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Objective: The study aimed to identify patient characteristics associated with differences in outcomes of acute treatment in day hospitals and conventional hospital wards.Methods: Data were from the European Day Hospital Evaluation (EDEN) (2000-2003), a multicenter randomized controlled trial comparing acute treatment in day hospitals and conventional wards in five European countries. All 880 adult patients in the EDEN study who had a diagnosis of schizophrenia, mood disorders, neurotic disorders, and behavioral syndromes (ICD-10 codes F20-F59) and complete data on baseline variables were included. Outcomes were symptom levels (Brief Psychiatric Rating Scale), subjective quality of life (Manchester Short Assessment of Quality of Life), and social disability (Groningen Social Disabilities Schedule) assessed at discharge and at three and 12 months postdischarge. Mixed- and main-effects models of interaction effects between patient characteristics and outcomes were generated.Results: Patients' age, diagnostic category, and living status (alone or not) did not predict differences in outcomes between the two settings. However, patients with higher symptom levels at baseline experienced greater symptom improvements after treatment on a ward, and those with more years of education had greater symptom improvements after day hospital treatment. Female patients had more favorable social disability outcomes after day hospital treatment, but no difference between the two settings was found for male patients.Conclusions: More severe symptoms may be a reason for admission to acute treatment on a conventional ward rather than a day hospital. Female patients and those with more education may benefit more from acute treatment in day hospitals. [ABSTRACT FROM AUTHOR]

Background: Although the fluctuating nature of suicidal ideation (SI) has been described previously, longitudinal studies investigating the dynamics of SI are scarce., Aim: To demonstrate the fluctuation of SI across 6 days and up to 60 measurement points using smartphone-based ecological momentary assessments (EMA)., Method: Twenty inpatients with unipolar depression and current and/or lifetime suicidal ideation rated their momentary SI 10 times per day over a 6-day period. Mean squared successive difference (MSSD) was calculated as a measure of variability. Correlations of MSSD with severity of depression, number of previous depressive episodes, and history of suicidal behavior were examined., Results: Individual trajectories of SI are shown to illustrate fluctuation. MSSD values ranged from 0.2 to 21.7. No significant correlations of MSSD with several clinical parameters were found, but there are hints of associations between fluctuation of SI and severity of depression and suicidality., Limitations: Main limitation of this study is the small sample size leading to low power and probably missing potential effects. Further research with larger samples is necessary to shed light on the dynamics of SI., Conclusion: The results illustrate the dynamic nature and the diversity of trajectories of SI across 6 days in psychiatric inpatients with unipolar depression. Prediction of the fluctuation of SI might be of high clinical relevance. Further research using EMA and sophisticated analyses with larger samples is necessary to shed light on the dynamics of SI.

Background: Substance use disorders are associated with unemployment. An employment-focused case management (CMRE) has been conceptualised as a specific intervention to help substance use disorder patients return to competitive employment immediately after inpatient rehabilitation. This study investigated the effect of the intervention on return to work of persons with substance use disorders., Method: The study was conducted in four German inpatient rehabilitation departments, and included unemployed patients (aged between 18 and 63 years) with a main clinical diagnosis of ICD-10 F10-19 disorders. Six weeks before discharge, patients were randomly allocated to CMRE or standard care (SC) using a quasi-randomised approach. The primary outcome measure was integration into competitive employment 24 months after discharge from rehabilitation. Secondary outcome domains were abstinence, duration of employment, proportion of publicly funded employment, satisfaction with life, precarious housing situation and precarious financial situation, and use of follow-up services. Outcome measures were assessed 6 weeks and 1-2 days prior to discharge, and 12 and 24 months after discharge from rehabilitation., Results: One hundred sixty patients were allocated into the CMRE group and 160 patients into the control group. 267 resp. 179 participants could be included in the analyses performed for the 12-, and the 24-months follow-up assessments. At the study endpoint the rate of integration into the primary labour market was 35.6 % in the CMRE group and 41.2 % in the control group, respectively (Relative Risk 0.92, 95 % CI, 0.47; 1.79). There was a significantly higher proportion in the CMRE group, however, which immediately after discharge linked with services of the Federal Employment Agency or Job Centres. There were no statistically significant differences in other outcomes between the groups., Conclusions: Compared to SC, the additional specific CMRE intervention did not result in superior effects on return to work rates, abstinence, satisfaction with life, and housing and precarious financial situation. But CMRE was more effective on linking substance use disorder patients with services of the Federal Employment Agency or Job Centres. Reasons for the finding that such close linking does not have an impact on return to work rates are discussed in detail., Trial Registration: Identifier: DRKS00003574 ; March 12, 2012. The trial was retrospectively registered.

