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Purpose: This systematic review aimed to investigate the therapeutic relationship (TR) between mental health professionals (MHPs) and their patients in community mental health services (CMHS)., Methods: PubMed (Medline), PsycINFO, CINAHL, CENTRAL, and Web of Science were searched for studies that assessed TR in CMHS using quantitative measures developed specifically for this setting (i.e., Helping Alliance Scale [HAS] and the Scale to Assess the Therapeutic Relationship [STAR]). Studies were included if they considered adult patients with a psychiatric disorder and/or any MHP working in CMHS. Meta-analysis and narrative synthesis assessed the association between patients' and MHPs' ratings and identified predictors of TR., Results: Of 1934 studies, 15 were included in the review, including 3004 patients. A total of 1127 patients and 963 MHPs were considered in the meta-analysis. The heterogeneity of the studies was high, and there was no significant difference between the patients' and MHPs' TR ratings in the random-effects model (standardized mean difference [SMD]: - 0.39 [95% CI: - 1.03; 0.24]). In the multivariable meta-regression, only duration of illness was significantly associated with TR ratings (unstandardized regression coefficient [B]: 0.388 [95% CI: 0.217; 0.558]). A recovery-oriented service, shared decision-making, and the recognition of patient needs contributed to more positive TR ratings., Conclusion: Patients and MHPs converged in their TR ratings, although patients gave lower ratings. Routine assessment of TR in CMHS can inform reflective practice and service development, as TR can be assessed easily and early in the treatment process. Future research should focus on developing and testing interventions to improve TR in CMHS., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

A two-factor structure of subjective quality of life (SQoL) was established for patients with schizophrenia with the dimensions being 'Life and Health' and 'Living Environment'. This study investigated whether the same structure applies in patients with mood and anxiety disorders and, if so, whether the dimension scores differ between the three diagnostic groups. SQoL data of 1366 patients with mood and 419 patients with anxiety disorders obtained on the Manchester Short Assessment of Quality of Life (MANSA) were retrieved from 3 multisite studies. We performed Confirmatory Factor Analyses (CFAs) based on the MANSA SQoL items of each diagnostic sample. Next, through a series of Kruskal-Wallis and Mann-Whitney tests, we compared the scores of the two factors across patients with mood disorders, anxiety disorders and schizophrenia. The two CFAs showed adequate fit of the two-factor structure across mood and anxiety disorders. The dimension scores on 'Life and Health' differed significantly between all three diagnostic groups. They were lowest in patients with anxiety disorders, higher in patients with mood disorders and highest in patients with schizophrenia. However, on the 'Living Environment' dimension, patients with mood disorders had significantly higher scores than patients with schizophrenia, whilst patients with anxiety disorders did not differ significantly from either other group. The findings suggest that a two-factor structure of SQoL applies across mental disorders. The two dimensions vary across diagnostic groups in different ways. Assessing two dimensions of SQoL may provide more specific and relevant information than global scores., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: People with psychosis are vulnerable to social isolation, which is associated with worse clinical outcomes. In general populations, people living in areas with higher population density have more social contacts, while those living in more socially deprived and fragmented areas are less satisfied with their relationships. We assessed whether and how neighbourhood factors are associated with social contacts and satisfaction with friendships for people with psychosis., Methods: We carried out a cross-sectional study including people with psychosis aged 18-65 years in urban and rural sites in England. Population density and social deprivation and fragmentation indexes were described within Lower Level Super Output Areas (LSOA). Their associations with participants' social contacts and satisfaction with friendships were tested with negative binomial and ordinal regression models, respectively., Results: We surveyed 511 participants with psychotic disorders. They had a median of two social contacts in the previous week (interquartile range [IQR] = 1-4), and rated satisfaction with friendships as 5 out of 7 (Manchester Short Assessment of Quality of Life; IQR = 4-6). Higher population density was associated with fewer social contacts (Z-standardised relative risk [RR] = 0.88; 95% CI = 0.79-0.99, p = 0.03), but not with satisfaction with friendships (RR = 1.08; 95% CI = 0.93-1.26, p = 0.31). No associations were found for social contacts or satisfaction with friendships with social deprivation or fragmentation indexes., Conclusions: Clinicians in urban areas should be aware that their patients with psychosis are more socially isolated when more people live around them, and this could impact their clinical outcomes. These findings may inform housing programmes., (© 2021. The Author(s).)

Background: Schizophrenia has a significant and lasting impact on the quality of life of patients and their families and is a leading cause of disability globally. Family interventions can be beneficial and may be particularly appropriate in settings with limited resources. We conducted an exploratory trial testing the effectiveness of a multifamily group intervention, which draws on the traditions of psychoeducation and trialogue, for improving the quality of life of patients with schizophrenia in Bosnia and Herzegovina., Methods: We conducted an exploratory, randomised controlled trial with patients with schizophrenia attending an outpatient clinic in Sarajevo. Our primary outcome was improved quality of life at 6-month follow-up. Secondary outcomes included objective social outcomes, psychiatric symptoms and psychiatric hospitalisation measured at 6 and 12 months. Experiences of participants were assessed in post-intervention interviews., Results: 72 patients were randomly assigned to either one of six multifamily groups or treatment as usual. Follow-up assessments were completed with 53 patients (74%) at 6 months and 55 patients (76%) at 12 months. The intervention significantly improved quality of life at 6 months (Cohen's d = 0.78, F = 6.37, p = 0.016) and 12 months (d = 1.08, F = 17.92, p < 0.001), compared with treatment as usual. Re-hospitalisation rates at 6 months and symptom levels also improved significantly whilst changes in other secondary outcomes failed to reach statistical significance., Conclusion: These findings suggest multifamily groups can be effective for improving the quality of life of patients with schizophrenia in Bosnia and Herzegovina. Further research is required to assess how multifamily groups may be scaled up in similar settings with limited resources., (© 2022. The Author(s).)

