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To investigate whether implementation recommendations derived from the German guidelines "Prevention of coercion" can be implemented on acute psychiatric wards by means of implementation consultants into ward work and if this contributes to an increased level of adherence to guideline intervention recommendations approved by the DGPPN (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde)?Two medical or nursing experts advised ward teams on the implementation of three individually selected recommendations from the guidelines in a structured consulting process over 6 months. The degree of implementation of the recommendations was assessed before and after the intervention by the ward teams together with the implementation consultants using a tool developed for this purpose (PreVCo rating tool).A total of five wards responsible for compulsorily admitted patients took part in the pilot study; three of them completed the intervention. On all three wards, implementation of the guideline recommendations improved for both selected and unselected recommendations. The strategy of using implementation consultants as well as the application of the PreVCo rating tool were well accepted and considered feasible by both the treatment teams and the implementation consultants.This pilot study showed that an implementation of recommendations on psychiatric wards derived from the German guidelines "Prevention of coercion" supported by implementation consultants is feasible, well acceptable among treatment teams and can lead to positive changes. The sample of five wards with diverse patient profiles was convincing. The efficacy in terms of reduction of coercive measures is currently being investigated in a randomized controlled trial on 55 psychiatric wards in different parts of Germany, with an intervention based on this pilot study.ZIEL DER ARBEIT (FRAGESTELLUNG): Können die aus der S3-Leitlinie „Verhinderung von Zwang“ abgeleiteten Implementierungsempfehlungen auf akutpsychiatrischen Stationen mittels Implementierungsberater*innen (IB) in der Stationsarbeit umgesetzt werden und führt die Umsetzung zu einem erhöhten Einhalten der von der DGPPN (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde) verabschiedeten Empfehlungen?Je zwei ärztliche oder pflegerische IB berieten psychiatrische Stationsteams bei der Umsetzung von jeweils drei aus der Leitlinie abgeleiteten, individuell ausgewählten Implementierungsempfehlungen. Die Beratung erfolgte in einem strukturierten Prozess über sechs Monate. Der Grad der Umsetzung der Empfehlungen wurde von den Stationsteams gemeinsam mit den IB mit einem für diesen Zweck entwickelten Instrument (PreVCo-Rating-Instrument) jeweils vor Beginn und nach Ende der Intervention eingeschätzt.Fünf Stationen mit Versorgungsverpflichtung auch für zwangseingewiesene Patient*innen nahmen an der Pilotstudie teil; drei vollendeten die Intervention. Bei den letztgenannten verbesserte sich sowohl die Einschätzung der Umsetzung der von den Stationen ausgewählten Implementierungsempfehlungen als auch die Einschätzung der Umsetzung der nicht ausgewählten Maßnahmen. Die Implementierungsberatung wurde von den Stationen als hilfreich empfunden. Die Anwendung des PreVCo-Rating-Instruments wurde von den IB und Behandlungsteams als gut durchführbar beurteilt.Die vorliegende Pilotstudie zeigt, dass eine durch IB gestützte Implementierung der 12 Empfehlungen durchführbar ist, von den Behandlungsteams als hilfreich erachtet wurde und zu positiven Veränderungen führen kann. Die Stichprobe der Pilotstudie war mit fünf Stationen unterschiedlichen Profils aussagekräftig. Ob auch die Häufigkeit und Dauer von Zwangsmaßnahmen auf diese Weise reduziert werden kann, wird aktuell in einer randomisiert-kontrollierten Studie mit einer auf dieser Pilotstudie basierenden Intervention an 55 psychiatrischen Stationen in unterschiedlichen Regionen Deutschlands untersucht.

