a much higher cost-effectiveness. Thus, this rise of costs must be seen as a consequence of the great deficits and the resulting basic improvement of care for chronically mentally ill patients in Germany, which was demanded by an expert-commission of the government in the mid-seventies.

Does the place of treatment influence the quality of life of schizophrenics?

OBJECTIVE

Chronically mentally ill patients in community mental health care report a better quality of life (QOL) than those in long-term hospital care, which suggests that the treatment setting per se influences their QOL.

METHOD

In a region where both treatment settings are of a comparable high standard, we assessed the QOL of 96 schizophrenic patients from these two treatment settings, and the factors which most influenced their QOL.

RESULTS

Community-care patients reported a better QOL than long-term hospital-care patients. However, when other factors influencing QOL were included in a regression analysis, the place of treatment was no longer significant, but rather the social support, the severity of the illness, educational level and certain illness concepts.

CONCLUSION

It is probably not the place per se which influences the QOL, but apart from personal, sociodemographic and illness-related factors, the amount of social support that is provided in different settings.

[The attitude of medical students to psychiatric patients]

Numerous studies conducted during the past decades indicate that the public's attitude toward the mentally ill is strongly prejudiced. Since the attitude of the general public also has an effect on community-based psychiatric care, we must ask how public opinion might be influenced. One possible approach could be through so called key community leaders--those who are highly respected in society because of their competence in a particular area. Doctors belong to this group of people. For this reason we questioned medical students, as future key community leaders, with respect to their attitudes toward the mentally ill within the framework of their first contact with psychiatric patients during their studies. In order to make a direct comparison possible, we interviewed a sample of the Mannheim population who live in a part of the city where a variety of complementary facilities have been set up. The comparison shows that medical students do not have a more positive attitude toward the mentally ill; in fact, in certain areas they have an even more negative attitude toward the mentally ill than the general population has. We were not able to establish what effect teaching has with respect to changing attitudes.

[Voluntary aids in psychiatry]

Lay helpers fill in in situations where the natural system of help-family and friends-can no longer cope or where professional help is also not able to offer adequate help. Since no representative studies on this group of people exist, we wanted to take stock of the current situation by conducting a questionnaire in Baden-Württemberg. We identified 891 lay helpers in psychiatric facilities, of which 330 (37%) took part in the survey. The results of the study point out that lay help is the domain of older women. Their main duties are to give support through conversation and leisure activities. Although many lay helpers have been active over a long period of time, most of them express a high level of satisfaction with their occupation. A higher level of satisfaction is shown among those lay helpers who receive a certain amount of professional support in their work.

[Health report data in the management of chronic psychiatric patients]

Reforming mental health care in the Federal Republic of Germany was clearly impeded by a lack of health care data which would allow for a precise description of the state of the reorganisational process. Since these deficits are not a specific problem of mental health care, the need for a national health report providing health care statistics from all medical disciplines is widely recognised and has led to appropriate political initiatives. The difficulties in interpreting mental health care statistics of restricted validity and the resulting dangers will be discussed by means of examples, and the need for a special health report in mental health care is justified.

The cost of comprehensive care of people with schizophrenia living in the community. A cost evaluation from a German catchment area

BACKGROUND

In community mental health care, knowledge about costs of care is very limited. Only few studies have related costs to outcome measures.

METHOD

This German study assesses the cost of psychiatric care of 66 schizophrenic patients during one year of living in the community. Predictors of high cost were identified.

RESULTS

The average cost of comprehensive community care of one patient of the cohort was US$ 363 per week. This was only 43% of the cost of constant long-term care in a psychiatric hospital. Significant predictors of total cost of community care were the number of rehabilitative problems at the beginning and at the end of the study period, the type of accommodation before index hospitalisation and the gender of patients.

CONCLUSIONS

Results must be understood in terms of the characteristics of the special patient group and the catchment area we studied and are of high relevance in planning future care.

[Cost assessment in a fragmented psychiatric treatment system]

While Anglo-American countries increasingly integrate cost-effectiveness-studies into mental health care, in Germany there is still a basic need for empirical data with regard to the cost of care for the mentally ill. This study assesses the total cost of community mental health care of 66 schizophrenic patients prospectively over the course of 12 months. The comprehensive community care of the patients proved to be 43% of the cost of long-term treatment in a state mental hospital. Rehabilitative need, as well as living conditions and gender, showed significant influence on the total cost of community care.

[Psychiatric departments in general hospitals--developmental status in Germany]

Departments of Psychiatry in Germany were approached by direct investigations via a questionnaire regarding various parameters of structure and performance during 1993, since only insufficient administrative data on the structure of inpatient care were available. An expert inquiry that had been officially conducted in Germany in 1975 had recommended for 200 beds for inpatient accommodation. The present investigation, however, revealed that the average number of beds was only 80 in almost all hospitals. The majority of the Departments approached were engaged in 100% patient care, so that the discussion regarding two classes of psychiatry in respect of impatient nursing care is now obsolete. There is also no significant difference between the Departments of Psychiatry in hospitals in the pre-reunification West German and East German areas, the only exception being the sizes and hence the capacities of the relevant departments.

