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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: 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: 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.

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.

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.

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.

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.

Objective: Differences in the intensity of social psychiatric care for mentally ill people are examined in two communal socio-psychiatric services in Saxony. Service users are subdivided into three groups according to intensity of service use (low utilization, average utilization and high utilization)., Methods: The analyses are based on data from a standardized documentation system in a rural and urban catchment area., Results: Intensity of care varies with structural parameters (geographical distance between patient home and service, staff resources). A small group (about 20 % of all clients) with a high frequency of contacts with service staff (high users) receive more than 50 % of all care contacts., Conclusion: Standardized documentation is a good basis for the description of different patterns of service utilization, but more information is needed about service users, e.g. data on their health care needs.

Objective: 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., Methods: 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., Results: 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., Conclusions: Requirements for the further development of the complementary psychiatric care system are deduced.

In a cohort of patients with chronic schizophrenic disorders (n = 115) characterized by many social deficits and a high level of psychopathology, suggestions concerning rehabilitation were examined in an exploratory way and analysed referring to their relevance for community psychiatric care. The schizophrenic patients were followed up 1 and 12 months after discharge from hospital using an extensive array of instruments (among others: Needs for Care Assessment, Berlin Inventory of Care Needs). Included was a guided interview focusing on patients' subjective views relevant for the course of the disorder and for therapeutical procedures. Using a content analysis of the verbal material received at both points of study, the following main defining elements of the term rehabilitation (or reintegration, resp.) could be identified from the patients' perspective: vocational reintegration, independent residential setting, recovery of normality, and acceptance of responsibility. The rate of individualized confirmation in each category established after the first interview was between 75% and 93% 1 year after discharge from hospital.--Results from multiple and logistic regression analyses demonstrate that a higher degree of differentiation concerning individual rehabilitation suggestions exerts influence on the extent of subjective and normative needs for (psychiatric) care at the first point of study and moreover can be identified as a predictor of the decrease in the normative needs for care during the study period. To differentiate schizophrenic patients' suggestions referring to this subject can therefore be declared a therapeutical task. Furthermore it is a must to adjust individualized expert-based and subjective suggestions concentrating especially on the patients' main point of emphasis, i.e. vocational rehabilitation.

The necessity for a standardized documentation system for the complementary sector of psychiatric care is pointed out, and the goals and requirements to be met are debated. The test-version of such a documentation system (abbrev. BADO-K) is shown. It consists of modules for the assessment of client-centered data, and for the documentation of the treatment process in various facilities. Furthermore, a module of questionnaires and instruments for assessing outcome variables (e.g. quality of life) is integrated. The principles for using the paper-pencil-version and the EDP-version are outlined and discussed with regard to the legal regulations concerning the protection of personal data. Finally, possibilities and limitations of the presented documentation system are discussed. It is argued that the BADO-K is an useful instrument for evaluating the process and outcome of community psychiatric care.

Purpose: Evaluating the establishment of social psychiatry services (SPS) in Saxony was part of a public health research project., Method: One of the variables in a specifically designed assessment instrument--used in 8 SPS during the period 08/95-01/97--was the retrospective statement concerning changes in the client's vocational situation caused by the social upheavals in 1989., Results: 40.6% (n = 335) answered in the affirmative. Men are significantly overrepresented in the group with vocational changes; compared to the population without vocational changes the proportion of currently unemployed persons (56%) is five times higher; only 16% are still employed. Neurotic/personality disorders as well as brief mental disturbances and dependency disorders are more frequent than in the whole SPS-clientele.--The most important constellation (19%) identified by a configuration-frequency analysis is that of patients with prolonged psychotic disorders (started < 1990, not associated with dependency disorder) who were employed at sheltered workplaces during the GDR-period despite of their mental disorder., Conclusion: Following the political German reunification possibilities of vocational rehabilitation have deteriorated and up to now the number of newly established alternatives in regional mental health services is insufficient.