Effectiveness of Inpatient Equivalent Home Treatment (IEHT) was examined in comparison to standard psychiatric inpatient treatment. IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity.This retrospective matched control study used routine data of 86 patients (IEHT, n = 43, standard inpatient treatment n = 43). Readmission rates and cumulative hospital days were compared within a 12-month-follow-up time period.The readmission rate was lower and cumulative treatment days were longer after IETH. However, both group differences were not statistically significant.The present study indicates that IEHT is not inferior to standard inpatient treatment in terms of the risk of readmission.Überprüfung der Wirksamkeit einer stationsäquivalenten psychiatrischen Behandlung (StäB) im Vergleich mit einer vollstationären psychiatrischen Routinebehandlung.Im Rahmen einer retrospektiven Verlaufsstudie wurden 43 Patient*innen aus der StäB (Interventionsgruppe/IG, n = 43) mit einer gematchten vollstationären Kontrollgruppe (KG, n = 43) hinsichtlich vollstationärer Wiederaufnahmerate und Behandlungstage im 12-Monats-Follow-up verglichen.Bei den Patient*innen der IG zeigte sich eine um etwa 9 % geringere Wiederaufnahmerate in die vollstationäre Behandlung. Im 12-Monats-Follow-up zeigte sich in dieser Gruppe eine um etwa 30 % längere vollstationäre Behandlungsdauer. Beide Gruppenunterschiede waren statistisch nicht signifikant.Die vorliegende Studie deutet darauf hin, dass StäB hinsichtlich des Wiederaufnahmerisikos einer stationären Behandlung nicht unterlegen ist.

To get information about different ways inpatient equivalent treatment (IET) is implemented and organized eight specialized psychiatric hospitals and departments in Germany were asked to report on implementation details. OUTCOME: Organization and treatment processes depend on local conditions and existing structures. Legal barriers complicate the implementation process, however patients as well as team members report very positive experiences.Current data only give first hints but aren't sufficient to draw viable conclusions. Consequential issues will be picked up within the AKtiV-Study of the Innovationsfonds.Seit 2018 kann in Deutschland aufsuchende stationsäquivalente Behandlung (StäB) durchgeführt werden. Acht Kliniken der ersten Stunde legen erste Zahlen zu 658 in StäB behandelten Patienten vor. Allgemeine Kennzahlen werden vergleichend, die Details zu Organisationsstruktur, Kooperation, Behandlungsablauf sowie Mitarbeitenden- und Patientenbewertung differenziert nach Standort dargestellt.Die Ergebnisse zeigen eine hohe Heterogenität der Strukturen und Abläufe bei einer insgesamt sehr positiven Bewertung durch alle Beteiligten. Für gesicherte Schlussfolgerungen reicht die bisherige Datenlage noch nicht aus. Wichtige Hinweise für die weitere Forschung sind aber ableitbar. Entsprechende wissenschaftliche Fragestellungen werden in die AKtiV-Studie des Innovationsfonds eingebracht.

Based on international randomized controlled trials (RCT) the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) recommends acute treatment in the domestic environment (AHU) and intensive outreach treatment (IAB) with the highest level of evidence; however, due to large differences in national healthcare systems the transference of results from international studies to the healthcare systems in Germany, Austria and Switzerland could be limited.Evaluation of studies on outreach psychiatric treatment forms in Germany, Austria and Switzerland and discussion of the results in the light of international evidence.A systematic literature search for clinical trials on outreach community treatment from Germany, Austria and Switzerland was conducted in the PubMed database.A total of 19 publications were identified which could be assigned to 5 publications on 4 studies with 2857 patients on AHU and 14 publications on 10 studies with 3207 patients on IAB. The studies on AHU showed this treatment form to be superior regarding the duration of inpatient stay and healthcare costs. The studies on IAB showed more positive outcomes in comparison to controls regarding symptoms, severity of illness, substance abuse, functioning level, remission, satisfaction with treatment, quality of life, healthcare costs, work and housing situations.The studies from Germany, Austria, and Switzerland suggest that outreach community treatment is superior regarding several outcome parameters. Thus, there are no indications suggesting that international evidence could not be valid for these countries. Additionally, with one RCT for AHU and one for IAB the requirements for an evidence level of 1b for outreach community treatment in the healthcare systems in question are fulfilled.HINTERGRUND: Akutbehandlung im häuslichen Umfeld (AHU) und intensiv-aufsuchende Behandlung (IAB) werden von der Deutschen Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e.V. (DGPPN) aufgrund internationaler randomisierter Studien (RCTs) mit dem höchsten Evidenzgrad empfohlen. Die Übertragbarkeit internationaler Befunde auf die Versorgungssysteme in Deutschland, Österreich und der Schweiz könnte jedoch eingeschränkt sein, da sich nationale Gesundheitssysteme stark voneinander unterscheiden.Auswertung der Studienlage zu aufsuchenden psychiatrischen Behandlungsformen in Deutschland, Österreich und der Schweiz sowie eine Diskussion der Ergebnisse im Kontext internationaler Befunde.Systematische Literaturrecherche in der Datenbank PubMed zu klinischen Studien zu aufsuchenden Behandlungsformen aus Deutschland, Österreich und der Schweiz.Es konnten 19 Publikationen identifiziert werden, von denen sich 5 Publikationen zu 4 Studien mit insgesamt 2857 Patienten der AHU und 14 Publikationen zu 10 Studien mit insgesamt 3207 Patienten der IAB zuordnen ließen. In den Studien zu AHU zeigten sich positive Werte bez. stationärer Behandlungsdauer und Kosten zugunsten der AHU. In den Studien zu IAB zeigten sich im Vergleich zu den jeweiligen Kontrollbedingungen positive Werte bez. Symptomatik, Krankheitsschwere, Substanzmissbrauch, Funktionsniveau, Remission, Behandlungszufriedenheit, Lebensqualität, Kosten, Arbeits- und Wohnsituation.Da die vorliegenden Studien hinsichtlich vieler Parameter auf eine Überlegenheit aufsuchender Behandlung hindeuten, gibt es keine Hinweise, dass international gut abgesicherte Befunde für Deutschland, Österreich und die Schweiz nicht gelten könnten. Zudem zeigte sich, dass mit je einer RCT für AHU und IAB ein Evidenzgrad von mindestens 1b für aufsuchende Behandlung in den fokussierten Versorgungssystemen vorliegt.