Purpose: Providing effective treatment for immigrants is an increasing challenge for mental health services across Europe. Yet, little is known as to whether current practice is associated with different outcomes in migrant and non-migrant patients. We compared outcomes of inpatient psychiatric treatment for migrants and non-migrants in a sample from five European countries., Methods: Patients with psychotic disorders, affective disorders or anxiety/somatisation disorders admitted to routine psychiatric inpatient treatment were assessed in hospitals in Belgium, Germany, Italy, Poland and the United Kingdom. Treatment outcomes were satisfaction with care during hospitalisation, length of stay, readmission to hospital (any and, specifically, involuntary re-hospitalisation), as well as untoward incidents in a 1-year follow-up period. Outcomes were compared between patients born inside (non-migrants) and outside (migrants) the country of treatment, through mixed regression models., Results: Across all sites, 985 migrant patients and 6298 non-migrant patients were included. After accounting for the influence of confounding patient characteristics, migrants reported significantly lower treatment satisfaction, but there were no significant differences for length of stay and re-hospitalisations, in general and involuntary ones. Migrants had a lower rate of suicide attempts, but there was no significant difference in other types of untoward incidents in the year following the index admission., Conclusion: The study suggests that migrants are less satisfied with their hospital treatment, there is no evidence that routine inpatient care as currently provided results overall in poorer objective outcomes for migrants than in non-migrant populations., (© 2021. The Author(s).)

Background: People with severe mental illness often struggle with social relationships, but differences among diagnostic groups are unclear. We assessed and compared objective and subjective social relationship indicators among patients with psychotic, mood and neurotic disorders one year after hospitalisation in five European countries (Belgium, Germany, Italy, Poland and United Kingdom)., Methods: The number of social contacts, including family members and friends during the previous week (Social Network Schedule), and satisfaction with the number and quality of friendships (Manchester Short Assessment of Quality of Life Quality) were assessed by face-to-face interview. Linear regression models were used to analyse associations with diagnostic groups., Results: Participants (n = 2155) reported on average 2.79 ± 2.37 social contacts overall in the previous week, among whom, a mean of 1.65 ± 1.83 (59.2 ± 38.7%) were friends. Satisfaction with friendships was moderate (mean 4.62, SD 1.77). In the univariable model, patients with psychotic disorders reported having less social contact with friends than those with either mood (p < 0.05) or neurotic disorders (p < 0.001), but this difference disappeared when adjusting for socioeconomic and clinical variables (β = - 0.106, 95% CI - 0.273 to 0.061, p = 0.215). Satisfaction with friendships was similar across diagnostic groups in both univariable (β = - 0.066, 95% CI - 0.222 to 0.090, p = 0.408) and multivariable models (β = 0.067, 95% CI - 0.096 to 0.229, p = 0.421). The two indicators showed a weak correlation in the total sample (total social contacts, r s  = 0.266; p < 0.001; friends, r s  = 0.326, p < 0.001)., Conclusion: While objective and subjective social relationship indicators appear to be weakly correlated concepts, there is no variation in either indicator across diagnostic groups when confounders are taken into account among patients with severe mental illness. Interventions specifically targeting social relationships are needed, but they do not necessitate diagnosis-specific adaptations.

Purpose: Long lengths of stay (LoS) in psychiatric hospitals or repeated admission may affect the social integration of patients with psychiatric disorders. So far, however, studies have been inconclusive. This study aimed to analyse whether long LoS or repeated admissions in psychiatric wards were associated in different ways with changes in the social integration of patients., Methods: Within a prospective cohort study, data were collected on 2181 patients with a main ICD-10 diagnosis of psychotic, affective, or anxiety disorder, hospitalised in the UK, Italy, Germany, Poland, and Belgium in 2015. Social integration was measured at baseline and 1 year after admission using the SIX index, which includes four dimensions: employment, housing, family situation, and friendship. Regression models were performed to test the association between LoS, the number of admissions, and the change in social integration over the study period, controlling for patients' characteristics (trial registration ISRCTN40256812)., Results: A longer LoS was significantly associated with a decrease in social integration (β = - 0.23, 95%CI - 0.32 to - 0.14, p = 0.03), particularly regarding employment (OR = 2.21, 95%CI 1.18-3.24, p = 0.02), housing (OR = 3.45, 95%CI 1.74-5.16, p < 0.001), and family situation (OR = 1.94, 95%CI 1.10-2.78, p = 0.04). In contrast, repeated admissions were only associated with a decrease in friendship contacts (OR = 1.15, 95CI% 1.08-1.22, p = 0.03)., Conclusions: Results suggest that a longer hospital LoS is more strongly associated with a decrease in patients' social integration than repeated admissions. Special attention should be paid to helping patients to find and retain housing and employment while hospitalised for long periods.

Background: The current debate on organisation of the mental health care raises a question whether to prioritise specialisation of clinical teams or personal continuity of care. The article explores the experiences of patients and clinicians regarding specialisation (SC) and personal continuity (PCC) of care in five European countries., Methods: Data were obtained via in-depth, semi-structured interviews with patients (N = 188) suffering from mental disorders (F20-49) and with clinicians (N = 63). A maximum variation sampling was applied to assume representation of patients and of clinicians with different characteristics. The qualitative data from each country were transcribed verbatim, coded and analysed through a thematic analysis method., Results: Many positive experiences of patients and clinicians with the PCC approach relate to the high quality of therapeutic relationship and the smooth transition between hospital and community care. Many positive experiences of patients and clinicians with the SC approach relate to concepts of autonomy and choice and the higher adequacy of diagnosis and treatment. Clinicians stressed system aspects of providing mental health care: more effective management structure and higher professionalization of care within SC approach and the lower risk of disengagement from treatment and reduced need for coercion, restraint, forced medication or involuntary admission within PCC., Conclusions: Neither the PCC, nor the SC approach meets the needs and expectations of all patients (and clinicians). Therefore, future reforms of mental health services should offer a free choice of either approach, considering that there is no evidence of differences in patient outcomes between PCC and SC approaches.