In the wake of the disintegration of the policlinical system which had prevailed in the former German Democratic Republic, far-reaching restructuring has become necessary in the "new" German laender in the field of complementary psychiatric care. Establishment throughout the state of Saxony of a uniform outreach-based ambulatory service ranks as a first component towards building regionalized community psychiatric networks. In light of some twenty years of experience in the old laender, this function is considered a task of the Social Psychiatric Services ("Sozialpsychiatrische Dienste", SPDIs). The present study had been directed at a state-wide investigation of the expectations community-practice psychiatrists (n = 165), physicians in psychiatric clinics (n = 95) and staff working in SPDIs (n = 138) in Saxony hold regarding service programmes and operating methods of these newly established service delivery structures. Given the high return rates in this anonymous postal questionnaire study, the findings presented are considered near-representative. A concurrent finding for all of the groups interviewed, expectations concerning the client population to be serviced by the SPDIs focus on the group of persons with chronic mental illness. Also, the expectations expressed concerning major care/therapeutic services to be rendered by the SPDIs concur in their emphasis on a core area of immediately client-oriented SPDI activities. Between the two medical groups, a major difference found is that community-practice psychiatrists more frequently expect high SPDI commitment regarding sociotherapeutic programmes at an institutional level, whereas clinical physicians expect them to focus on taking over medical therapies in the narrower sense. The expectations SPDI staff hold relative to the therapeutic services to be rendered by themselves go beyond the scope of what has so far been implemented in their current activity, and qualitative content analyses are presented in the article for each of the areas concerned. Along with better staffing levels, removal of in-service organizational and further education deficits are identified by SPDI staff as the two main requirements for stabilizing their operations. In order to counter undue burdening of the SPDI with service expectations and to enable a more clear-cut positioning of its programme structures within a complex psychosocial service delivery system, it is necessary--at least in the state of Saxony--that further needs-oriented establishment and/or extension of community-based psychiatric services and agencies take place.

Associations between somatic as well as, in particular, neurological diseases and suicidal acts are outlined, with studies of different diseases having shown that they represent only one factor in motivating the suicidal act. Biographical predispositions and stressful variables from the current social situation are always added. Depressive and organic brain syndromes that can often be found during neurological rehabilitation are discussed in their significance as risk factors for suicidal behavior, also seeking to identify distinct phases of the rehabilitation process afflicted with high suicide risk. An active and carefully directed approach to exploration as well as grasping the psychopathological symptomatology are fundamental elements in the assessment of suicide risk. In this respect, observations of the patient's behaviour and information obtained from relatives are of special importance in neurological rehabilitation clinics. The "presuicidal syndrome" (Ringel) continues to be of high clinical value in assessing the psychodynamics of the individual patient in his development towards the suicidal act. Reflections of suicidal tendencies in countertransference reactions and the communication pathology of suicidal behaviour are more recent aspects that enrich the assessment of suicide risk. Therapeutic management of suicidal patients can firstly be characterized by the principle of specific diagnosis and treatment of the underlying disease; this means that optimum medical care even has a suicide-preventive function. The other principle considers the establishment of a therapeutical relationship as a must, and some critical points in the personal contact with suicidal patients are dealt with in some detail. Especially in neurological rehabilitation clinics, custodial aspects must not be neglected.(ABSTRACT TRUNCATED AT 250 WORDS)

Starting out from a short description of typical life situations at stroke onset as well as a number of coping definitions, specific elements in stroke patients' disease experience are set out. Further, five typical intrapsychic reaction patterns during rehabilitation are outlined. Various variables relevant to the coping process are discussed in detail: somatic disease characteristics, personality traits and their impact on adaptability, previous crisis experience and coping strategies, social network, prognosis. Special attention is focussed on the significance of subjective perceptual, evaluation and interpretation processes. The implications specific disease symptoms (neuropsychological impairment, organic brain syndrome) may have for stroke patients' coping mechanisms are dealt with. By commenting on eight theses posited, psychotherapy specifies in stroke patients are described, emphasizing the need for careful diagnosis, also in view of somatic side effects of psychotherapeutic methods. A flexible approach is demanded, in line with each patient's capabilities. Highest initial priority is given to therapy elements that address basal human needs. With increasing recovery, a gradual transition from a verbal/unblocking/exercising methods to verbal/conflict-oriented ones as well as from a more guiding/supportive to an insight-oriented approach seems possible. The rank of behavioural therapy, psychoanalysis and group therapy is discussed in detail. Reasons are given for integration of system theory concepts, as well as constant availability of crisis intervention; participation in supervision activity is considered a must.

On an average of 16 months after discharge a questionnaire was sent to 156 female patients with depressive disorders who underwent treatment in an open psychiatric ward of the Nervenkrankenhaus Bayreuth during the years 1987 and 1988. The patients were asked to estimate the therapeutical value of treatment-elements available during the hospitalization. In each of the two diagnostic subgroups (endogenous vs. psychogenic depressive disorders) 60% of the patients sent the questionnaire back. Out of a great number of findings prominence must be given to the fact that independent of the diagnosis some therapeutical elements got especially high ratings: close interpersonal contacts, individual psychotherapy and efforts toward rehabilitation. The same could be found for therapeutical elements that were considered less helpful with regard to improvement of complaints and symptoms: somatic therapies, group-psychotherapy, talks with nurses and therapeutical activities that require autonomy as well as continuous collaboration. Differences between the diagnostic subgroups concerning the given ratings are discussed. In consideration of the so far published literature it is attempted to assess the significance of this study's main results in regard to treatment of patients with depressive disorders.