The obstacles to implementation of a German variation of psychiatric Home-Treatment (HT), called "Inpatient Equivalent Home-Treatment" (IEHT) are examined.43 employees from 11 psychiatric hospitals in the federal states of Berlin and Brandenburg were questioned using interviews and focus groups. A thematic analysis was conducted using the socio-institutional theoretical model.At system-level, implementation is hampered by an inadequate service definition, staff shortages, as well as performance assessments by health insurances. This leads to reluctant implementation at hospital-level with insufficient staffing of the teams. Other barriers include a lack of mobile devices for documentation and team communication. At the level of employees, poor information, and cooperation as well as unclear assignment of tasks are impeding factors.For a more needs-oriented, flexible, and nationwide introduction of HT according to IEHT, improvements to the underlying framework conditions and further research addressing efficacy, effectiveness and implementation are necessary.ZIEL: Untersucht werden die Bedingungen und Hürden der Einführung von Stationsäquivalenter Behandlung nach § 115d SGB V (StäB).Qualitative Analyse von Interviews und Fokusgruppen mit Mitarbeitenden (n = 43) an 11 psychiatrischen Kliniken in Berlin/Brandenburg.Auf Systemebene wird die Implementierung u. a. durch eine inadäquate Leistungsdefinition, fehlende Vorgaben auf Landesebene, Personalmangel und MDK-Prüfungen erschwert. Dies führt bei Kliniken zu zurückhaltender Umsetzung mit teilweise unzureichender personeller Ausstattung der StäB-Teams. Weitere Barrieren betreffen das Fehlen mobiler Lösungen zur Dokumentation und Teamkommunikation. Auf Ebene der Mitarbeitenden wirken sich ein Mangel an Information und Kooperation sowie unklare Aufgaben und Rollen hinderlich aus.Für eine bedürfnisorientierte, flexible und flächendeckende Einführung von StäB sind Nachbesserungen an den Rahmenbedingungen sowie weitere Forschung zur Wirksamkeit und Implementierung notwendig.

