Search

In 2013 at the Rodewisch Clinic for Psychiatry, four folders were found that contain original documents from the office of former head of the clinic Rolf Walther. These original sources provide new insights into the organisational background of the International Symposium on Psychiatric Rehabilitation of 1963, as a result of which the groundbreaking Rodewisch Propositions were framed. The documents founds reveal that, apart from the persons already identified, Halle/Saale - based hygienist Karlheinz Renker was deeply involved in the preparation of this event. They also show that for ideological reasons the GDR Ministry of Health restricted the number of participants from non-socialist countries, in particular Western Germany, to be admitted. Finally, the sources suggest that a volume compiling all talks given at the symposium as one publication and as such making its content and resolutions known to a wider public failed, among other reasons, due to the fact that Karl Leonhard, then head of the GDR Association for Psychiatry and Neurology, was "not interested" in it.

In this observational study indicators for the quality of psychiatric care in a psychiatric hostel will be examined for all residents over a period of 7 years.Data has been collected at an annual basis. Relationships among variables have been analysed by means of random effects regression analyses for longitudinal data.GAF score increases slightly. Number of psychopharmacological drugs and neuroleptics as well as inpatient costs remains stable. Psychiatric treatment costs are negatively related to the functional level, residents' age and the duration of stay in the residential facility. Even under control of several variables, variance of total costs was found to be mainly explained by the costs of inpatient and psychopharmacological treatment.Increase of the general functional level indicates a positive development of autonomy. Changes and the influence factors of psychopharmacological treatment may indicate a need-oriented drug therapy. Some findings may indicate an institutionalisation process and an increasing of medical conditions in chronically mentally ill people.

This study analyzes, to which extent clients formerly detained in forensic psychiatric units can be integrated into the community and what kind of assistance they need.Analysis of basic documentation in community mental health care in 2 regions.Integration into the community is feasible. Former forensic patients are more likely to show aggressive behaviour than clients without forensic history. These aggressive acts nevertheless can be handled. Aggressive acts decrease with the duration of integration. Crisis interventions are not more frequent in patients with forensic history.Integration of patients who are "difficult to place" into a community can be accomplished by community based services with obligation to provide assistance.

In the end of the deinstitutionalization of "old-long-term" hospitalised patients, restrictive psychiatric homes were created on the grounds of psychiatric hospitals exclusively to take in the remaining "difficult-to-place" patients. However, new chronic mentally ill persons have been accumulating in these institutions since then. This study analyses the characteristics of the "new long-stay" population.Interviews with all patients and their caring staff in eight hospital-hostels in one German federal state.Characteristics and reasons for admission as well as for previous exclusion from the established community care were found in a marked requirement for control and surveillance as well as need for help and high dependence in everyday life, markedly dissocial behaviour and low social functioning.Despite there are promising opportunities specific programs that are effective to prevent a subgroup of chronic mentally ill persons from inappropriate re-institutionalisation, exclusion or forensic psychiatry are not yet sufficiently provided by general psychiatric services.

In the last decades, long-time patients were systematically discharged from psychiatric hospitals in order to integrate this disadvantaged population into the community. This procedures where adequately evaluated and are regarded to be completed in the western world today. However, few evidence has been presented regarding the further course of integration following discharge from mental hospitals: was integration into community really successful or were patients permanently placed in sheltered housing staffed 24 hours 7 days a week. This review focuses on the question whether papers describing large de-institutionalisation projects mention the level of institutional support in the years following discharge from hospital. Furthermore we tried to find out which parameters are dealt with when describing successful community integration."Pubmed" was searched for studies on de-institutionalisation projects published between 1997 and 2007.The discharge from the mental hospital wards was in all studies described as successful, positive effects like an increased quality of life were found. However, studies describing the years following discharge mentioned that patients continuously stayed in sheltered housing with care offered 24 hours a day.Reviewing the available data about the level of support regarding accommodation of former long time patients, the danger of "trans-institutionalisation" has to be pointed out. Evidence is lacking concerning support models tailored to the individual needs of the patients. Similarly, possible side effects of long-term stays in sheltered housing staffed 24 hours a day have not yet been established. Therefore, we see a need for further evaluation of different models of supported housing for former long-term hospitalised patients, as well as for new chronic mentally ill patients.