Background: Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied., Methods: 291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed., Results: When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men., Conclusions: Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the "excitement/hostile" cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

The general aims of this article are: a) to cover the current status of research on the important clinical and human rights issue of involuntary psychiatric hospitalization, and b) to discuss some factors which might influence future developments in this area of mental health care provision. Firstly, the article will outline main results from two literature reviews on outcomes of involuntary hospital admission. Secondly, selected results from the clinical part of a recent European multi-site research project on coercion in psychiatry (Acronym: EUNOMIA) will be presented in detail on the following issues: the association of patients' views of involuntary hospital admission and differences in legislation, patient characteristics associated with more or less positive outcomes of coerced hospital admission, coercive measures (e.g. mechanical restraint, seclusion and forced medication) used during these hospitalizations. Thirdly and finally, the article will shed some light on future prospects of this topic. Thus, some recommendations for best clinical practice in the use of involuntary hospital admission will be discussed, and arguments for two future scenarios, increase vs. decrease of involuntary psychiatric hospitalizations, will be contrasted and analyzed.

Objective: Involuntary treatment in mental health care is a sensitive but rarely studied issue. This study was part of the European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice (EUNOMIA) project. It assessed and compared the use of coercive measures in psychiatric inpatient facilities in ten European countries., Methods: The sample included 2,030 involuntarily admitted patients. Data were obtained on coercive measures (physical restraint, seclusion, and forced medication)., Results: In total, 1,462 coercive measures were used with 770 patients (38%). The percentage of patients receiving coercive measures in each country varied between 21% and 59%. The most frequent reason for prescribing coercive measures was patient aggression against others. In eight of the countries, the most frequent measure used was forced medication, and in two of the countries mechanical restraint was the most frequent measure used. Seclusion was rarely administered and was reported in only six countries. A diagnosis of schizophrenia and more severe symptoms were associated with a higher probability of receiving coercive measures., Conclusions: Coercive measures were used in a substantial group of involuntarily admitted patients across Europe. Their use appeared to depend on diagnosis and the severity of illness, but use was also heavily influenced by the individual country. Variation across countries may reflect differences in societal attitudes and clinical traditions.

Objectives: The issue of whether depression increases or decreases with age remains unclear. Methodical aspects play an important role in the research on depression in the elderly., Methods: In a representative survey of the German general population aged 50 years and older (n = 1.156) depressive symptomatology was assessed using the CES-D and the PHQ-2, generalized anxiety (GA) was assessed using the GAD-7., Results: According the CES-D 15.9 % and according to the PHQ-2 9.6 % of the population under study are classified as depressed. Prevalence rates increase with increasing age, but only few age groups show significant differences. The CES-D reveals higher prevalence rates than the PHQ-2. Nevertheless depending on the age group 3.6-7.8 % of the sample exclusively identified by the PHQ-2, and 9.0-14.9 % of the sample are exclusively identified by the CES-D. 4.8 (50-59 yrs.) to 10.3 % (80+ yrs.) report a moderate symptomatology of GA. GA is highly comorbid with depressive symptomatology., Conclusions: The prevalence rates in our study are consistent with previous findings of other studies. Moreover our study underpins the importance of methodical aspects for the prevalence rates identified.

Objective: Within the last few years, a small number of German cost analyses of patients treated in community mental health care settings was presented. None of these studies, however, examined direct health care costs of the patients' close reference persons focusing on costs associated with providing informal care. Therefore, our study aimed to analyse health-related direct costs of severely ill patients suffering from affective or schizophrenic disorders, and of their informal carers during community mental health care; further, we examined if these costs differed between the diagnostic groups., Methods: 69 patients currently treated by community mental health services of the Dresden region and their closest reference person providing informal care were assessed twice within an interval of 3 months by use of the CSSRI- D. Thus, direct health care costs of patients and their informal carers covering a 6-months-period could be calculated., Results: 25.35% and 38.24%, respectively, of the closest reference persons' direct health care costs were caused by the situation of acting as informal carer. This was 9.12% and 22.74%, respectively, of the patients' direct health care costs assessed at the same time-points. Patients' costs did not differ between the diagnostic categories, but were influenced by the current severity of psychopathological symptoms. Reference persons' costs were influenced by the severity of the patient's psychopathological symptoms, but also by the social control behaviour of the reference persons themselves as well as by their sense of coherence., Conclusions: While a replication of our findings is urgently needed, they point at the economic significance of direct health-related costs caused by acting as informal carers. Further, therapeutic approaches adequate for minimizing these costs could be suggested, like emphasizing protective factors of mental well-being in psycho-educational programmes for relatives.

Background: A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components., Methods: We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery., Results: We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation)., Conclusion: Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.