Over the last decades, many high-income countries have successfully implemented assertive outreach mental health services for acute care. Despite evidence that these services entail several benefits for service users, Germany has lagged behind and has been slow in implementing outreach services. In 2018, a new law enabled national mental health care providers to implement team-based crisis intervention services on a regular basis, allowing for different forms of Inpatient Equivalent Home Treatment (IEHT). IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user’s home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity. The presented naturalistic, quasi-experimental cohort study will evaluate IEHT in ten hospitals running IEHT services in different German regions. Within a multi-method research approach, it will evaluate stakeholders’ experiences of care, service use, efficacy, costs, treatment processes and implementation processes of IEHT from different perspectives. Quantitative surveys will be used to recruit 360 service users. Subsequently, 180 service users receiving IEHT will be compared with 180 matched statistical ‘twins’ receiving standard inpatient treatment. Assessments will take place at baseline as well as after 6 and 12 months. The primary outcome is the hospital re-admission rate within 12 months. Secondary outcomes include the combined readmission rate, total number of inpatient hospital days, treatment discontinuation rate, quality of life, psycho-social functioning, job integration, recovery, satisfaction with care, shared decision-making, and treatment costs. Additionally, the study will assess the burden of care and satisfaction with care among relatives or informal caregivers. A collaborative research team made up of researchers with and without lived experience of mental distress will conduct qualitative investigations with service users, caregivers and IEHT staff teams to explore critical ingredients and interactions between implementation processes, treatment processes, and outcomes from a stakeholder perspective. By integrating outcome, process and implementation research as well as different stakeholder perspectives and experiences in one study, this trial captures the various facets of IEHT as a special form of home treatment. Therefore, it allows for an adequate, comprehensive evaluation on different levels of this complex intervention. Trial registrations: 1) German Clinical Trials Register (DRKS), DRKS000224769. Registered December 3rd 2020, https://www.drks.de/drks_web/setLocale_EN.do ; 2) ClinicalTrials.gov, Identifier: NCT0474550 . Registered February 9th 2021.

Evaluation of the changes of ward atmosphere and job satisfaction after the implementation of the Safewards model in acute psychiatry in Germany.A multi-perspective pre-post study design was conducted in two locked wards among patients (n = 80) and staff (n = 88) before and after the implementation of the Safewards model over a period of 12 months.After the implementation of the Safewards model, ward atmosphere and job satisfaction improved. Both correlated positively amongst staff. Furthermore, job satisfaction correlated positively with a high degree of implementation of two interventions. Fidelity to the Safewards model was high.Implementing the Safewards model in acute psychiatry with high fidelity can have positive effects on positive ward atmosphere and job satisfaction. Thus, patients as well as staff benefit from this model. With regards to high fluctuation in acute psychiatry, the implementation of the Safewards model can additionally facilitate retention management.Evaluation und Implementierung des Safewards-Modells in der Akutpsychiatrie.Prä-Post-Befragung auf 2 geschützten Stationen von Patienten (n = 80) und Mitarbeitern (n = 88).Nach der Implementierung wurden das Stationsklima und die Arbeitszufriedenheit günstiger eingeschätzt. Zudem zeigten sich positive Korrelationen zwischen der Arbeitszufriedenheit und dem Stationsklima bzw. dem Umsetzungsgrad einzelner Interventionen.Die Implementierung des Safewards-Modells in der Akutpsychiatrie kann sich sowohl auf das Stationsklima als auch auf die Arbeitszufriedenheit positiv auswirken.

To investigate the clinical effectiveness of "Home Treatment" (HT) together with intensive outpatient treatment (IAB) in comparison to the usual psychiatric inpatient treatment.In a retrospective controlled pre-post-study 83 patients receiving HT plus IAB were matched with 83 patients receiving inpatient treatment as usual. Routine data were compared with regard to length of stay and hospital readmission rate in a follow-up period of 6 and 12 months respectively.There was no significant reduction of the length of stay of the first hospital admission. However, there was a significant, notable reduction with regard to length of stay and hospital readmission rate in the intervention group in a follow-up period of 6 and 12 months respectively.HT plus intensive outpatient treatment is an effective complement to the usual psychiatric inpatient treatment. It can reduce the risk of hospital readmission and the length of stay for eligible patients.Verglichen wurde die klinische Wirksamkeit von „Home Treatment“ (HT) zusammen mit intensiver ambulanter Behandlung (IAB) im Modellprojekt „FlexiTeam“ (FT) mit einer stationär-psychiatrischen Routinebehandlung.Im Rahmen einer kontrollierten gematchten Vorher-Nachher-Studie wurden Routinedaten von jeweils 83 Patienten im FT und in der stationär-psychiatrischen Routinebehandlung hinsichtlich (teil-)stationärer Wiederaufnahmerate und Verweildauer im 6- und 12-Monats-Follow-up verglichen.Es zeigt sich keine signifikante Reduktion der (teil-)stationären Verweildauer im Index-Aufenthalt. Durch die Behandlung im FT konnte eine signifikante Reduktion sowohl der (teil-)stationären Wiederaufnahmerate als auch der Verweildauer im 6- und 12-Monats-Follow-up erreicht werden.Eine flexible Kombination aus IAB und HT stellt eine wirksame Ergänzung zur stationär-psychiatrischen Routinebehandlung dar und kann bei geeigneten Patienten das Risiko stationärer Wiederaufnahmen senken.