The study was intended to evaluate the therapeutic and healthcare services utilized by 116 former long-stay patients after an average of 42.9 months of deinstitutionalization during a follow-up time of (1/2) year and to calculate the costs thus incurred.116 patients and their caregivers were interviewed during a period of 6 months using the German version of the Client Sociodemographic and Service Receipt Inventory.On average, 3.3 institutions/facilities were contacted per patient, most often by younger patients living in group homes and least often by patients in psychiatric nursing homes. During the 6-month follow-up time costs of euro 14,665 were incurred per patient. Of these costs, 87.2 % were for the residential facilities. The costs of outpatient care accounted for 41.4 % of the costs that would have been incurred for inpatient care in a psychiatric hospital.Deinstitutionalization of psychiatric long-stay patients in Upper Austria provided for considerable reductions in costs while maintaining a high quality of care.

The aim of this study was to assess the needs for care of 116 former long-stay patients during the first 42.9 months after discharge.Patients and mental health professionals rated needs using the "Berliner Bedürfnisinventar" (Berlin Needs for Care Inventory).Out of a total of 16 needs areas, patients reported a mean number of 7.6 needs, therapists reported 10 needs. Patients with lower global functioning scores showed a significantly lower number of needs, while patients living in psychiatric nursing homes and patients with learning disabilities had a significantly higher number of needs. In most areas, agreement between patients' and therapists' assessment was good to moderate. In most areas the rate of unmet versus total needs was above 90 %. Patients received help almost exclusively from institutions or mental health services.The care needs of discharged patients were generally met and placement in institutions was considered appropriate.

In Germany the competent institution for supported housing for mentally ill and handicapped persons is traditionally the regional welfare authority, while welfare authorities on state (Lander) level hold the competencies for accommodation in hostels and homes: Assessment of the impact of policies that try to overcome this separation of competencies.1. Analysis of the practise of distributing the competencies for accommodation for mental ill and handicapped persons in the 16 German Lander. 2. Assessment of the supply with accommodation for mental ill and handicapped persons in the Lander. 3. Investigation of a possible relationship between distribution of competencies for accommodation and number of accommodation in supported housing and hostels/homes.Data about available accommodation in supported housing and hostels are inconsistently limited and available. As far as this data can be interpreted, Lander that have the administrative and particularly financial competency for accommodation uniquely organised, generally offer more supported housing. At the same time they provide relatively less accommodation in hostels and homes. Despite having the competencies for accommodation uniquely organised, some Lander continue to provide accommodation for mentally ill persons predominantly in hostels and homes.A comprehensive and between the Lander comparable system of documentation of accommodation for mentally ill and handicapped persons is highly needed. Unique organisation of competencies for accommodation of mental ill and handicapped persons is a necessary - however not commensurate precondition for the increase of the supply in supported housing. Beyond that, other factors seem to be influential, such as political will, attitudes towards the mentally ill, interests of hostel providers, pre-existing hostel infrastructure. In respect of these factors more research is needed.

In Upper Austria, a total of 409 long-stay patients were discharged to various residential facilities between 1995 and 2000. This paper describes psychopathology and sociodemographic characteristics.A random sample of 116 former long-stay patients were followed for an average 42.9 months after discharge.Patients had spent an average 19.3 years in psychiatric wards. 47 patients (40.5 %) were placed in nursing homes, 16 patients (13.8 %) in old-age homes, 32 patients (27.6 %) in other institutions and only 15 patients (12.9 %) in group homes, and 6 patients (5.2 %) with families. ICD-10 diagnosis was schizophrenia in 56 patients (48.3 %) and mental retardation in 33 patients (28.4 %). Level of social and functional disabilities was high.Most long-stay patients were able to live outside psychiatric hospitals, but institutional care still plays an essential role.

To obtain indicators for the setup and further development of appropriate provisions for relatives of long-term schizophrenia patients in Tyrol (Austria), the quality of life of the main caring relatives of these patients was assessed and compared to that of a control group from the general population. In addition we were interested in identifying variables that may be useful predictors of the relatives' quality of life.Fourty-four relatives of long-term schizophrenia patients and 90 controls of the general population were included in the study. To assess their quality of life we employed the generic questionnaire WHOQOL-100, complemented by own questions reflecting the special situation of the relatives.The quality of life of the relatives was significantly lower than that of the general population in almost all domains assessed. Fear of discrimination, concern about the care of the patient in later life and the feeling of a lack of security because of the patient correlated significantly with a reduced quality of life of the relative. Living in separate households went along with a higher quality of life of the relative. The association between the relatives' quality of life and their involvement in self-help groups or patient participation in social-psychiatric rehabilitation was unexpectedly low.The results of our investigation indicate in which domains there is a need to improve mental-health services and to develop and extend efforts of self-help groups in order to raise the quality of life of relatives of long-term schizophrenia patients.