Background: Since 1990, the provision of mental healthcare has changed substantially across Western Europe. There are fewer psychiatric hospital beds and more places in forensic psychiatric hospitals and residential facilities. However, little research has investigated the drivers behind these changes. This study explored qualitatively the perspectives of mental health professional experts on what has driven the changes in Western Europe., Methods: In-depth interviews were conducted with twenty-four mental health experts in England, Germany and Italy, who as professionals had personal experiences of the changes in their country. Interviewees were asked about drivers of changes in institutionalised mental health care from 1990 to 2010. The accounts were subjected to a thematic analysis., Results: Four broad themes were revealed: the overall philosophy of de-institutionalisation, with the aim to overcome old-fashioned asylum style care; finances, with a pressure to limit expenditure and an interest of provider organisations to increase income; limitations of community mental health care in which most severely ill patients may be neglected; and emphasis on risk containment so that patients posing a risk may be cared for in institutions. Whilst all themes were mentioned in all three countries, there were also differences in emphasis and detail., Conclusions: Distinct factors appear to have influenced changes in mental health care. Their precise influence may vary from country to country, and they have to be considered in the context of each country. The drivers may be influenced by professional groups to some extent, but also depend on the overall interest and attitudes in the society at large.

There has been a debate in the literature about the distinction between primary and secondary negative symptoms of schizophrenia. Our aim was to study the associations between negative symptoms and potential sources of secondary negative symptoms over time. A sample of 275 participants with at least mid-moderate negative symptoms was randomized into body psychotherapy or Pilates class in a previous study. No significant differences were found between groups over time and changes in the symptom domains were modest. The present investigation considers the longitudinal correlation between variables of interest at baseline, 3 and 9 months follow-up. Measures were the Clinical Assessment Interview for Negative Symptoms (CAINS), the Positive and Negative Symptom Scale (PANSS), the Calgary Depression Scale (CDSS) and the Simpson-Angus Extrapyramidal side-effects Scale (SAS). Mixed models were computed to test the longitudinal association between these variables. In a sensitivity analysis, the dosages of antipsychotic, illness duration and allocated intervention were taken into account. Overall, the course of extrapyramidal side-effects, depressive and positive symptoms was significantly related to the course of negative symptoms. Only extrapyramidal effects were longitudinally correlated to expressive negative symptoms. The sensitivity analyses showed unaltered results for positive symptoms and depression but a lack of association between extrapyramidal effects and the CAINS outcomes. In conclusion, the unambiguous interpretation between primary and secondary negative symptoms may lead to refined treatment approaches for schizophrenia and to increased effects of the interventions.

Purpose: Large numbers of volunteers provide one-to-one support for people with mental illness, sometimes referred to as befriending. However, there has been very little research on their characteristics and motivations. This study aimed to assess the personal characteristics and motivations of such volunteers across different regions in Austria., Methods: Questionnaires assessing characteristics and motivations were distributed to 663 volunteers providing befriending for people with mental illness within volunteering programmes organised in four Austrian regions., Results: Questionnaires were completed and returned by 360 out of 663 approached volunteers (response rate 54%). Whilst most socio-demographic characteristics were widely distributed, 78% were female; 42% reported to have a family member and 56% a friend with a mental illness. Most volunteers cited motivations to do something both for others (e.g. "feel a responsibility to help others") and for themselves (e.g. "enhance my awareness of mental health issues"). When the total group was divided into four subgroups in a cluster analysis based on their socio-demographic characteristics, a subgroup of female, single and younger volunteers in full-time employment expressed motivations to achieve something for themselves significantly more often than other subgroups., Conclusions: The study provides the largest sample of volunteers in befriending programmes for people with mental illness in the research literature to date. The findings suggest that people with different characteristics can be recruited to volunteer for befriending programmes. Recruitment strategies and supervision arrangements should consider motivations both to help others and to achieve something for themselves, and may be varied for specific volunteer subgroups.

Purpose: Continuous observation of psychiatric inpatients aims to protect those who pose an acute risk of harm to self or others, but involves intrusive privacy restrictions. Initiating, conducting and ending continuous observation requires complex decision-making about keeping patients safe whilst protecting their privacy. There is little published guidance about how to balance privacy and safety concerns, and how staff and patients negotiate this in practice is unknown. To inform best practice, the present study, therefore, aimed to understand how staff and patients experience negotiating the balance between privacy and safety during decision-making about continuous observation., Methods: Thematic analysis of qualitative interviews with thirty-one inpatient psychiatric staff and twenty-eight inpatients., Results: Most patients struggled with the lack of privacy but valued feeling safe during continuous observation. Staff and patients linked good decision-making to using continuous observation for short periods and taking positive risks, understanding and collaborating with the patient, and working together as a supportive staff team. Poor decision-making was linked to insufficient consideration of observation's iatrogenic potential, insufficient collaboration with patients, and the stressful impact on staff of conducting observations and managing risk., Conclusions: Best practice in decision-making about continuous observation may be facilitated by making decisions in collaboration with patients, and by staff supporting each-other in positive risk-taking. To achieve truly patient-centred decision-making, decisions about observation should not be influenced by staff's own stress levels. To address the negative impact of staff stress on decision-making, it may be helpful to improve staff training, education and support structures.

Purpose: Although community mental health services aim to support patients' autonomy and independence, they have repeatedly been criticised for making patients dependent. Yet, it remains often unclear what exactly is meant with dependency in this context. This review aimed to identify the meaning of the term dependency on community services in the literature., Methods: A systematic search and conceptual review of papers where dependency is used in the context of community mental health services. Narrative synthesis was used to identify thematic concepts linked to dependency in these settings., Results: Fifteen papers met the inclusion criteria. The analysis identified five different concepts of dependency on community mental health services: dislocation from the outside world; inflexibility and lack of freedom; obligation as resentment or appreciation; living with or without meaningful activities; and security., Conclusions: The findings suggest that, distinct from the exclusively negative connotation of the term dependency in a conventional medical context, dependency on community mental health services contains both negative and positive aspects. The different aspects might guide the future evaluation of the care provided in such services.