Severe mental illness (SMI) is associated with a large burden for affected individuals and their relatives. Psychosocial therapies are a central pillar of the treatment in SMI.Recommendations on psychosocial treatment on the basis of current scientific evidence and structured consensus-finding procedure are provided in the update of the S3 guideline "Psychosocial therapies for severe mental illness".The update of the guideline includes 33 recommendations and 12 statements in the areas of system-level and individual-level interventions (e. g., to work, housing and psychoeducation) as well as on approaches to self-help (e. g. to self-management and peer services) and on general strategies and orientations (e. g., recovery). A so-called Matrix Chapter meets the specifics of the German healthcare system.There is a large body of international scientific evidence on various psychosocial interventions, outlining chances of improved social and work participation of people with severe mental illness (SMI). Further developments in the areas of implementation and quality assurance are urgently needed.Schwere psychische Erkrankungen sind mit besonderen Belastungen und Risiken für die Betroffenen und deren Angehörige verbunden. Psychosoziale Therapien sind eine zentrale Säule der Behandlung.Im Update der S3-Leitlinie „Psychosoziale Therapien bei schweren psychischen Erkrankungen“ werden auf der Basis aktueller wissenschaftlicher Evidenz und strukturierter Konsensfindung in einem repräsentativen Leitliniengremium umfassende Empfehlungen zur psychosozialen Behandlung gegeben.Das Update der Leitlinie umfasst 33 Empfehlungen und 12 Statements in den Bereichen der System- und Einzelinterventionen (z. B. zu Arbeit, Wohnen und Psychoedukation) sowie zu Ansätzen der Selbsthilfe (z. B. zu Selbstmanagement und Peer-Arbeit) sowie zu Aspekten, die die Ausrichtung des täglichen Handelns aller Beteiligten umfassen (z. B. zu Recovery). Ein sogenanntes Matrixkapitel wird den Besonderheiten des deutschen Versorgungssystems gerecht.Es liegt international umfassende wissenschaftliche Evidenz zu verschiedenen psychosozialen Interventionen vor, die Chancen auf eine verbesserte soziale und berufliche Teilhabe für Betroffene eröffnet. Die Implementierung von Leitlinien ist ein wichtiges Entwicklungsfeld, um das Wissen und die Empfehlungen praxiswirksam werden zu lassen.

In recent years public and research interests focused more and more in lifestyle as a key factor for health. Particularly lifestyle of people with severe mental illness in combination with modifiable risk factors and adverse effects of the antipsychotic medication is especially critical. The present paper investigated the effect of multimodal healthy lifestyle interventions concerning weight and BMI reduction.We systematically searched electronic databases (Medline, EMBASE, PsycINFO, Cochrane Library) for reviews and RCTs.Six systematic reviews and three single RCTs met inclusion criteria. Analyzed lifestyle interventions, mostly combined approaches of nutrition and sports, showed short and medium term effects in weight and BMI reduction compared with controls.Lifestyle interventions appear effective for treating overweight among people with serious mental illness. Further research is needed for evaluating long-term effects of the lifestyle interventions as well as focusing special components of the interventions with especially high user benefit.Menschen mit schweren psychischen Erkrankungen sind deutlichen Risiken somatischer Morbidität und erhöhter Mortalität ausgesetzt. Gesundheitsfördernde Interventionen sollen die Risiken dafür reduzieren. Die Arbeit trägt die Evidenz in diesem Bereich zusammen.Systematische Suche in Medline, EMBASE, PsycINFO und der Cochrane Library nach Übersichtsarbeiten und RCTs.Gesundheitsfördernde Interventionen zeigten nahezu durchweg positive Effekte in Bezug auf die untersuchten Parameter.Weitere nachhaltige Untersuchungen sind erforderlich.