This article systematically reviews the literature on the outcome of acute hospitalization for adult general psychiatric patients admitted involuntarily as compared to patients admitted voluntarily. Inclusion and exclusion criteria qualified 41 out of 3,227 references found in Medline and PSYNDEXplus literature searches for this review. The authors independently rated these articles on six pre-defined indicators of research quality, carried out statistical comparisons ex-post facto where not reported, and computed for each adequate result the effect size index d for the comparison of means, and the Phi- or contingency coefficient for cross-tabulated data. Methodological quality of the studies, coming mostly from North American and European countries, showed significant variation and was higher concerning service-related than clinical or subjective outcomes. Main deficits appeared in sample size estimation, lack of clear follow-up time-points, and the absence of standardized instruments used to assess clinical outcomes. Length of stay, readmission risk, and risk of involuntary readmission were at least equal or greater for involuntary patients. Involuntary patients showed no increased mortality, but did have higher suicide rates than voluntary patients. Further, involuntary patients demonstrated lower levels of social functioning, and equal levels of general psychopathology and treatment compliance; they were more dissatisfied with treatment and more frequently felt that hospitalization was not justified. Future methodologically-sound studies exploring this topic should focus on patient populations not represented here. Further research should also clarify if the legal admission status is sufficiently valid for differentiating the outcome of acute hospitalization.

Obtaining valid information about the opinions of relatives on the causes and social consequences of mental disorders should be an important component in specifically tailoring therapeutic interventions for relatives according to their needs. The available range of instruments is small, however, the most prominent being the Italian Questionnaire on the Opinions of the Family (QOF), developed specifically for schizophrenic disorders. The German validation study of this instrument sought to determine whether the subscale structure of the QOF can be replicated in a group of relatives (N=161) of patients with schizophrenic disorders as well as recurrent depressive and bipolar disorders. Results demonstrate that the original QOF subscales cannot be transferred to groups of relatives of patients with affective disorders, nor to a German group of relatives of patients with only schizophrenic disorders. Therefore, a German version of the QOF was created. Using this modified version of the instrument, researchers established a three-factor solution differentiating the opinions of relatives on chronic mental disorders into three components, reflecting orientation towards pathology, towards normality and towards optimising resources for treatment. None of these factors showed significant relationships with the relatives' causal attributions about mental disorders. Further research is needed to establish cross-nationally valid versions of such instruments.

Aims: To analyse factors that differentiate patients who attend follow-up assessments versus those who do not, and to identify predictors for drop-out within the context of the European Day Hospital Evaluation Study (EDEN-Study)., Methods: The EDEN-Study, a multi-center RCT comparing acute psychiatric day care with inpatient care, required re-assessment of patients at discharge, 3 and 12 months after discharge. Follow-up rates varied between 54.0% and 99.5%. Socio-demographic and clinical characteristics of patients who did and did not attend follow-up were analysed using uni- and multivariate statistical methods., Results: Univariate analyses showed differences between patients regarding study site, treatment setting, living situation, employment, age, psychopathological symptoms and treatment satisfaction. They were not confirmed in multivariate analyses thus meaningful predictors of drop-out could not be identified., Conclusions: Results emphasize the general need to compare patients re-assessed and not re-assessed in terms of their most relevant socio-demographic and clinical variables to assess the generalizability of results.

Objective: Individual costs of non-pharmacological treatments in acute day and inpatient care were assessed within a randomised controlled trial., Methods: For 37 modes of treatment used by 191 patients during their index-hospitalization (92 in day, and 99 in inpatient care) personnel costs were calculated. Data were analysed with non-parametric Mann-Whitney-U-tests and regression-analytic models for cost prediction., Results: Day care patients caused mean costs of 1559.41 euro per person and received a mean of 198.8 treatments, whereas inpatients caused 947.22 euro and received 138.0 treatments. As concerns inpatient treatment, length of stay, the diagnosis of an ICD-10 F4-disorder, and the level of positive symptoms at admission could be identified as predictors of individual costs. For day hospital treatment, length of stay and illness chronicity contributed significantly to the prediction of individual costs., Conclusion: The direct health care cost advantage of acute day care--found in several trials which had performed unit-cost analyses--did not appear if personnel costs of the individually received non-pharmacological treatments were used as calculation basis.

Objective: One aim of the multi-site EUNOMIA-project was to establish a European recommendation for the best clinical practice of administering coercive measures. This article reports the results on mechanical restraint., Methods: Local expert groups in 11 countries worked out their recommendations mostly in semi-structured group discussions. By use of a system of categories developed with a content-analytical method, these national documents were comparatively assessed, and integrated into a common clinical recommendation., Results: Legal and clinical pre-conditions for the use of mechanical restraint, specific instructions for the clinical behaviour of different professional groups, ethical issues, and procedural aspects of quality assurance are reported in detail., Conclusions: Compared with established clinical guidelines, similarities concerning basic principles of clinical use appear to be higher than similarities concerning practical details. Future development of guidelines for the best practice of coercive measures urgently needs the use of advanced methodology.