Purpose: There are well-established risks for parents with severe mental illness (i.e. psychotic and bipolar disorders), both for their children and themselves. Interventions to help parents fulfil their role should therefore be a public health objective, but their implementation needs to be underpinned by research evidence. This systematic review determines what is known about the nature and effectiveness of interventions for parents with severe mental illness., Methods: We conducted a narrative synthesis of controlled and uncontrolled studies reporting interventions for this patient group after the post-natal period (i.e. after the child has turned 1 year old)., Results: Eighteen publications reported data from 15 studies. All but two studies were rated as low quality studies. Interventions included home visiting programmes, complex community programmes, residential treatments, and online interventions. Interventions targeted diverse areas, with parenting skills and understanding the impact of mental illness on parenting most frequently addressed. Both parent and child-related outcomes improved, but children were only assessed via observers and follow-up times were short., Conclusions: Interventions were diverse with respect to their nature and effectiveness. Future interventions should combine different intervention strategies to target multiple areas in a flexible manner. The addition of positively focussed and resource-oriented components should be investigated. Trials should include direct assessments of both parents and children, outcomes that are relevant from a public health perspective, and establish the long-term effects ideally until children have reached 18 years of age.

Purpose: Whilst formal coercion in psychiatry is regulated by legislation, other interventions that are often referred to as informal coercion are less regulated. It remains unclear to what extent these interventions are, and how they are used, in mental healthcare. This paper aims to identify the attitudes and experiences of mental health professionals towards the use of informal coercion across countries with differing sociocultural contexts., Method: Focus groups with mental health professionals were conducted in ten countries with different sociocultural contexts (Canada, Chile, Croatia, Germany, Italy, Mexico, Norway, Spain, Sweden, United Kingdom)., Results: Five common themes were identified: (a) a belief that informal coercion is effective; (b) an often uncomfortable feeling using it; (c) an explicit as well as (d) implicit dissonance between attitudes and practice-with wider use of informal coercion than is thought right in theory; (e) a link to principles of paternalism and responsibility versus respect for the patient's autonomy., Conclusions: A disapproval of informal coercion in theory is often overridden in practice. This dissonance occurs across different sociocultural contexts, tends to make professionals feel uneasy, and requires more debate and guidance.

Purpose: This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries., Methods: Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients' sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries' effect., Results: The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20-F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries' effect, the risk of being coerced was higher in Poland. Patients' sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model., Conclusions: The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries' effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

Background: Studies have shown patient attitudes to be an important predictor for health related behaviours including medication adherence. It is less clear whether patient attitudes are also associated with medication adherence among patients with psychoses., Method: We conducted a systematic review and meta analysis of the data of studies that tested the association of attitude measures with medication adherence among patients with psychoses. 14 studies conducted between 1980 and 2010 were included., Results: Results show a small to moderate mean weighted effect size (r (+) = 0.25 and 0.26 for Pearson and Spearman correlations, respectively)., Conclusions: Theory based interventions that target potentially modifiable attitude components are needed to assess the relationship between positive patient attitudes and adherence behaviours among patients with psychoses.

Purpose: While there has been systematic research on the experiences of immigrant patients in mental health services within certain European countries, little research has explored the experiences of mental health professionals in the delivery of services to immigrants across Europe. This study sought to explore professionals' experiences of delivering care to immigrants in districts densely populated with immigrants across Europe., Methods: Forty-eight semi-structured interviews were conducted with mental health care professionals working in 16 European countries. Professionals in each country were recruited from three areas with the highest proportion of immigrants. For the purpose of this study, immigrants were defined as first-generation immigrants born outside the country of current residence, including regular immigrants, irregular immigrants, asylum seekers, refugees and victims of human trafficking. Interviews were transcribed and analysed using thematic analysis., Results: The interviews highlighted specific challenges to treating immigrants in mental health services across all 16 countries including complications with diagnosis, difficulty in developing trust and increased risk of marginalisation., Conclusions: Although mental health service delivery varies between and within European countries, consistent challenges exist in the experiences of mental health professionals delivering services in communities with high proportions of immigrants. Improvements to practice should include training in reaching appropriate diagnoses, a focus on building trusting relationships and measures to counter marginalisation.

Purpose: To explore involuntary patients' retrospective views on why their hospitalisation was right or wrong., Methods: Involuntary patients were recruited from 22 hospitals in England and interviewed in-depth. The study drew on grounded theory and thematic analysis., Results: Most of the patients felt mentally unwell before admission and out of control during their treatment. Despite these common experiences, three groups of patients with distinct views on their involuntary hospitalisation were identified: those who believed that it was right, those who thought it was wrong and those with ambivalent views. Those with retrospectively positive views believed that hospitalisation ensured that they received treatment, averted further harm and offered them the opportunity to recover in a safe place. They felt that coercion was necessary, as they could not recognise that they needed help when acutely unwell. Those who believed that involuntary admission was wrong thought that their problems could have been managed through less coercive interventions, and experienced hospitalisation as an unjust infringement of their autonomy, posing a permanent threat to their independence. Patients with ambivalent views believed that they needed acute treatment and that hospitalisation averted further harm. Nonetheless, they thought that their problems might have been managed through less coercive community interventions or a shorter voluntary hospitalisation., Conclusions: The study illustrates why some patients view their involuntary hospitalisation positively, whereas others believe it was wrong. This knowledge could inform the development of interventions to improve patients' views and treatment experiences.