If one changes the paradigm--what should be changed, what has been changed? Even today, the number of beds at the department head's disposal represents power. Is power the purpose of psychiatry? Rather isn't the purpose the adequate treatment of a mentally impaired persons, about adequate support in a natural environment? In our society, and in particular in psychiatry, the striving for power must be questioned. Our memory of the deportation and the disappearance of mentally ill, of the extermination of "unworthy life", of Hartheim, Grafeneck and Brandenburg is still too fresh. It is imperative to convey the idea of a life worth living even then when this seems hopeless to us. Outpatient psychiatric care has bid farewell to outdated conventional structures, which in their time under certain social conditions had proven not to be unreasonable. Outpatient psychiatric care is about the rediscovery of a sense of life that gives reason for hope. Only the joint contemplation of new resources can bring us forward.

The paper aims to identify perspectives for future mental health care.Personal reflection based on the history of mental health care, own experience and current developments.Mental health care and the relationship between patients and professionals within it have changed significantly in the last five decades. Current developments may be seen as characterised by a) a widening remit of mental health care with an increasing clientele with non-severe mental disorders; b) re-institutionalisation for the severely mentally ill, e.g. with a rising number of forensic beds; and c) a tension between consumer orientation in a post-modern society and dominance of evidence-based medicine. Mental health care has always lived in a balance between social control and therapeutic aspiration. Yet, we now seem to witness a stronger split between the two with re-institutionalisation for patients with severe mental illnesses who might upset the public on one hand, and a growing private market of various treatment options for patients who actively seek treatment and can--directly or indirectly--pay for it on the other. This leads to the anticipation of positive as well as negatives scenarios for the future which are briefly described and contrasted.

In the controversy about severely chronic mental patients, who still reside in the psychiatric hospital after decades of deinstitutionalization, their quality of life (QoL) has become a main topic. On the basis of a critique of the dominant, mere standardized approach to QoL this method is compared with a qualitative approach in such a schizophrenic "residual" patient group (n = 144). While in the standardized approach a high level of subjective QoL could be found that correlated positively with the duration of hospitalisation, the open interviews yielded specific experiences of deficiencies. The appraisal of the quality of life especially of chronic or hospitalized patients is reconsidered.

This paper analyses, in what way psychiatrists considered housing and work as criteria of social integration of mentally ill people and what models of care were suggested in Germany throughout the 20th century.Publications in 29 German professional and scientific psychiatric journals through the complete period from 1900 to 2000 and monographs were searched for papers on the above issues.Until the second half of the century, integrative initiatives related to housing and work generated in asylums without the aim of a full social integration of the patients. In the activistic concept of NS-psychiatry, work became an obligation for patients and a criterion for selection that decided on life and death. Not until the late 1950s, there again was an orientation towards integration in psychiatric care in both German states. Whilst already in 1963 the "Rodewisch Theses" outlined recommendations for the rehabilitation of the mentally ill already in the GDR (East Germany), a similar mark of reform ideas was published in the "enquete" in the FRG (West Germany) in 1975. In the GDR initiatives were limited to a small number of locations. In the FRG and the re-unified Germany various forms of sheltered housing and work were established - also with significant regional variation. However, a clear discussion of underlying aims and implications for the structure of mental health care was not found in the psychiatric literature.In the 20th century a tradition of psychiatric ideas related to housing and work did not develop in Germany. Particularly, there were only sporadic contributions from university psychiatry. Work was more frequently explicit subject of discussions than housing. Both areas were - slowly and in discontinuity - established as criteria of integration of people with mental illnesses, which was increasingly accepted as an aim of mental health care.

Long-standing processes of deinstitutionalization often display processes of selection that result in groups of patients with marked disability profiles left in hospital. According to the literature socially deviant and unacceptable behaviour are a main obstacle to living in the community. Therefore, a group of "remnant" chronic schizophrenic patients was analysed by means of a latent class analysis with indicators of social behaviour and compliance. Three different subgroups were found, one of which had an extremely poor level of adaptation. However, prognosis of staff with regard to patients' ability to live outside the psychiatric hospital, and the rates of patients being moved into the community in the course of subsequent deinstitutionalization were not different among the three groups. Characteristics of "most-difficult-to-place patients' " as discussed in the literature are called into question on the basis of the results of this study.