Objective: To provide an overview on the increase of forensic psychiatric hospitalizations in Saxony, and present findings on criminal conviction and recidivism rates of 277 criminal offenders ordered to a forensic psychiatric facility caring for addictive disorders between 1996 and 2001., Methods: Cluster- and regression-analytic procedures identified predictive variables for declaring the forensic psychiatric hospitalization as useless, and for relevant criminal offences after discharge., Results: About 85 % of the study sample showed more than four offences and more than 1.5 years of imprisonment before admission to the index-treatment episode. About half of the patients was successfully treated as indicated by being released on licence. Socialization in institutions, social disintegration before admission, and absconding during the index-treatment episode are important factors increasing the probability of declaring the hospitalization as useless. In the 2-year observation period, the criminal recidivism rate was 40.0 %., Conclusions: Social reintegration of this group of mentally disordered criminal offenders is as difficult as important. Findings on recidivism rates indicate a need for extending the number of specialized forensic outpatient departments and a need to focus on primary prevention.

Objective: Acute psychiatric day care has been proposed as an alternative to conventional inpatient care, yet the evidence of its effectiveness is inconsistent and based only on single-site studies in 3 countries. The aim of this multicenter randomized controlled trial was to establish the effectiveness of acute day hospital care in a large sample across a range of mental health care systems., Method: The trial was conducted from December 2000 to September 2003 in 5 European countries, with a sample of 1117 voluntarily admitted patients. Immediately before or very shortly after admission to the participating psychiatric facilities, patients were randomly allocated to treatment in a day hospital or an inpatient ward. Psychopathology, treatment satisfaction, subjective quality of life, and social disabilities were assessed at admission, at discharge, and 3 and 12 months after discharge. An intention-to-treat analysis was conducted using fixed-effects linear models with structured error covariance matrices and covariates., Results: Day hospital care was as effective as conventional inpatient care with respect to psychopathologic symptoms, treatment satisfaction, and quality of life. It was more effective on social functioning at discharge and at the 3- and 12-month follow-up assessments., Conclusion: This study, which has more than doubled the existing evidence base, has shown that day hospital care is as effective on clinical outcomes as conventional inpatient care and more effective on social outcomes., Clinical Trials Registration: ClinicalTrials.gov identifier NCT00153959.

Objective: To compare the effectiveness of acute psychiatric day-hospital treatment and inpatient treatment with respect to a one-year follow-up., Method: Within a randomised controlled trial, patients and relatives were assessed at different levels of outcome three months and 12 months after patients' discharge using the Brief Psychiatric Rating Scale (24-Item-Version), the Manchester Assessment of Quality of Life (MANSA), the Groningen Social Disabilities Schedule (GSDS), the Berlin Inventory for the Assessment of Needs (BeBI), and the Involvement Evaluation Questionnaire (IEQ). Using estimation and test of contrasts in linear models of analysis of variance with structured covariance matrix, analyses conducted included data of all n = 191 patients having been included into the German centre of the study., Results: With respect to all measures, day-hospital treatment proved to be at least as effective as inpatient care., Conclusion: The study supports earlier findings that showed no differences in long-term effectiveness of acute psychiatric day-hospital treatment as compared to inpatient treatment.

Background: For optimizing the validity of diagnoses of mental disorders, several sources of information should be used to assess psychopathological symptoms. Among these are relatives of patients with mental illness. The very low number of empirical studies examining the assessment of psychopathology by relatives of adult, nondemented mentally ill patients stands in significant contrast to the clinical importance of this source of information, however., Sampling and Methods: Using the Positive and Negative Syndrome Scale (PANSS), researchers asked 163 relatives of patients with the main clinical ICD-10 diagnosis of schizophrenic, recurrent depressive or bipolar disorders to rate the current symptoms of the patients at the time of outpatient community-oriented treatment., Results: On average, severity of symptoms was rated as absent or minimal, although anxiety, depression and passive/apathetic social as well as emotional withdrawal, motor retardation, poor attention, and disturbance of volition were clearly rated above the PANSS mean total score for all patients. A six-factor structure identified by factor analysis better illustrates the significant differences in the assessments of the three main diagnostic groups than the three established PANSS scales. With the exception of 'problematic social behavior', differences among the diagnostic groups appeared in all factors and were particularly pronounced for 'delusional beliefs' and 'motor impairments'., Conclusions: The results of this study showed that the use of standardized instruments such as PANSS for the assessment of psychopathology by relatives is not only practical, but produces adequately reliable results. The use of PANSS for this purpose, however, requires interviewing of relatives by trained experts able to explain technical terms. Because this study did not sufficiently explore the validity of this approach, further research on this specific issue is urgently needed and should, for example, assess the concordance of ratings between professionals and relatives as well as correlation with suitable external criteria., ((c) 2007 S. Karger AG, Basel.)