Background: Assertive community treatment for the severely mentally ill is being implemented increasingly internationally. It is unclear whether recommended characteristics of assertive outreach (AO) teams influence care and outcomes. We hypothesised that recommended characteristics of AO teams such as joint health and social care management would predict reduced hospitalisation in the first year of an AO client programme and related outcomes throughout England., Methods: A two-stage design was used: a stratified sample of 100 of the 186 'stand-alone' AO teams in England and a systematic sample of clients from each team with stratification for black and ethnic minority patients. Team characteristics, treatment and outcomes were collected from teams. Analyses took account of patients' histories, clustering and ethnic minority over-sampling., Results: Under AO the proportion of time spent in hospital following admission decreased. Only 3/1,096 patients went missing in 9 months. Although patient' histories significantly predicted outcomes almost no team characteristics predicted re-admission or other patient outcomes after 1 and 3 years. Ethnic minority clients were more likely to be on compulsory orders only on jointly managed teams (P = 0.030). Multidisciplinary teams and teams not working out of hours significantly predicted that patients received psychological interventions, but only 17% of sampled patients received such treatments., Conclusions: Characteristics of AO teams do not explain long-term patient outcomes. Since recommended team characteristics are not effective new models of care should be developed and the process of care tested. Managing teams to implement evidence-based psychological interventions might improve outcomes.

Objective: Suicides account for more than 30,000 deaths per year in the US alone. Suicide rates change over time, and the factors influencing them remain poorly understood. Economic factors, in particular unemployment, have been suggested as a major influence. However, the evidence for this has been inconsistent, which may be partly explained by shortcomings of the statistical methods used., Methods: Time series analytical techniques (unit root and co-integration tests) were applied to test the associations over time between economic factors, i.e. unemployment, real gross domestic product per capita (RGDP) and the consumer price index (CPI) and death rates by suicide as collected by national agencies in the UK (1901-2006), US (1900-1997), France (1970-2004) and Italy (1970-2001). Traditional correlation analyses were used when appropriate., Results: Co-integration and correlation tests showed a long-run association between economic factors and suicide rates. Increase/decrease of unemployment predicted an increase/decrease of suicide rates over long historical periods and in different nations. RGDP and the CPI were also linked with suicide rates, but this was not consistently so and the direction of the association varied., Conclusions: Unemployment is a major factor influencing suicide rates over long periods of time and in different national contexts. It needs to be considered as a confounding factor in evaluations of suicide prevention strategies.

Purpose: Previous research has shown a link between treatment satisfaction and global psychopathology in different groups of psychiatric patients. However, neither the relationship between treatment satisfaction and the sub-syndromes of global psychopathology nor their temporal ordering have been explored., Methods: Participants admitted involuntarily to psychiatric wards in the UK and diagnosed with psychotic disorders (N = 232) were included. Treatment satisfaction and psychopathological sub-syndromes (i.e., manic excitement, anxiety-depression, negative symptoms, positive symptoms) were measured within 1 week and at 1 month after admission., Results: Repeated measures ANOVAs showed that higher treatment satisfaction is associated with lower scores on the manic excitement, anxiety-depression and positive symptom sub-syndromes, while no significant association was found for negative symptoms. However, cross-lagged panel analyses showed that treatment satisfaction predicted change only in positive symptoms while none of the paths from the relevant sub-syndromes to treatment satisfaction was significant., Conclusion: Treatment satisfaction can be regarded as an antecedent of changes in positive symptoms only. These results underline the importance of examining psychopathological sub-syndromes separately as they may relate differentially to other important correlates of psychoses.

Background: The effectiveness of psychosocial interventions in community mental healthcare has been shown to depend on the setting in which they are implemented. Recently structured patient-clinician communication was found to be effective in a multi-centre trial in six European countries, the DIALOG trial. In the overall study, differences between centres were controlled for, not studied. Here, we test whether the effectiveness of structured patient-clinician communication varies between services in different countries, and explore setting characteristics associated with outcome., Methods: The study is part of the DIALOG trial, which included 507 patients with schizophrenia or related disorder, treated by 134 keyworkers. The keyworkers were allocated to intervention or treatment as usual., Results: Positive effects were found on quality of life (effect size 0.20: 95% CI 0.01-0.39) and treatment satisfaction (0.27: 0.06-0.47) in all centres, but reductions in unmet needs for care were only seen in two centres (-0.83 and -0.60), and in positive, negative and general symptoms in one (-0.87, -0.78, -0.87). The intervention was most effective in settings with patient populations with many unmet needs for care and high symptom levels., Conclusions: Psychosocial interventions in community mental healthcare may not be assumed to have uniform effectiveness across settings. Differences in patient population served and mental healthcare provided, should be studied for their influence on the effectiveness of the intervention. Structured patient-clinician communication has a uniform effect on quality of life and treatment satisfaction, but on unmet needs for care and symptom levels its effect differs between mental healthcare settings.

The Study aimed to assess clinical and social outcomes following involuntary admissions over 1 year and identify socio-demographic and clinical patient characteristics associated with more or less favourable outcomes. Seven hundred and seventy-eight involuntary patients admitted to one of 22 hospitals in England were assessed within the first week after admission and at 1 month, 3 month and 12 month follow-ups. Outcome criteria were symptom levels, global functioning, objective social outcomes, and subjective quality of life (SQOL). Baseline characteristics and patients' initial experience were tested as predictors. Symptom levels and global functioning improved moderately. Objective social outcomes showed a small, but statistically significant deterioration, and SQOL a small, but significant improvement at 1 year. In multivariable analyses, admission due to risk to oneself and receiving benefits predicted poorer symptom outcomes. Female gender and higher perceived coercion were associated with better objective social outcomes, whilst higher initial satisfaction with treatment predicted more positive SQOL at follow-ups. Over a 1-year period following involuntary hospital admission, patients on average showed only limited health and social gains. Different types of outcomes are associated with different predictor variables. Patients' initial experience of treatment, in the form of perceived coercion or satisfaction with treatment, has predictive value for up to a year following the admission.