In part IV of the Berlin Deinstitutionalisation Study, we reported a positive change in quality of life for 65 resettled patients one year after discharge. In this part, we investigated changes in a longer follow-up period.A group of 66 patients discharged into supported housing was assessed one and five years after baseline. Quality of life, needs for care, patients' assessment of treatment, re-hospitalisation and characteristics of care were studied in a control-group design.After five years, 61 % of the patients continued to live in highly staffed settings (mean staff-patient-ratio: 1 : 3.5). Eleven percent had moved on to independent living and 16 % had returned into an institutional setting. Standard mortality ratios were 4.4 (all causes of death) and 62.5 (2 suicides only of schizophrenic patients). After one year patients (n = 20) showed a significant increase in satisfaction with their living situation and more social contacts. Over the longer period of time, there were also favourable changes, which failed to reach statistical significance (n = 24). Average length of inpatient stay per year of the illness was decreased significantly at both follow-ups.Interpretation of the findings is difficult because of the small sample size and selection effects. Most of the former long-stay patients appear able to live in the community with a significant decrease of time spent in hospital. Whilst patients were particularly satisfied with their accommodation at one year follow-up, this did not lead to a generalised improvement in subjective quality of life and other subjective criteria in the long term. In line with other recent studies on community mental health care one may conclude that small case loads alone do not have major beneficial effects. Further research should evaluate more systematic and targeted models of mental health care in the community in general and of supported housing in particular.

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.

After the German reunification the deinstitutionalisation of long-term hospitalised psychiatric patients and the restructuring of the complementary psychiatric care has become necessary in the "new" German states. Hereby it became possible to offer alternative residential settings and new community-oriented care programmes for the mentally disabled.Ten years after the beginning of this process we analysed the impact of the housing conditions and the subjective satisfaction of 245 chronic schizophrenic patients living in different residential care-settings or with family resp. on their own in the Dresden region. Additionally we asked for the satisfaction with the organisation of the deinstitutionalisation process.The subgroups--defined by the residential setting--differ in sociodemographic variables and in the levels of psychopathology (PANSS) and social disabilities (DAS-M). It is shown how deficiencies and restrictions of the living situation and the deinstitutionalisation process are reflected in the respective judgments of the patients especially referring to autonomy and self-determination.Requirements for the further development of the complementary psychiatric care system are deduced.

Since the 1980's psychiatric care in Spain changed considerably (Reforma psiquiátrica española). In the course of this reform, many positive results were achieved. An extensive community network of mental health centres was build up which resulted in the majority of psychiatric patients being integrated in the Spanish general health care system and making a better organized mental health care structure possible. New legislation also improved the care and civil rights of patients. An analysis of the experiences of the Spanish psychiatric reform shows that the tendency to retain the old mental hospitals, alongside the other institutions still exists. The process of deinstitutionalization and the original aims of the psychiatric reform cannot only be satisfied by the closure of large psychiatric hospitals as during the reform new aspects and problems as well the great complexity of the task have become apparent. This article together with the details of the Spanish sources gives the German public a good overview of the developments in Spanish psychiatry.

The reform of psychiatric services started in Germany in 1975 with the publication of the governmental "Enquete"-Report. In the area of housing for chronic patients the recommendations made 1975 have not been fulfilled. A greater number of chronic patients as planned live in institutionalised homes with little access to the community and shortcomings in the area of individual self determination. The process of deinstitutionalization of the old chronic patients from psychiatric hospitals has created new problems. Some 60,000 patients have been deinstitutionalized, but in some parts of the country to a considerable degree just by renaming parts of the hospital into a home for the disabled. There is a need for research on who lives where and how and efforts have to be made to change this situation by the development of more community centered and individualised forms of living as shown by many successfully working regions in the country.

Psychiatric reform and the current system of mental health care in England are outlined, the system context of the National Health Service (NHS) is described. Recent institutional change in the NHS has introduced internal market elements. More than 90 mental hospitals have been closed. The TAPS study, a longitudinal study evaluating mental hospital closure is described. Results show a range of advantages of the post-discharge care arrangements. Studies evaluating services with a home treatment and community focus (DLP, PRiSM) suggest that community mental health care is feasible. Shortages and problems of the current system of care (acute beds, intensive residential and rehabilitation services) are outlined.