Objective: To analyse the influence of structural (service) aspects and context (catchment area) variables on the individual use of socio-psychiatric services in Saxony., Method: Data collected in 34 services were used. For the analysis of the variance components a multi-level model with random effects was computed using data at two levels ([1] client, and [2] service/catchment area)., Results: Service use was substantially influenced by structural/context factors which accounted for a proportion of 10 to 50 % of the variance depending on the (sub-)group of users included in the analysis. The impact of service structure and context on service use was particularly strong in the subgroup of service users with very high service utilisation.

Background: Studies on the attitudes of relatives of psychiatric patients have usually focused on views of causes and treatment options for schizophrenic disorders. Comparative surveys, especially those dealing with attitudes on social distance and restrictions, have to date been rather an exception., Methods: In the present study, 161 relatives and other close reference persons of patients with schizophrenic, recurrent depressive, or bipolar affective disorder were interviewed with the German version of the Questionnaire on the Opinions of the Family between February and July 2003., Results: Relatives of patients with schizophrenic disorder differ from the other two groups especially in attitudes displaying greater social distance toward mental disorders and less hope for social reintegration of these patients. Independently of the form of disorder, natural relatives exhibit the greatest social distance toward mental disorders. Differences in attitudes on the basis of patients' and relatives' socio-demographic and clinical characteristics are rather scarce., Conclusions: Attitude toward mental disorders is an important trait of relatives supporting mentally ill persons. Differences in the effects of disorder-specific attitudes on relatives' well-being and their perception of burden have to be investigated further to enable the development of supportive strategies suited to the various groups of psychiatric patient relatives.

Objective: To search for predictors of the discharge status in day-hospital patients and inpatients, within a randomized controlled trial on the effectiveness of acute psychiatric day hospital treatment as compared to inpatient treatment., Method: The study was conducted at the Department of Psychiatry and Psychotherapy, Dresden University of Technology. Regression analyses assessing the relationship between theoretically chosen predictor variables and the discharge status as measured using the Brief Psychiatric Rating Scale (BPRS 4.0) were conducted on a sample of 69 day-hospital patients and a sample of 76 inpatients., Results: In both settings, admission status was the strongest predictor of discharge status. As concerns day-hospital patients, those suffering from a personality disorder as well as those showing a higher degree of social disability were discharged with a higher level of psychopathological symptoms. Among inpatients, those suffering from an anxiety, obsessive-compulsive, or adjustment disorder as well as those being retired or unemployed benefited less from treatment., Conclusions: Given the explorative character of the present study, further prospective studies are needed in order to cross-validate findings on the potential criteria for allocating acute mentally ill either to day-hospital or inpatient treatment.

Objective: Within the context of the EDEN-study, a multi-centre randomised controlled trial comparing acute psychiatric day hospital with inpatient care, patients' assessments of treatment as well as their setting-preferences for future treatment have been studied., Method: Patients' assessments were collected using the Clients' Scale for Assessment of Treatment (CAT). The quantitative content analysis refers to the answers to the open questions of the CAT by all day hospital patients and inpatients in the Dresden project centre who completed the questionnaire one week after admission and again at discharge., Results: Day hospital patients as well as inpatients assessed their treatment altogether as pleasant and effective. Interpersonal contact to the staff and other patients was evaluated as sound and helpful. Differences between the settings appeared primarily with regard to criticisms: Day hospital patients were mainly dissatisfied with their daily routine, inpatients criticized particularly structural conditions such as premises and food. In case of a hospital readmission, the majority of the patients would prefer that setting they had been randomised to within the EDEN-study. However, a tendency to prefer treatment in the day hospital was found., Conclusions: Acute mentally ill patients provide a substantially favourable assessment of both day hospital and inpatient care. Particularly the criticism of the day hospital patients contains important information for improving the quality of psychiatric care.

Objective: A systematic review should take into account epidemiological, clinical, ethical, and legal aspects., Method: Search for literature was performed by Medline and Medpilot, guidelines were obtained via the internet or from own ongoing research projects., Results: Epidemiological data on the frequency of involuntary medication is only scarcely available. The incidence on psychiatric wards seems to be between 2 % and 8 % of patients, predominantly with schizophrenic or bipolar disorder. In general, the efficacy of involuntary medication has been poorly evaluated in inpatients, two randomised controlled trials from the U. S. are available regarding involuntary outpatient commitment including involuntary medication. Therefore, the empirical database on aspects of clinical safety of involuntary medication is quite small. However, a considerable body of literature exists with respect to patients' opinions on involuntary medication, mostly demonstrating a highly critical attitude. Some European countries already have guidelines, but the overall situation suggests the need for further improvement. In 2004, the EU Council ratified a guideline for future European legislation on involuntary treatment of people with serious mental illness (white paper)., Discussion: A very controversial discussion of former years has become more reasonable, ideological anti-psychiatric criticism being increasingly replaced by search for evidence, development of guidelines, clearer legislation, and a tendency of European harmonization.