Background and Aims: Various studies assessed mental disorders and psychological symptoms following natural disasters, including earthquakes. Yet, samples were often non-representative, and the periods of time between earthquake and assessments were usually short. This study aims to assess the prevalence of mental disorders, level of psychological symptoms and subjective quality of life in a random sample in a rural region in Italy 8 years after an earthquake., Methods: Using a random sampling method, a pool of potential participants of working age who had experienced the earthquake were identified 8 years after the earthquake. They were sequentially approached until the target sample of 200 was reached. Mental disorders were assessed on the MINI, psychological symptoms on the Brief Symptom Inventory (BSI) and the Impact of Event Scale-Revised (IES-R), and subjective quality of life on the Manchester Short Assessment of Quality of Life (MANSA)., Results: 200 people were interviewed, and the response rate of contacted people was 43%. In the MINI, 15 participants (7.5%) had any type of mental disorder; 5 participants had PTSD at any time since the earthquake, and 1 participant at the time of the interview. Symptom levels were low (Global Severity Index of BSI mean = 0.29, SD = 0.30; IES total mean = 0.40, SD = 3.33) and subjective quality of life (MANSA mean = 5.26, SD = 0.59) was in a positive range. The distribution of mental health outcomes made it difficult to explore factors associated with them., Conclusion: There is no evidence that the earthquake had a negative impact on the mental health of the affected population years later. Possible reasons include the relatively weak nature of the earthquake, strong community support that helped overcome mental distress, the long period of time (8 years) between the occurrence of the earthquake and the study, and a capacity of people to maintain or restore mental health after a natural disaster in the long term.

Background and Aims: Since de-institutionalisation, housing services have taken a central role in the care of patients with severe mental illness. Yet, little is known about the characteristics of patients in different housing services, what care they receive, and what costs are generated. This study aimed to assess patient characteristics, care provision and costs in different types of housing services in England., Methods: In 12 representative local areas in England, 250 housing services were randomly selected. Information on services, characteristics of randomly selected patients and care received were obtained from managers., Results: Data from 153 services (61% response rate) and 414 patients were analysed. Most patients receive support with activities of daily living and are involved in some sort of occupational activities. 52% have a care co-ordinator in a community mental health team. Care provision and costs differed significantly between care homes, supported housing services and floating support services., Conclusions: Quality standards may have to be defined and applied to ensure that all patients in housing services receive appropriate care. More input of mental health services may be required for the rehabilitation and recovery of patients.

Background and Aims: Various studies assessed rates of post-traumatic stress disorder (PTSD) following natural disasters including earthquakes. Yet, samples were often non-representative or small or both. This study aims to assess the prevalence of PTSD and predictors of PTSD 6 months after an earthquake in a rural region of Italy., Methods: A questionnaire was handed out to a representative sample of approximate 3,000 people in the region of Molise in Italy 6 months after an earthquake in October/November 2002. The questionnaire assessed socio-demographic characteristics, aspects of the event, the experience of symptoms immediately after the earthquake, and symptoms of PTSD., Results: Questionnaires of 2,148 people were returned, representing a response rate of 73.7%. The final analysis was based on 1,680 people. The screening tool provided a PTSD prevalence rate of 14.5%. Male gender, age under 55 years, and better school education predicted lower rates of PTSD. More variance was explained when psychological symptoms of immediately after the event were also included as predictors., Conclusion: The findings on predictors are consistent with the literature. Whilst personal characteristics explain only a small variance of PTSD six months after the event, early psychological distress allows a better prediction of who is likely to have PTSD 6 months later.

Background: Mental health interventions should demonstrate an effect on patients' functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment., Methods: Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition., Results: At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect., Conclusions: Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions.

Background: Mental health service research can require the selection of representative geographical areas for data collection. This study designed and tested a new method of combining different relevant selection criteria within the context of a survey of housing services for people with mental health disorders in England., Methods: Six criteria were considered relevant to select areas for the survey: deprivation, urban-ness, provision of community mental health care, residential care provision, total mental health care spend and pressure on housing generally. A measure was identified for each criterion and established for each of 166 local areas. Variables were converted to standardised scores and multi-dimensional scaling undertaken to produce a single axis representing all six variables. Study sites were chosen from this. Identifying the spread of the constituent variables among the finally selected areas we established how successfully the resulting selection represented each of the selection criteria. Reliability analyses were performed on the rank positions of each area., Results: The measures were converted into one axis, and all areas were ranked according to the score on that specifically developed new axis. The scores on the axis showed good reliability when single criteria were eliminated from the equation. The finally selected six areas demonstrated a reasonable spread of scores of each of the constituent variables., Conclusion: Converting several relevant criteria into one score is a feasible approach to ranking geographical areas to assist in identifying small samples that are arguably representative. The method may be used widely in similar research, but requires the availability of reliable data on relevant selection criteria.

Background: While there is a need to assess morale in community mental health professionals, it still remains to be determined how to obtain and interpret data in a sound and meaningful way. The aims of the present study were to assess the extent to which levels of morale are sensitive to differences between professional groups and health care systems, and identify factors influencing morale across groups and settings., Methods: A literature search of electronic databases was undertaken to identify studies measuring morale in different groups of community mental health professionals. Data was subjected to a pooled analysis. Differences between groups and sites were tested using factorial ANOVA and respective effect sizes were estimated based on Cohen's [1] work., Results: Data of four studies and a total of 723 professionals (from Austria, Germany, Italy and United Kingdom) were combined in a pooled analysis. Significant differences of morale levels were found between professional groups and study sites, and differences between professional groups varied significantly by study site. Effect sizes estimated for differences between particular groups of different health care systems ranged from small to large. Age was found to be a factor independently associated with morale., Conclusions: Staff in community mental health care show substantial differences in morale levels depending on the professional group and context. These differences can often be identified even if in sample sizes of only 30 participants per group. Levels of morale need to be established specifically for different professional groups and context, and age should be controlled as an influential factor. The findings show a discriminant validity of assessment instruments for staff morale in community mental health care, and underline the rationale for such assessments in research and routine care.

