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PubMed1985

Changing patterns of mental health care.

The evaluation of intra- and extramural psychiatric care nowadays calls for new models and methods of services research as the transition from custodial to community mental health care results in patterns of utilization of high complexity. Not only the capacity and the components of the care system has changed considerably but also the composition of the cared patient groups. In Mannheim 3/4 of the schizophrenic patients requiring institutioned care for one year or more are admitted to sheltered homes and apartments due to the establishment of complementary services in the last 15 years. Data of a representation cohort of 148 schizophrenics observed over a period of 18 months show that corresponding to the multiple needs of the patients multiple utilization prevails. The effectiveness of extramural care can be demonstrated by a reduced probability of readmission to inpatient treatment. The economic efficiency of the provision of complementary care was evaluated by analyzing costs of service use by the cohort. The direct costs per case of all the services utilized over one year averaged 43% compared with an uninterrupted stay in a mental state hospital. Also in community mental health care almost 80% of the total costs accrue from hospital readmission due to relapses.

Adolescent↗
PubMed1986

Dehospitalization of psychiatric care in The Netherlands.

What are the major changes in the Dutch mental health system? In this article some main lines of the de jure mental health policy are compared with de facto developments in the period 1970-1982, utilizing data from a national inpatient case register.

Adolescent↗
PubMed1986

Effectiveness and application of partial hospitalization.

Especially during the past 15 years, partial hospitalization (PHP) has been studied extensively. This article reviews the effectiveness and applicability of PHP. To clarify where PHP might fit into the overall mental health care system, the results of empirical research are evaluated with special attention to topics such as treated population, program evaluation, comparison of PHP with inpatient treatment, PHP as alternative to outpatient treatment, comparison of different PHP's, cost effectiveness and burden on the family. The general conclusion is that PHP can be a reasonable alternative to inpatient as well as to outpatient treatment, taking into account factors such as symptomatology, cost and family burden. PHP seems in particular to enhance social role functioning, which might be attributed to the fact that contact between patient and environment is not disturbed by hospitalization. Suggestions for further research are presented. Furthermore it is recommended in order to improve generalizability of results to differentiate the different functions PHP can fulfil in the mental health care system.

Ambulatory Care↗
PubMed1988

Patterns of mental health care in two European areas: Mannheim, Federal Republic of Germany; and Groningen, The Netherlands.

All consecutive cases entering the mental health services cooperating with the cumulative psychiatric case register of Mannheim between 1-31 July 1976 were followed up until the end of June 1978 and compared with the consecutive cases entering the mental health services cooperating with the psychiatric case register of Groningen between 1 January and 1 May 1979. Patterns of in-, day- and outpatient care delivered to these 2 cohorts of patients, who were greater than or equal to 15 years of age, and who had not been in contact with one of the services for at least 6 months prior to entry, were compared by diagnostic category. The most common episode of care was the relatively brief outpatient one. Mixed types of care and chronic cases were more common among patients with a psychosis or an addiction than in other diagnostic categories. Between 6 and 24 months after first contact 76% of the patients in Mannheim and 43% of the patients in Groningen had no more contacts. Between 18 and 24 months after the first contact the percentages had increased to 90 and 72% (respectively). In Groningen a higher percentage of patients received outpatient care only. Although a larger percentage of patients in Mannheim received inpatient care, the accumulation of "new chronic" patients was larger in Groningen, as a result of a greater length of stay in Groningen.

Adult↗
PubMed1988

The Italian mental health reform nine years on.

It is 9 years since the mental health reform was passed by the Italian Parliament. The author presents a data-based evaluation of the effects of the Italian mental health reform. There are still many problems to be resolved: More than 30,000 inpatients are still in psychiatric hospitals and little is known of the fate of those discharged in recent years. District mental health services are still lacking, especially in the south of the country; Psychiatric units in the general hospital function much the same way as the "old" psychiatric hospitals. The pattern of mental health services consumers have changed: They are younger with less severe psychiatric diagnosis and come from a higher social background.

Adolescent↗
PubMed1989

Patterns of psychiatric care in south Verona and Groningen. A case-register follow-up study.

The pattern of utilization of mental health services in south Verona (Italy) and in Groningen (the Netherlands) was studied. The local psychiatric case registers were used to select patients aged 15 years or more who had at least one contact in 1982 and no contacts in the previous 365 days. Each patient was followed for 36 months after the first contact in 1982. The 2 cohorts differed in size (373 in south Verona and 590 in Groningen), age, diagnosis and pattern of care, whereas the sex distribution was similar. The cohort in Groningen was characterized by a higher number of elderly people, suffering from organic psychoses. Drug dependence prevailed in south Verona, while alcohol dependence was predominant in Groningen. The pattern of care was classified according to 2 basic measures, the gross duration of care and the net duration of care. In south Verona single consulters were almost 3 times more common than in Groningen. In general, patients in Groningen tended to depend more on the mental health services. Linear regression analysis was used to determine the extent to which the pattern of care was predicted by the sociodemographical and clinical characteristics of the patients. Only the site where the contacts were made (south Verona or Groningen) and the diagnosis were significantly associated with the pattern of care.