Previous national research has shown significant variation in several aspects of coercive treatment measures in psychiatry. The EUNOMIA project, an international study funded by the European Commission, aims to assess the clinical practice of these measures and their outcomes. Its naturalistic and epidemiological design is being implemented at 13 centres in 12 European countries. This article describes the design of the study and provides preliminary data on the catchment areas, staff, available facilities and modalities of care at the participating centres.

Purpose and Methods: One of the outcomes of reforming mental health care in Germany has been the establishment of a range of community mental health services. However, current evidence for the effectiveness of these services is slight. Based on a literature search this article provides a systematic overview of empirical research in this sphere. In detail, social psychiatric services, crisis centres, psychosocial contact points, day care centres, and various models of supported housing and work/employment are assessed. Available results on effectiveness are classified according to their level of scientific evidence., Results: The current state of research is characterised by the situation that effectiveness of the care approach provided by social psychiatric services and some types of supported housing and work/employment has been demonstrated at a medium level of scientific evidence. In contrast, the evidence level of mental health care provided in crisis centres, psychosocial contact points, and day care centres is poor., Conclusion: The major reasons for this lack of research are: heterogeneity of care models and staffing levels in the different community mental health services, lack of standardised documentation and reporting system in these services, and lack of research culture to utilise routine outcome data. The consequences of aiming at increasing the level of scientific evidence in this sphere would be to intensify funding of research projects and to implement high quality research designs such as randomised controlled trials.

Objective: So far only five randomized controlled trials on acute day hospital care have assessed direct health care costs and compared these with costs of conventional inpatient treatment. This paper aims to close this research gap for German speaking countries., Method: Another trial was conducted at the Department of Psychiatry and Psychotherapy, Dresden University of Technology. Using the Client Service Receipt Inventory interviews with patients at three time-points (admission, discharge, three months after discharge) assessed their utilization of health care services. Based on the results of a separate regional cost-calculation project, costs of individual care packages could be calculated. 144 patients (day care: n = 75, inpatient care: n = 69) with complete data sets for all time-points of assessment were included in the intention-to-treat-analysis. Means of direct costs (given in Euro and referred to Deutsche Mark prices in 2000) were computed, and t-tests and bootstrap-procedures were used for group comparison. Furthermore, missing and sensitivity analyses were conducted., Results: Patients in the acute day hospital caused mean direct health care costs of 12 401 per person within the entire period assessed. Thus, their cost level falls below the mean costs of inpatient care (15,924 euro per person) by 22.1 %. Missing analyses showed no selection effects on cost results caused by patients who could not be assessed at all defined time-points. Costs for inpatient and day care services were the most sensitive parameters for maintaining the statistically significant differences of cost means demonstrated between the two study groups., Conclusion: For German-speaking countries, this study shows for the first time that acute day care -- which has been demonstrated to be clinically at least as effective as inpatient care - is the less expensive option if these two settings are comparatively assessed.

Objective: Currently, there is still a severe lack of methodologically sound empirical studies on acute psychiatric day hospital treatment in German-speaking countries that analyse the effectiveness of this increasingly important mode of service provision., Methods: Within a randomised controlled study design implemented at the Department of Psychiatry and Psychotherapy, Dresden University of Technology, 99 general psychiatric patients received conventional inpatient treatment and 92 patients received acute day hospital treatment. At up to four time-points during the index-treatment episode patients were assessed at different levels of outcome: Psychopathology was rated by researchers using the Brief Psychiatric Rating Scale (24-Item-Version), and patients evaluated their satisfaction with treatment (Patientenbogen zur Behandlungszufriedenheit); at admission and discharge patients also assessed their subjective quality of life (Manchester Assessment of Quality of Life). Mean scale scores of these instruments are used for the intention-to-treat-analysis. Discharge status on these scales as well as mean ratings on these scales within the index-treatment episode serve as measures of effectiveness. For statistically identifying differences between the two settings five linear (co-)variance-analytical models were calculated for each target variable. Four models were adjusted to baseline-rating or to the individual period spent in treatment., Results: Initially, both groups did not differ in their relevant socio-demographic and illness-related features. Day hospital treatment (87,7 days) lasted significantly longer than inpatient treatment (67,8 days). Only results from an unadjusted statistical model as well as from a model adjusted to the individual period of index-hospitalisation demonstrated superior effectiveness of day hospital treatment on the discharge status of psychopathological symptomatology. However, in all statistical models there were no systematic differences of treatment-effectiveness related to satisfaction with treatment and subjective quality of life., Conclusion: For the first time in German-speaking countries, this study provides evidence for the effectiveness of acute day hospital treatment as compared to conventional inpatient treatment. If detailed eligibility criteria for patients are used as defined here, approximately 30 % of the general psychiatric patients in need of acute hospital-based treatment may be cared for in this special mode of day hospital service provision.