Trust, choice and empowerment of patients are emerging as important issues in mental health care. This may be due to an increasingly consumerist attitude amongst patients and as a consequence of postmodern cultural changes in society. This study aimed to find evidence for the influence of trust, patient choice and patient empowerment in mental health care. A literature review was undertaken. Six searches of PubMed were made using the key terms trust, patient choice and power combined separately with psychiatry and mental health. The literature search found substantial research evidence in the areas of trust, choice and power including validated scales measuring these concepts and evidence that they are important to patients. Trust in general health clinicians was found to be high and continuity of care increases patients' trust in their clinician. However, only qualitative research has been found on trust in mental health settings and further quantitative studies are needed. Patient choice is important to patients and improves engagement with services, although studies on outcome show varying results. Empowerment has impacted more at an organisational level than on individual care. Innovative research methodologies are needed to expand on the present significant body of research, utilising qualitative and quantitative techniques.

Introduction: Morale and job perception of staff in community mental health care may influence feasibility and quality of care, and some research has suggested particularly high burnout of staff in the community. The aims of this study were to: a) assess morale, i. e. team identity, job satisfaction and burnout, in psychiatrists, community psychiatric nurses and social workers in community mental health care in Berlin and London; b) compare findings between the groups and test whether personal characteristics, place of working and professional group predict morale; and c) explore what tasks, obstacles, skills, enjoyable and stressful aspects interviewees perceived as important in their jobs., Methods: In all, 189 mental health professionals (a minimum of 30 in each of the six groups) responded to a postal survey and reported activities per week using pre-formed categories. Perception of professional role was assessed on the Team Identity Scale, job satisfaction on the Minnesota Job Satisfaction Scale, and burnout on the Maslach Burnout Inventory. Seven simple open questions were used to elicit the main tasks, skills that staff did and did not feel competent in, aspects that they did and did not enjoy in their job, and obstacles and factors that caused pressure. Answers were subjected to content analysis using a posteriori formed categories., Results: Weekly activities and morale varied between sites and professional groups. Some mean scores for groups in London exceeded the threshold for a burnout syndrome, and are particularly less favourable for social workers. Working in London predicted higher burnout, lower job satisfaction and lower team identity. Being a psychiatrist predicted higher team identity, whilst being a social worker was associated with higher burnout and lower job satisfaction. Male gender predicted lower burnout and higher team identity. However, professional group and site interacted in predicting burnout and job satisfaction. Psychiatrists in London had much more favourable scores than the other two groups, whilst this did not hold true in Berlin. Answers to open questions revealed universal aspects, such as enjoying direct patient contact and disliking bureaucracy, but also various views that were specific to a site or professional group or both., Conclusions: Burnout remains a problem for some, but not all, professional groups in community mental health care, and social workers in London appear to be a group with particularly low morale. Differences between professional groups depend on the location, and it remains unclear to what extent job-related and general factors impact on the morale of mental health professionals. Answers to open questions reveal general as well as specific aspects of the job perception of the professional groups, some of which may be relevant for service development, training and supervision. More conceptual and methodological work and more extensive studies are required to develop a better understanding of how community mental health professionals perceive their job and how morale may be improved.

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.

Background: Coping strategies may influence the psychological outcome after a stressful event, both as coping at the time of the event and as strategies of dealing with its consequences after the event. The aim of the study was to investigate coping strategies used by civilians during the air attacks in Yugoslavia in 1999, and their association with the level of exposure, gender and psychological symptoms 1 year later., Method: The sample is a non-selective group of 139 medical students from the University of Belgrade, Yugoslavia. Open questions and content analysis were used to assess coping strategies. Symptoms of intrusion and avoidance were assessed, as well as general psychological symptoms., Results: Content analysis of answers to open questions revealed nine categories of coping strategies (sport and walks, leisure activities, talking and gathering, humor, avoidance, philosophical approach, getting information, work, and substance abuse). A cluster analysis identified three groups of students with different styles of coping. Students that used dominantly 'talking and gathering' had the highest, and the ones that mostly used 'leisure activities' the lowest scores on intrusion. There were significant gender differences in how coping strategies were associated with intrusive symptoms., Conclusion: The type of coping strategies used during the air attacks may contribute to the level of intrusive symptoms 1 year after the event. Different coping strategies might be effective in men and women to reduce intrusive symptoms. Longitudinal and prospective studies are needed to draw definite conclusions on causal relationships between coping strategies and levels of posttraumatic stress.

Objective: The study investigated whether long-stay patients would benefit from discharge into the community in Berlin, Germany., Method: In a prospective controlled study, all long-term hospitalised psychiatric patients from a defined catchment area were assessed using established standardised instruments. Quality of life, treatment satisfaction, needs and psychopathology were re-assessed in 63 non-discharged patients 1.5 years later, and in 65 resettled patients 1 year after discharge., Results: Discharged patients were younger and had spent less time in psychiatric hospitalisation. Whilst patients who remained in hospital care did not show significant changes over time, discharged patients did. Changes in subjective quality of life and total number of needs - but not in psychopathology, unmet needs, and treatment satisfaction - were significantly more favourable in resettled patients as compared to the control group., Conclusion: The findings are in line with other studies and suggest that long-stay patients can benefit from discharge into the community, particularly with respect to their quality of life. Positive changes in the process of deinstitutionalisation seem not dependent on the specific national context, and also apply to younger patients who have not yet spent 10 or more years in psychiatric hospitals.

Background: De-institutionalization has led to the provision of various forms of housing with or without support for people with mental illness in the community. In this paper, we review the conceptual issues related to the provision of supported housing schemes, the characteristics of residents, research methods and outcomes, and the factors influencing the quality of care provided., Methods: A Medline and hand search of published literature was complemented by information derived from contacting expert researchers in the field., Findings: There is considerable diversity of models of supported housing and inconsistent use of terminology to describe them. This makes it difficult to compare schemes, processes, and outcomes. Patients in supported housing are characterized by deficits in self-care and general functioning, whilst behavioral problems such as violence, drug abuse and extreme antisocial habits predict exclusion from supported housing. Most evaluative studies are merely descriptive. In terms of outcomes, it seems that functioning can improve, social integration can be facilitated, and residents are generally more satisfied in supported housing compared with conventional hospital care. Further evidence suggests that most patients prefer regimes with low restrictiveness and more independent living arrangements, although loneliness and isolation have occasionally been reported to be a problem. Little information is available on the factors that mediate outcomes and on skills required by staff., Conclusion: Research in supported housing for psychiatric patients has so far been neglected. Large scale surveys on structure, process, and outcomes across a variety of housing schemes may be useful in the future to identify some of the key variables influencing outcomes. The use of direct observation methods in conjunction with other more conventional, standardized instruments may also highlight areas for improvement. In conducting research, structure and process, as well as outcomes, need to be considered. Thus, we need to know not just what to provide, but how to provide it in such a way that it will maximize beneficial outcomes. This represents a considerable research agenda.