Adult↗
PubMed1989

Collaboration with families for the rehabilitation of schizophrenic patients and the concept of expressed emotion.

Recent interest in community care of schizophrenic patients has led to publication of a number of studies that deal with patients' rehabilitation in their families. Joint efforts of psychologists, psychiatrists and social workers have produced a number of techniques for collaboration with families of schizophrenic patients, including techniques based on the concept of expressed emotion. This concept is presented with reference to its spectrum consistency in time, generalizability to nonfamily setups, relationship to relapse, prevalence in disorders other than schizophrenia and usefulness in comparison to other concepts in family therapy of schizophrenia. Caution is urged in not incriminating the family in causing relapse, after the quiet abandonment of older theories that blamed families for initiating the illness of schizophrenic members.

Deinstitutionalization↗
PubMed1989

Utilization of psychiatric inpatient care. A study of changes related to the introduction of a sectorized care organization.

Utilization of inpatient care in a catchment area was studied by means of a 4-year comparison before and after a sectorization of the care organization. There was almost no reduction in the number of patients hospitalized, but the number of admissions was reduced by 20% and the total number of days in hospital by 40%. An initial rise in the hospitalization of nonpsychotic patients was found in the new organization, probably because of the increased accessibility and availability of psychiatric care in the catchment area. The rate of hospitalization decreased for schizophrenic patients and remained unchanged for other psychotic patients. There was a significant reduction in rates of readmission, and mean length of stay in hospital was reduced for all groups of patients except patients with a diagnosis of neurosis or personality disorder. A reduction in rates of compulsory care, primarily for patients with alcohol diagnosis, was found. The sectorized care organization has fulfilled the objective of reducing inpatient care. However, great attention must be paid to evaluating new patient categories reached by the development of outpatient facilities, especially in areas where accessibility to and availability of the care organization were formerly low.

Commitment of Persons with Psychiatric Disorders↗
PubMed1990

The new revolving-door patients: results from a national cohort of first admissions.

A cohort of all first admissions to New Zealand psychiatric hospitals and psychiatric wards of general hospitals in 1980 and 1981 was followed up for 5 years. The cohort consisted of 3875 males and 3965 females aged from 15 to 64 years. Of these subjects, 59.4% had only one admission; 14.6% met our criteria for a revolving-door patient, as they had 4 or more admissions within the 5-year follow-up period. Based on first-admission information, patients who were younger and had a psychotic diagnosis had an increased likelihood of becoming a revolving-door patient. Stepwise logistic regression showed that younger age and psychotic diagnosis independently and in interaction were associated with a high probability of becoming a revolving-door patient. Although patients with a first-admission diagnosis of schizophrenia constitute a large group of the new revolving-door patients for both males and females, for women those with affective disorders and for men those with substance abuse comprise the largest proportion of the new revolving-door patients. This is because affective disorders in women and substance abuse in men are the most common diagnoses on first admission, rather than because the disorders themselves are associated with a high probability of the patients having multiple admissions.

Adolescent↗
PubMed1990

From community mental health services to specialized psychiatry: the effects of a change in policy on patient accessibility and care utilization.

In 1975, a community mental health (CMH) centre with most of its resources channelled to outpatient services was set up in a defined catchment area of 75,000 inhabitants near Stockholm. In 1981, the CMH centre was allocated 3 inpatient wards of its own. An outpatient unit to treat long-term psychotic patients was also built up from existing resources. Emergency cases were directed to the primary health care services or to the emergency department of a hospital. During the same period, the number of doctors in the area's primary health care services increased fourfold. The social, demographic and diagnostic composition of the patient population and its utilization of in- and outpatient care in connection with these organizational changes are described. The population of the cathment area increased by 12.5% and the patient population decreased by 40%. The decrease was particularly great among first-time visitors (-54%), patients from lower social groups (-53%) and those with crisis diagnosis (-71%). The number of patients with psychoses increased (+26%). Outpatient visits and hospital utilization increased by one third. The number of compulsory admissions increased by 20% (still being far below the mean number in Stockholm). The decrease in the patient population is attributed to the reduction in accessibility to the CMH centre at a time when primary care services in the area were undergoing a sizeable expansion. The increased care utilization is the result of an internal redistribution of resources in favour of resource-demanding, long-term psychotic patients.

Adolescent↗
PubMed1991

Need for community care among psychotic outpatients.