Objective: As the use of "day hospitals" increases, conceptual models of these services are changing dramatically across Europe. Therefore, the need arises for mental health services research to assess this process cross-nationally in a standardised and systematic way. Such research approaches should seek to maximise the generalisability of results from high-quality (e.g. randomised controlled) single- or multi-site trials assessing specific models of day hospital care., Method: Using a self-developed structured questionnaire, the European Day Hospital Evaluation (EDEN) study group carried out national surveys of the characteristics of day hospitals for general psychiatric patients in Germany, England, Poland, the Slovak Republic and the Czech Republic, during the period 2001--2002., Results: Response rates varied from 52 to 91 %. Findings show that day hospitals have no consistent profile of structural and procedural features. Similarities across countries focus on three main issues: on average, consideration of concepts oriented toward providing acute treatment are equivalent; disorders associated with disabled functioning in everyday life, high risk of somatic complications, and need for behaviour control are excluded to a comparable degree; and some core therapeutic activities are consistent with the main approaches of social psychiatry. Identified according to self-rated conceptions and extended with data from individual hospital's statistics on the clientele in 2000, three clusters of limited selectivity subdivide the services. One category focuses mainly on rehabilitative tasks; two categories are oriented toward providing acute treatment as an alternative to inpatient care, but combine this either with rehabilitative tasks or with equal additional functions of shortening inpatient treatment and providing psychotherapy. The distribution of services across these three clusters varies significantly in the five European countries., Conclusion: Future day hospital studies should always clarify the type of services being assessed. To fully consider the impact of their results, the current national and international health policy environment of these services should be taken into account. Such surveys require enhanced methodology, however, in order to identify clear, distinct categories of services characterised by overlapping programme functions, and to increase the generalisability of valid results from single- or multi-site trials.

Objective: Within the deinstitutionalization process of a large psychiatric hospital, the development of two cohorts of patients with chronic schizophrenia is compared over a two-year period: patients living in the hospital's nursing-home area (n = 50) vs. patients already released to two social therapeutic hostels (n = 51). Results of the cohort study were compared with assessments of nurses working in the nursing home (n = 55), focusing on their subjective views of the deinstitutionalization process and its impact on their working conditions., Methods: Patients are assessed through yearly home-visits in their place of residence. The instruments used measure several outcome parameters: psychopathology, social disabilities, subjective quality of life, and normative needs for care. Concurrent staff assessments were conducted using standardized survey instruments focusing on current working conditions and quality of teamwork. Nineteen nurses participated in qualitative interviews evaluating the deinstitutionalization process., Results: For all measures, patients living in the nursing home show significantly worse outcomes. Furthermore, during the study period 34 % experienced a change in their living situation with which they were dissatisfied. Needs for care and the number of areas of "unmet" need increased significantly for this subgroup. Patients living in social therapeutic hostels demonstrate stable levels of psychopathological symptoms, social disabilities, and needs for care. Assessments indicating a deterioration in patients' subjective quality of life focus mainly on areas important for social contacts. Regarding "personal concerns" and "insecurity at work", ratings from nursing home staff were significantly worse than those of a reference group from several other health care institutions (n = 224). Staff showed a tendency to give higher ratings for their opportunities to participate in decisions, in contrast with the low ratings for chances to improve their knowledge in the workplace, a result which may indicate a lack of prospects. In general, staff faces the conundrum of being asked to adopt a new mental health care paradigm while organisational structures are being eliminated and insecurity about career opportunities is increasing., Conclusion: To adequately manage deinstitutionalization of care, all participating parties must be involved in the process as early as possible to clarify expectations and to demonstrate commitment to future opportunities in the new system.

Background: Specific problems of long-term community care of chronic schizophrenic patients are an under-researched area interesting for the provision of regional mental health care., Methods: This study focuses on a 4 1/2-year prospective assessment of normative needs for care in a cohort (initially N = 115) living in the Dresden care region (Germany). At six time-points, normative needs for care were assessed with the Needs for Care Assessment (NFCAS)., Results: The total number of problems did not change significantly over the study period. The average number of met needs was lower at the longer-term follow-up assessments,due particularly to a decrease in the social section. This trend is also demonstrated for the average number of unmet needs. In contrast, the mean number of "unmeetable needs" increased. Consistently, 70-80% of the patients exhibit problems in positive psychotic and negative symptoms, household affairs and recreational activities. Communication, occupation and recreational activities constitute a trio of social needs not met for nearly one-third of the patients disabled in these respects. Logistic analyses of regression could not identify a predictive model for the total needs development within the 4 1/2-year community treatment., Conclusion: The rather stable pattern of needs for care seems to define clear long-lasting tasks for community mental health services. For chronic schizophrenic patients, services should especially focus on social skills training and psychoeducational approaches. Due to a wide range of possible factors of influence, however, planning long-term context-dependent processes of care in the community lacks a clear evidence base.