[Social legislative and structural deficits of ambulatory management of chronic psychiatric and handicapped patients]

In the past 25 years, psychiatric care for the chronically mentally ill in Germany has improved steadily. However, has improved steadily. However, this patient group continues to be discriminated against, especially in the sphere of outpatient care. The mentally ill often do not meet the requirements that the respective social security agencies, i.e. in particular pension and health insurance, set out for the granting of benefits. Moreover, contrary to scientific knowledge, measures aimed at the treatment of social disabilities are defined not as psychiatric rehabilitation measures, but as measures of social integration. For these reasons welfare is highly overrepresented in the financing of rehabilitation for the mentally ill. In recent years, legislators have attempted to compensate certain cases of discrimination. Significant legislative changes and administrative developments are described and discussed in terms of their implications.

[Community management needs a community that cares--the attitude of the population to psychiatric management and psychiatric patients]

Since community mental health care started public attitudes towards mentally ill and mental health care had been development to an important influencing factor in planning mental health care and in rehabilitation of patients. This paper describes the historical development of research in public attitudes in psychiatry, which started with deinstitutionalization. It discusses the interaction between types and quality of mental health care and public opinions or attitudes towards the care of mentally ill patients, considering own empirical results.

Factors affecting public attitudes towards mental health care

This study presents a telephone survey of 501 randomly sampled residents of the Grand Duchy of Luxembourg older than 15 years of age. The interviewees were questioned on their attitudes and judgements towards mental health care in Luxembourg. The implementation of a community-based mental-health-services delivery system in Luxembourg is in its initial stages. Being the smallest member of the European Community Luxembourg offers the opportunity to analyze a whole catchment area in transition marked off clearly by national borders. As a general rule the people of Luxembourg are undecided when it comes to mental health care. Almost half of the sample answered "don't know" when asked about the quality of several sectors of mental health care, excluding inpatient care. The factors that had a significant influence on the attitude of the people of Luxembourg regarding mental health care were nationality, age, class and personal contact with mentally ill persons, with a tendency of worse judgements in younger age groups and in members of upper social classes. We fitted multivariate models including these variables. The results of our study point to entrenched prejudice. The findings suggest, however, that attitudes are changeable by direct or indirect contact with mentally ill persons. Possible strategies that could change public attitudes towards mental health care in a mental health care system that is in transition are discussed.

[Psychiatrically ill homeless persons--the forgotten minority]

In Germany for a long time mental illness among homeless people didn't occur as an urging problem. Only lately the number of surveys about mental health problems among homeless people is slowly rising (along with a strong increase of homeless people), most of them being cross-sectional among users of local homes, hostels or shelters. The paper gives a short summary of the historical development, describes the services provided for homeless people in Germany and discusses the findings of the studies conducted in Germany during the last years.

[Current status and developments in psychiatric care. A European comparison]

In most European countries several reform indicators point to a marked change in psychiatric care during the last three decades. Almost everywhere the size of psychiatric hospitals was reduced and the number of beds decreased. The development in the outpatient and complementary sector is less clear. Different European countries provide sheltered living accomodations, workshops and outpatient treatment to varying degrees. Comparably complex are financing and legal grounds of psychiatric treatment. Beside still existing institutional deficits, the negative attitude of the public toward mentally ill and psychiatric care is a serious obstacle for further implementation of community based psychiatric care.

Longitudinal statistics of mental health care in Germany

In 1975, an expert committee was commissioned by the government to evaluate psychiatric care in the Federal Republic of Germany. The results of this study showed that Germany lacked the infrastructure to provide appropriate care for the mentally ill. Since then, measures have been taken to improve in-patient, out-patient and non-hospital care. However, in spite of these efforts, problems still exist. A closer analysis revealed that, though state mental hospitals have consolidated their position in in-patient care, there are still few psychiatric departments in general hospitals. Also, there are extreme regional differences regarding non-hospital care as seen by the varying number of long-term inpatients in each region. Out-patient care, especially for the chronically mentally ill, is also widely criticized. However, the biggest problem remains that of financing psychiatric care. Because most mentally ill persons are not properly insured and depend on social welfare, the burden falls on the government. In addition to this, efforts to modernize the antiquated mental health care system in the former East Germany are especially costly. In the future, a larger part of the available resources will go to providing community-based care in East Germany, which was nonexistent before unification.

[Maternal phenylketonuria. Problems in detecting and risk educating identified females]

Maternal PKU is an embryo-fetopathy caused by elevated plasmaphenylalanine levels in pregnant women with hyperphenylalaninemia and phenylketonuira. Leading symptoms are microcephaly, mental retardatioin and congenital malformations, especially congenital heart disease. Maternal PKU becomes more important since early treated and normally developed girls with PKU are reaching their reproductive age in increasing numbers. There is a lack of adequate knowledge about the dangers of maternal PKU in at-risk women. Only 43% of these women in the Federal Republic of Germany are located by now and can be informed and instructed. Ways and conditions of tracking are described.