The article summarizes in an international perspective what kind of results psychiatric deinstitutionalization has brought so far: a profound change of size and functions of the psychiatric hospital; better services for people with less severe problems; and the failing of community services to compensate for some of the functions of the former asylums, resulting in trans-institutionalization and/or neglect for many chronic patients. Three different sociological versions to explain the background and typical outcomes of psychiatric deinstitutionalization have been brought forward so far: political economy, professional dominance and post-structuralism. They are confronted with an approach using the concept of medicalisation which offers a more comprehensive understanding of the process.

Deinstitutionalization is a complex process that in the past was often misunderstood solely as a run down or even closure of psychiatric hospitals. Although chronically mentally ill patients were prevented from long term hospitalisation some fundamental mistakes were repeated often: patients were simply discharged without any preparations and outpatient care was badly organised. In some cases this led to therapeutic neglect, social disintegration, homelessness, incarceration or other forms of dramatic loss of quality of life. These findings are internationally confirmed although there are remarkable differences between various health care systems. Especially when primarily determined by purely economic interests deinstitutionalization constitutes a severe danger for the whole psychiatric system of care and in particular for chronic patients. Intensive research is required to avoid severe disadvantages for the further development of psychiatry.

The special position of psychiatry among the various medical disciplines is determined not least by the phenomenon of violent behaviour of some of its patients and the possibility of coercive measures against patients. The worldwide process of deinstitutionalization since the last decades is characterized by a substantial reduction of inpatient treatment and the expansion and improvement of increasingly specialized community care offers. Yet, at the same time paradoxically we are confronted with an increasing neglect of the special care requirements of a certain group of difficult-to-place patients (mostly severely chronically ill with high rates of comorbidity). Despite different social and legal conditions this has uniformly led to an increasing shift of these patients into the forensic system which is illustrated by a comparison of international and Austrian data. Forensic psychiatry is hardly able to cope with this development because of structural and personal deficits existing and is in danger of being misused primarily as an instrument of social control. From the position of forensic psychiatry the limits of deinstitutionalization are set by the feeling of responsibility of general psychiatry for a subgroup of troublesome and difficult to treat patients.

Following a historic introduction the development of the chronics' departments of the big psychiatric hospitals in Saxony since 1990 is described: the goal of ending the care of the chronic mentally ill younger than 65 years in these departments, the newly restructured care of the mentally ill in Saxony and the problems attached to these processes.

Two perspectives of mental health care in Leipzig are outlined. Critical aspects of deinstitutionalization are discussed from the point of view of an office-based Nervenarzt (neurologist and psychiatrist). The limitations of office-based practice in providing care for the severely mentally ill (SMI) are described, i.e. lack of a multidisciplinary community mental health team, community psychiatric nursing and social work back-up in particular. Residential service and nursing homes are often under-staffed and ill-prepared for caring for people with SMI. A second view-point describes the Verbund Gemeindenahe Psychiatrie, a community psychiatric service for the just under 500,000 population of Leipzig in seven community mental health centers each combining day hospital, out-patient clinics and multidisciplinary community psychiatric care. This service is unique in Saxony and well accepted by service users and professionals.

The article shows the development of the long-stay departments at the psychiatric hospitals in Eastern Germany from the perspective of a local government. Against the apparently increasing scepticism of concepts of de-institutionalisation, the example of the city Leipzig is used to show how the process of reintegrating residents of long-stay institutions can be supported, and how decentralized out-patient psychosocial services--which can also be used by the community inhabitants--can be built up at the same time. Reference is also made to the well-developed out-patient services and clearly structured treatment offers for the inpatient sector which have already existed in the city before the political changes in Eastern Germany. Further, the role of the local Social Welfare Office in the realization of de-institutionalisation projects will be outlined.