Psychiatric teams examined a representative sample of 177 psychotic patients in community care. The patients' need for care was assessed using a standardized method. The need for alternative, noninstitutional forms of care (i.e. day and residential services) was greater than the actual use of these services. The same was true of the need for support in social activities, for occupational therapy, training in domestic skills, counselling for relatives and psychotherapy. Unmet needs for care were commonest among patients who were young, who drank heavily, and who suffered from many psychotic symptoms and drug side effects. Outpatient care based primarily on visits to the community mental health centres did not provide adequate services for the most disabled patients. It is concluded that decrease of hospital care has brought a growing need for psychiatric day and residential services among outpatients suffering from psychotic disorders.

Adult↗
PubMed1991

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

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

Activities of Daily Living↗
PubMed1991

Trends in long-stay hospitalization in Denmark: a descriptive register study, 1972-1987.

By means of 4 cross-sections at 5-year intervals from 1972 to 1987, information on long-stay inpatients and daypatients was extracted from the computerized, cumulative psychiatric case register in Denmark. Long-stay refers to continuous hospitalization of more than 1 year. The prevalence of long-stay patients declined from 101 per 100,000 general population in 1972 to 38 per 100 000 in 1987. As the prevalence of all diagnoses declined, regardless of age and sex, it is suggested that the major cause of the observed trends is altered political and administrative strategies, influenced by and influencing altered capabilities and methods of treatment. The trends are described in detail and their implications discussed.

Adolescent↗
PubMed1992

Evaluation of community psychiatry: a cross-sectional study.

This study demonstrates a simple epidemiological method to evaluate the changes in service pattern for a defined catchment area after the establishment of a hospital-based community psychiatry service in Denmark. It measures the number of patients in contact with the service on 2 census days, before the new service was introduced and 3 years later, and deals with quantitative measures of sex, age, diagnosis and type of service contact. The services for 2 other areas are used as controls. A new community psychiatry service with an office situated outside the hospital is described and is shown to be superior to both the psychiatry service from the hospital and the rest of the hospital service: the number of inpatients and day patients were reduced by 42% vs 12% and 16% respectively. The number of outpatients increased by 104% in the new service compared with 23% for the service located at the hospital. The increase in outpatient care for the service outside the hospital was mainly caused by contact with middle-aged women with personality disorders.

Adult↗
PubMed1992

Housing conditions and residential needs of psychiatric patients in Copenhagen.

A study of the extent of homelessness among 1581 psychiatric patients in Copenhagen found that 342 patients (22%) in contact with the psychiatric services had serious housing problems. A total of 112 (7%) were long-stay patients without a home address, 134 (8%) were in an unstable housing situation and 96 (6%) were actually homeless. The homeless among the psychiatric patients were characteristically single, on disability pension or general public assistance, most often under 45 years of age, often schizophrenic and, among the men, almost one third were alcohol abusers. The majority of the homeless preferred separate apartments, and the psychiatrists also considered this form of housing to be the most appropriate for them. Approximately one fifth were estimated to need staff-supported housing, and the number of places in psychiatric group homes or halfway houses should therefore be increased.

Activities of Daily Living↗
PubMed1993

Mortality in Danish psychiatric long-stay patients, 1972-1982.

By use of the computerized, nationwide psychiatric case register in Denmark, 3 cohorts of psychiatric patients hospitalized for at least one year in 1972, 1977 and 1982, respectively, were identified and followed until April 1, 1988, regarding cause of death. A decline in overall excess mortality compared with the general population was seen from the 1972 cohort to the 1982 cohort irrespective of sex, age group and diagnosis. To analyse cause of death, 298 long-stay patients at Aarhus Psychiatric Hospital were followed for 5.5 years. Lung diseases caused the highest excess mortality. The authors emphasize that risk of death in long-stay patients below 50 years of age is still fourfold compared with the general population and point to the necessity of improving medical care.

Adult↗
PubMed1994

A latent variable causal model of the quality of life and community tenure of psychotic patients.

Services are intended to maintain patients in the community while improving the quality of their lives. The purpose of this study was to determine the extent to which psychiatric patients' diagnoses, levels of autonomy, objective living conditions and degree of service utilization are associated with their perceived quality of life and, in turn, community tenure. A latent variable causal model was developed and tested using data from 152 schizophrenic and affective psychotic patients. Information was obtained using a semistructured interview, a quality of life scale, ratings on the Global Assessment Scale and patient hospital records. Results indicate that greater autonomy is significantly associated with greater perceived quality of life and that greater quality-of-life ratings are associated with greater community tenure.

Activities of Daily Living↗
PubMed1994

Does community care reduce the need for psychiatric beds for schizophrenic patients?

For schizophrenics, the closing down of the old traditional hospital has in many places ended up in a scenario characterized by homelessness, relapse, patients overcrowding acute psychiatric but also somatic hospital wards, increased suicide figures, low living standards--and an increased burden on the family. The beds for schizophrenics have been considerably reduced in many countries. For schizophrenia the critical low number of institution beds--hospital as well as nursing home--seems to be 0.07% of the general population. Schizophrenia in all phases must be treated as the disease it is, not as a social problem.

Adult↗