In the provision of mental health care for chronic schizophrenic patients, the specific problems and requirements of long-term community care of suicidal behavior is an area of research not yet fully explored. This study focuses on a 4 1/2-year prospective assessment of normative and subjective needs for care related to this specific area for a cohort living in the Dresden region (Germany). One significant result of this study shows the constant high level of needs for care in the area of suicidal behavior imposed on community services by 30-40% of this diagnostic group. Furthermore, the study identified a special high-risk subgroup for suicides as well as specific needs for care. This subgroup is characterized by clinical reasons for the index hospitalization (suicidal risk or attempt) as well as by psychopathological features (suicidal thoughts and higher levels of anxiety/depression) 1 month after release from index hospitalization. Four items of care were rated as potentially effective for addressing suicidality in the community setting: clinical assessment, increased supervision or systematic recording of (suicidal) behavior, medication, and a sheltered environment. Because these care measures are provided, the percentage of unmet normative needs for the area of suicidal behavior was rather low. Due to limitations of the instrument used for assessment of normative needs, the Needs for Care Assessment (NFCAS), the care measures most frequently provided do not define a quality standard of community care for this problem. A subjective needs assessment differing from the normative approach has to be integrated in establishing guidelines for effective community care.

In the Federal Republic of Germany, rebuilding the structures of complementary care in the newly formed eastern states created the opportunity to provide at-home care in the community as a low-threshold flanking measure for chronically mentally ill individuals generally capable of living independently. For a group of patients with chronic schizophrenic disorders (ICD-10: F20) living on their own in the community with at-home mental health care ( n=83), a study of data focusing on psychopathology, social disability, need for psychiatric care, and (subjective) quality of life demonstrates that the principle of need-oriented care has not yet been realized consistently. This applies especially to the provision of community services of varying treatment intensity based on the differing severities of psychopathological symptoms and social disabilities of individual clients. Furthermore, the results of the study show that the severity of psychosocial impairments is associated with a rather negative assessment of the subjective quality of life, whereas the living arrangement has no influence on satisfaction with life. The conclusion for organizing community mental health care is to establish flexible provision of services oriented to standardized individual analyses of needs for care.

This study aims to assess the extent of needs for mental health care of patients with schizophrenia living in different residential settings and to evaluate the quality of care in these types of complementary services recently established in the East German region of Dresden. Survey data from the first wave of a longitudinal study of five patient subgroups (N=244) living in (1) a psychiatric nursing home, (2) social therapeutic hostels, (3) sheltered community residential care, (4) at home in the family and (5) alone in one's own home are reported. Normative individual needs for care were assessed using the needs for care assessment (NCA). The patient groups show clear differences in the extent of needs for care, especially in the social NCA section. Patients in the psychiatric nursing home and in the social therapeutic hostels exhibit the highest numbers of areas of need. Positive psychotic symptoms, negative symptoms and neuroleptic side effects are the most prominent clinical areas of need in all subgroups. Patients are most frequently socially disabled in terms of managing household affairs, recreational activities and household chores. Deficits in the need status could be found in the NCA areas of 'negative symptoms,' 'recreational activities,' and 'communication.' The basic needs for mental health care of patients with schizophrenia are met in the established sheltered residential settings. Current deficiencies in providing psychological and educational interventions focusing on coping strategies and social skills training should be minimised in order to decrease the identified deficits in the need status.

Background: Particularly in the last 10 years the conceptual models of partial hospitalization are subjected to major changes, reflecting to the integration of day hospitals in regional mental health service systems and especially to the provision of an alternative to acute inpatient treatment. Systematic nation-wide surveys assessing these changes are missing., Method: After developing a structured questionnaire integrating differences in European mental health care systems, a German national survey of current structural and procedural quality markers of psychiatric day hospitals was carried out in 2001. 51.4 % of the addressed psychiatric hospitals (N = 191) returned the questionnaire. Analysis is based on descriptive and correlational methods, compares the situation in the Eastern and Western German Federal States, and uses cluster analysis to differentiate the day hospitals according to their main program function., Results: In general, establishment of day hospitals in Germany has not yet reached the evidence-based capacity level. This statement especially applies to the situation in rural areas. 56 % of the day hospitals currently assess themselves as an alternative to inpatient treatment simultaneously providing differentiated psychotherapeutic treatment. Comparing clinical institutions in the Eastern and Western parts of Germany demonstrates the clearer orientation towards acute psychiatric treatment in the recently (mostly after 1995) established East-German hospitals. This is reflected in the spectrum of main clinical diagnoses, in the average length of treatment episodes, in the definitions of contraindications, and in the provided diagnostic measures. While administrative circumstances are homogeneous for day hospitals, there is a considerable variation in staff numbers related to the core professions., Conclusions: Guidelines for professional training and continuous qualification as well as staffing have to be modified according to requirements resulting from the change of clinical functions. Each day hospital has to clarify and define its main program function(s), and has to better communicate the consequences for the regional mental health service system.