In 1998, the 1876 founded "preussische Provinzialirrenanstalt", a large asylum in Merzig (Germany), was closed down. Instead several psychiatric departments were founded in the rural county ("Bundesland"). On the asylum's former area in Merzig a new and modern general hospital including a psychiatric department was established. The present article will show up the former psychiatric hospital's genuine working fields, treating violent, self-harming and mental ill people needing help. It will describe in a differentiating way how the new services for the different groups of mental ill persons run: Decentralized general psychiatric care in defined regional areas (without forensic patients), central treatment for the forensic patients, regional care for people with mental retardation. In completion of this network there exist regional solutions for the themes "living in a own home", "Working and occupation" and "day-structuring". In conclusion, deinstitutionalization will not have any limits, despite of a few exceptions, if the limits of institutional thinking can be overcome.

After a hopeful beginning, the social process of the reintegration of those with severe mental illness has come to a standstill. I am led to wonder whether "the community" really wants to live together with people suffering from severe mental illness, and if so, how closely? As long as the medical treatment of mental illness provided by the general practitioners is fundamentally deficient, as they are not able to prescribe the necessary interventions--such as out-patient psychiatric nursing, and service providers in the out-patient sector are content with offering increasingly intensive forms of care for the less seriously ill at the cost of the Social Welfare System--the reintegration of those with serious mental illness remains an illusion--which is mainly to the benefit of providers of residential care in homes and hostels.

During the last eight years we arranged an extensive process of change in Eckardtsheim, a part of Bethel in the city of Bielefeld. As part of the process of deinstitutionalization we tried to change institutional needs into the needs for help and support of the individuals. One important part of this process was working with family members of our clients in a variety of intervention strategies. We evaluated the relatives within the concept of customer orientation in different viewpoints. All family members got a mailed questionnaire (n = 1,068) in which they were questioned on their expectations and satisfaction with the most important aspects concerning the cooperation between family members and the treatment of the patients. We implemented support programs for the family members and asked them to judge these programs and the general process of change in the institution. 42% answered, mostly brothers and sisters. We received general support for our programs with a lot of individual criticism to certain parts of the process. Brothers and sisters were sceptical about deinstitutionalization of patients who had been institutionalized for decades. Working with families in these situations demands different ways of intervention, like information about the hospitalized family members and about the institutional change process as well as individualized support for the family members themselves. Services for the family members of long term hospitalized patients are extremely important and necessary for a positive outcome in the process of deinstitutionalization.

The aim of the study is the evaluation of essential characteristics of patients who entered the sheltered group homes of the Psychosozialen Dienst (PSD) in the city of Vienna after the establishment of sectorized psychiatric out-patient care facilities.Eighty patients who lived in these group homes on the first key day, June 30th 1993, were investigated. Any change in their living situation and rate of hospitalization was ascertained at follow-up, 3.5 years after the first key day.The patients had an average period of hospitalization of 240.5 days per year before entry to a group home, which decreased to 12.4 days per year after entry to a sheltered group home. At follow-up more than half of all patients (65%) were still able to live in the community successfully. The number and the length of hospitalizations between the first key day and the follow-up were lowest for patients who had moved to private homes.Sheltered group homes play an essential role in the process of rehabilitation towards independent living within the community. The results demonstrate that rehabilitation in private apartments can be possible even after 5.7 years of residence in sheltered group homes.

In a cross-sectional study in 79 schizophrenic patients the quality of life (QOL) of a group of community-based patients under supervision of an outpatient unit (n = 47) and a group of long-stay patients in an inpatient rehabilitation centre in the same area (n = 32) was compared.The patients' QOL was evaluated using the Lancashire Quality of Life Profile. Moreover psychopathology and extrapyramidal-motoric side-effects were assessed.Long-stay patients had a more distinct psychopathological symptomatology and more severe side-effects than community-based patients. After adjustment for psychopathology and side-effects, the subjective QOL of long-stay patients was significantly reduced in two out of eight life domains: housing and leisure activities. While psychopathology was negatively correlated with QOL, a subgroup with very marked psychopathology showed unexpectedly high QOL ratings.Results suggest that psychopathology is a stronger predictor of subjective QOL than side-effects and treatment setting. Patients with very distinct psychopathology probably use lower standards than others when evaluating their QOL which should be taken into consideration when analysing this type of data.

42 percent long-term patients from the Berlin Deinstitutionalization Study sample have been discharged to full-time institutional settings.The questionnaires of a mail-survey covered features of 58 different non-hospital full-time institutional settings and care for a group of 125 long-term mental patients.The return rate was more than 70 percent. For 78 percent of the discharged former long-term inpatients the political goal of complete psychiatric care in the patient's home area has been reached, but only 20 percent live in smaller institutions of up to 40 places.The significance of other data of the survey does not exceed that of stock-taking and certain indications because of the selective data and the limitations of the method. There is an urgent need for further research in examining the quality of non-hospital institutional care for psychiatric long-term patients.

