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Community care and sectorisation, specialisation and differentiation, integration of psychiatric and other medical services, crises intervention and emergency psychiatry--and patient's choice--are basic issues of the organisation of psychiatric services. They are discussed and evaluated in respect of the Region of Mannheim and the Mannheim Zentralinstitut für Seelische Gesundheit.

The two main types of mental health services research are (1) the evaluation of the mental health sector within comprehensive systems of health care and (2) the evaluation of individual mental health facilities or types of care. Depending on the information systems available, the difficulties of evaluating complex systems of care can be partially obviated by using descriptive approaches. Structural quality can be assessed by structural indices, the functioning of a system by monitoring utilization, and the overall effectiveness of a national mental health care system roughly by health indicators. Causal analyses of effectiveness are practical when they are based on individual facilities or types of care, which can be studied as isolated systems on the basis of intervention and outcome variables. Reliable and reproducible results can be achieved only if a standardized intervention is used or if the intervention and its objectives are described clearly, the output indicators are defined in terms of identifiable and repeatable operations. The assets and liabilities of quasi-experimental designs and three types of naturalistic approaches will be discussed. When the cost of a new type of care is compared with the cost of traditional mental health care, the section of the population actually served out of the total of patients with comparable needs for care should be considered. Results from the authors' studies will show how the neglect of this epidemiological aspect can lead to false statements.

The implementation of a community mental health service in Mannheim (FRG), a city with 315,000 inhabitants, is being evaluated by means of the data of the Cumulative Psychiatric Case Register at the Central Institute of Mental Health. Within a four-year period of extending services for crisis intervention and emergency care, aftercare (sheltered apartments, homes, workshops) and of providing psychiatric beds in the city, the total number of treatment episodes has increased by more than 100% from about 1.1 to about 2.2 per 1000 inhabitants aged over 14, mainly at the out-patient level of care. Admissions to hospital showed an increase of about 40% whereas bed occupancy remained stable at a rate of about 1.7/1000-respectively 1.3/1000 if beds provided by a psychogeriatric nursing home are deducted. This development can be attributed to various factors: (1) A true increase of morbidity may occur mainly in diagnostic groups I.C.D. No.300, 301, 305-308, especially an increase in attempted suicides and in alcohol- and drug-related diseases. (2) The increased provision of help, mainly on the sector of crisis intervention and emergency care and - in diagnostic categories - mainly in minor neurotic disorders, crises, and affective psychoses, has resulted in a large rise in utilization. (3) The continuous decrease of long-term hospital stays, above all in schizophrenic patients, has led to increased utilization of out- and in-patient services in the community when crises and relapses occurred. A comparison of two cohorts of "old" and "new" patients, the latter having accumulated under the conditions of a community mental health service, has shown that these patients are admitted for a long-term hospital stay considerably later and less frequently than formerly, mostly only after several attempts for rehabilitation. In the group of schizophrenic patients, only about 5% of all first admissions stayed in a psychiatric hospital for more than one year in 1979/80. About the year 1900, this group had still amounted to between 60% and 70%. A comparison with evaluations of comprehensive community care systems in other countries shows that there are largely identical trends, although the initial rate for psychiatric beds was comparably lower in Mannheim.

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

While the demand for deinstitutionalization, strongly supported by the economic aspect of the issue, has resulted in a steep decline in the number of psychiatric beds in many Western countries, the evaluation of extramural psychiatric care has several difficulties, including that of proving effectiveness without experimental control of confounding influences. For a cohort of schizophrenic patients we investigated the impact of out-patient psychiatric treatment on length of stay in hospital and length of stay in the community. Out-patient care had a significant influence on readmission, but no effect on the length of in-patient treatment. While the average cost of community care was less than half that of traditional hospital care, in 6% of the patients this threshold value of continued in-patient care was exceeded. There also seems to be a non-monetary threshold, above which community care is no longer appropriate.

In the city of Mannheim the introduction of an extensive community mental health service has been shown, by means of case-register data over 41/2 years, to have led to a considerable increase in utilization, mainly at the out-patient level of care. The rates of admission to hospital increased very little. Due to the simultaneous decline in long-term bed occupancy, the overall need for psychiatric beds remained stable at a rate of about 1.2/1000, a rate which is very low by international standards. The sharp decline in the "old' long-stay population was followed by a smaller increase in "new' long-stay patients which it has not been possible to prevent. These patients are, however, admitted for a long-term stay significantly later than formerly, and their diagnostic composition has changed significantly. The increase in the bed requirements for short- and medium-term stay patients resulted from different sources: an increasing morbidity in some groups of disorders, the rising utilization in case of emergencies and severe crises, and the transfer of long-stay patients to alternative care services. The level of these needs was very similar in Mannheim, Salford, Samsø and Camberwell, whereas the rates for long-term beds still show clear national differences.

Schizophrenic patients in Mannheim, West Germany, were studied to determine whether psychiatric treatment in the community reduces duration and frequency of rehospitalization, whether it has an impact on symptomatology and behavior, and whether it can be provided less expensively than hospital care. The findings showed a relationship between increased psychiatric outpatient treatment and lower levels of inpatient care as well as between psychiatric aftercare and reduced symptomatology and disease-related behavior. The cost of community care was found to be substantially lower than that of hospital care for less disabled patients, but it exceeded the cost of hospital care for the more severely disabled.

The changes in psychiatric service concern the realm of psychiatric hospitals, the ambulant services, and the complementary services for chronic patients. Influencing factors are the number of patients and the incidence of illnesses and their fluctuations, the available possibilities of therapy and provision and their changes, social changes, influences of the spirit of the age, and political and financial factors. The change in all these areas is briefly presented. There exist relevant figures in the literature. They are critically discussed. The quality of psychiatric services has been altered several times. The change concerns also the patients, in which general factors are to be mentioned like higher longevity, an increased number of chronic patients, aging of the population and the resulting increase in the incidence of psychiatric disturbances.