Background: Mental health care is delivered through a relationship between a clinician and a patient. Although this therapeutic relationship is of central importance for mental health care, it appears to be relatively neglected in psychiatric research. Empirical research has for the most part adopted concepts and methods developed in psychotherapy and general medical practice. Hence, unpacking the presuppositions that have informed research on the therapeutic relationship to date may be a useful first step in developing this field., Method: A review of the literature was carried out., Results: Six central theories are identified as framing the definitions and methods on this topic: role theory, psychoanalysis, social constructionism, systems theory, social psychology and cognitive behaviourism. To date, role theory, psychoanalysis and systems theory appear to be the frameworks most often applied in research in this field. Each perspective offers a unique emphasis in the analysis of the therapeutic relationship, which is reflected in the empirical work from each perspective discussed herein., Conclusions: None of the theories identified have been fully specified and comprehensively investigated in psychiatric settings. However, more than one approach may be used for thinking about relationships, depending on the treatment situation. Further specification and testing of the theories in psychiatric practice--taking account of the specific context--is warranted to underpin more pragmatic research. A stronger link between fundamental psychological and sociological research and applied health care research would advance our understanding of which elements of positive therapeutic relationships are instrumental in improving patient outcome and ultimately contribute to improving mental health care.

Background: We tested the hypothesis that the political change occurring in East Germany after the fall of the Berlin Wall in November 1989 affected patients with long-term schizophrenia, resulting in more and longer hospitalisations., Methods: In two samples in East Germany (120 patients in East Berlin, 70 patients in Chemnitz) and in a control group from West Berlin (40 patients), hospitalisations for each month between November 1984 and October 1994 were assessed. Each sample included all schizophrenia patients who were in continuous treatment in the given community mental health centre throughout the full observation period., Results: Hospitalisation indices were not higher after November 1989 than before in any of the groups., Conclusions: There is no evidence that political change in East Germany negatively affected the course of longterm schizophrenia as assessed by hospitalisations. If consistent medical care is provided, characteristics of the political system may have less impact on the course of schizophrenia than is sometimes assumed.

Empirical studies have shown that there are differences between women and men with respect to the onset of schizophrenia and the development of their mental and social conditions. It was therefore the goal of this study to assess the objective life situation and subjective quality of life, as well as the differences, similarities and interrelations, at the onset of schizophrenia in women and men. Ninety schizophrenic patients were interviewed between the second and fourth weeks of their first hospital stay using the Berlin Quality of Life Profile, and rated according to the BPRS. Areas of social problems (work, living circumstances, safety and drug abuse) had become manifest with several of the patients, particularly among the young men, prior to first admission. Although objective conditions, gender and psychopathology have an impact on the subjective quality of life, it cannot be fully explained by them. Multivariate analyses have demonstrated that the factors influencing it are probably different for women and men, and schizophrenic women appraise their life circumstances in a different manner from men, as is true for differences between the statements of acutely and chronically ill patients. It can be concluded from the results of this study that psychiatric services should offer specific social support measures before or at first hospital admission and not after the illness has become chronic. The subjective construct of global quality of life apparently differs from one sample to another, and gender-related aspects, among others, have an impact on it.

This study compared the subjective and objective quality of life and needs of patients with paranoid schizophrenia between inner city areas in Berlin (69 patients) and London (75 patients). Quality of life was assessed by means of the Lancashire Quality of Life Profile (German version Berliner Lebensqualitatsprofi), and need was quantified using the Camberwell Assessment of Need (German version Berliner Bedurfnisinventar). The hypotheses tested were that although Berlin patients may rate more highly on objective quality of life measures, the subjective quality of life would be similar as patients would judge their quality of life against their local expectations. The findings supported the first part of the hypothesis as on the objective measures the Berlin group was significantly better off financially and in living conditions, and had significantly fewer material needs. However, despite having more severe psychopathology, the Berlin groups' scores on global subjective quality of life were also higher. On particular life domains, subjective quality of life did not always reflect objective measures and sometimes went in the reverse direction. We concluded that the relationship between subjective and objective quality of life is complex, and great caution must be exercised in making quality of life comparisons between different cultures.

Quality of life (QOL) has become an important outcome measure for many disorders, including mental illness. The Lancashire Quality of Life Profile (LQOLP) was developed for use in operational contexts, and has been translated into several languages. It is in use in several European and North American community psychiatric services. The present paper addresses the questions: how easy is it to use?; how reliable is it?; do the results of the LQOLP vary by setting in a meaningful way?; how do the results co-vary with measures of clinical symptoms and social functioning?; how well does it measure change?; is it clinically useful? While most of the answers to these questions are favourable, there is a need for further research and development of the profile, in particular with reference to the consequences of the use of the profile as a routine monitoring instrument and the most appropriate form of statistical analysis in longitudinal data-sets.

Within a comprehensive community care system, we examined which patients became hospitalized during long-term treatment. We studied 60 consecutively admitted, and mainly chronic psychotic patients over 5 years. Full and partial hospitalizations were assessed by means of a hospitalization index. This index was significantly lower in the 2nd to 5th years after admission than in the 1st year. Sociodemographic and clinical characteristics failed to predict hospitalizations during the 1st year. Patients' age, gender and last occupational status were related to hospitalizations in the following 4 years. A better prediction of hospitalizations was allowed by treatment data obtained during the 1st year. It is suggested that long-term prognosis should be based mainly upon experience with a patient in a given care system, rather than on a patient's history and characteristics as known before treatment.