In 1996, the available number of hospital beds for inpatients care in psychiatry, psychotherapy and psychogeriatrics in Sachsen-Anhalt amounted to approximately 0.4 beds per 1,000 inhabitants. As compared to 1992, when most beds were still concentrated in four large psychiatric hospitals, some decentralisation had been achieved. Now, 13 of 23 catchment areas have clinical facilities of their own, five of which were newly founded. About 800 of 1,346 beds and 245 of 299 day hospital places are now located outside the former large institutions. Some of the recently established facilities, however, are not yet sufficiently equipped to serve their catchment areas, with regard to appropriate size, room, staffing, internal specialisation and authorization to cope with compulsory admissions. Even in general hospitals, psychiatric departments are often separated from the main building, with the spatial distance providing some obstacle to the desired cooperation of psychiatry with other medical specialties.

35 years ago the so-called Rodewisch theses were developed as the results of an international symposium on psychiatric rehabilitation. They were a recognised guideline in psychiatry in the GDR. During the implementation of the theses, ideological and financial limits were soon reached. Several aspects of the theses, such as decentralisation of psychiatric care, the creation of an open psychiatric system and continuity of care are still highly relevant today.

The psychiatric services of the Swiss region of Basel-Landschaft observed an increasing deterioration and shortage of accommodation offers for mentally ill persons. At the same time, it grew temporarily more and more difficult to let single rooms in flat-sharing communities. Therefore a psychiatric services research project aimed at evaluating the wishes and needs of specialists in the housing sphere, and of about 600 in- and outpatients, as well as for their caregivers. The results showed, similar to other studies, on the one hand patients' predominant wish to live independently, whereas on the other hand there was a great difference between the views of patients and their caregivers. The latter view this aspiration for independence rather skeptically. The striking disagreement between patients and caregivers may be fruitful for the therapeutic process; however, this applies only if both partners are aware of this fact.

Objective living situation, subjective quality of life, need for care, and assessment of treatment of long-term hospitalised patients were investigated.237 patients from 6 hospitals were examined using standardised instruments.Patients' satisfaction was generally relatively high, but varied greatly in subgroups and individuals. Patients were most satisfied with personal safety in the hospital and least satisfied with the expectation to live in the hospital for a long time. Therapists assessed clearly more needs for care in the patients than the patients did themselves. Statistical analysis revealed significant correlations between the subjective quality of life in different domains, the number of needs stated and plausible determining factors.Findings reflecting patients' living situation in the hospital are very heterogeneous. In respect of subjective evaluation criteria, there is little space for improvement in the future.

This study aimed at the systematic assessment of the burden imposed on the relatives of mentally ill persons. A postal survey was carried out on a sample drawn from the members of the Federal Association of Relatives of the Mentally ill (n = 557).Almost one third of those questioned experienced the care for their relatives as a heavy burden, a further third said that the burden was moderate. Among the negative consequences, health impairment was cited most often. Two-thirds of the participants reported constraints on their everyday life and the organisation of their leisure time. A (partly considerable) financial burden was cited with similar frequency. Further, the illness had a negative impact on the personal relationships of the caregivers. A quarter of the sample had lost touch with other family members. The same was found with regard to contact with friends. One-third reported discrimination by their environment.The results emphasize the necessity of creating opportunities to relieve some of the burden on relatives.

With a mean duration of hospitalisation of 28 years the patients of a long-term hospital had on the average only 2.6 visits from outside in one year. Above all the frequency of visits depended on the age, the duration of illness, the distance of the hospital to the homes of the patients and on communication inhibiting symptoms. In a three years follow-up the social integration of patients could be improved by specific rehabilitative treatment. Contacts to persons from outside the hospital and activities inside increased significantly. Improvement was not possible for patients whose homes were very far away and who had communication inhibiting symptoms at the outset of the follow-up.

The development of the care of mentally ill persons in the last 25 years is shown by the example of the district of Tübingen with about 200,000 inhabitants, a district that did not take part in the model program of the Government. Considering the current care situation, the problems of cooperation and coordination as well as the ensuring of quality, which are actually most important, are discussed; approaches for solutions are outlined. We try a view on the coming 25 years.