Objective To evaluate guideline adherence in in-patient medication care of psychotic disorders. Method A total of 508 persons with psychotic disorders were included in a naturalistic multisite hospital study. Subjects were assessed weekly on mental state, social functioning, socioeconomic factors and medication prescriptions. Results In total, 17% of individuals were prescribed antipsychotic dosages above the recommended value. Among those with persistent psychotic symptoms, 73% received insufficient antipsychotic drug management. About 58% of patients with depressive symptoms were not treated according to guidelines, and 53% of patients did not receive adequate management of side-effects from antipsychotic medications. Subjects with more than six previous psychiatric hospitalizations (OR 1.80, CI: 1.05-3.08) and those with a prominent thought disorder (OR 2.28, CI: 1.23-4.23) had a higher likelihood of not being treated according to guidelines. Conclusion Individuals with chronic and thought-disordered psychosis may be at a higher risk of receiving medication care not supported by guidelines.

To report about several approaches of social skills training and to evaluate the efficacy and key success factors in severely mentally ill adults.Systematic electronic literature search for systematic reviews and randomized controlled trials (RCTs) and assessment of the evidence.A variety of models for skills training have been designed and evaluated. In addition to the "basic" model and a "problem-solving" model of training there are complex programs consisting of several modules and specific approaches aimed to improve cognitive functioning or job related skills. Across all approaches, social skills training shows advantages in terms of raised social competence.Social skills training should be offered as a targeted treatment taking into account individual patient characteristics, impairments and needs. It is essential to deliver skills training within a comprehensive care concept combined with other elements focusing on generalization into the community setting.

Severe mental illness is associated with long-lasting symptoms and various impairments including individual, social and occupational aspects. The S3 guideline on psychosocial therapies in severe mental illness of the Germany Society for Psychiatry, Psychotherapy and Neurology (DGPPN) offers recommendations for psychosocial interventions. This paper emphasizes specific characteristics of the S3 guidelines on psychosocial therapies in severe mental illness and summarizes the primary results. Areas of future mental health service research are identified.

To report about existing evidence of effectiveness of home treatment for severely mentally ill adults and implementation in Germany.Systematic electronic and manual literature search.Compared to standard care, home treatment was equally or more efficacious with respect to general state of health and mental health. Home treatment was superior with regard to other outcomes. So far, implementation in Germany is limited.Home treatment can be seen as an effective addition to existing approaches of psychiatric care. It may be cost-effective also in Germany. Reasons for limited implementation in routine care are discussed.

The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia

The German Betäubungsmittelverschreibungsverordnung BtmVV (prescription regulation of narcotics), 5 part 2, 01 July 2001 commissioned the German Medical Association to establish guidelines on methadone maintenance therapy according to the medical-scientific state of the art. A joint commission of the German Medical Association and the National Association of Statutory Health Insurance Physicians developed guidelines for substitution therapy of opiate dependence which were adopted by the board of the German Medical Association in March 2002 and were published in the Deutsche Arzteblatt in May 24, 2002. The present study is a systematic review of the scientific literature on successful treatment in general, as well as on particular aspects of methadone substitution therapy considered by the German Medical Association's guidelines. The literature was updated until January 2004. Older randomised controlled trials and more recent quasi-experimental studies provide evidence that methadone maintenance therapy is an effective strategy to reduce illicit drug use, to improve the health situation of drug users, to diminish criminal behaviour, and to promote rehabilitation of opiate-dependent individuals. The evaluation of international studies clearly shows that access criteria to substitution therapy beyond the diagnosis of opiate dependence, e.g. the presence of a life-threatening co-morbidity, is not a prerequisite for substitution in other countries, and therefore is not discussed in the international literature. Study evidence shows that the German Medical Association's guidelines for substitution therapy of opiate dependence reflect the best evidence available from scientific studies and apply it to the conditions of the German healthcare system.

Background: Within a pharmacoepidemiologic study, characteristics of patients with schizophrenia switched from first- to second-generation antipsychotics (FGAs and SGAs, respectively) or to antipsychotic polypharmacy were compared with those of patients maintained on treatment with FGAs. The primary aim was to assess factors associated with antipsychotic switching and to compare disease course with regard to mental state and social functioning. Method: Adult inpatients with an ICD-10 diagnosis of schizophrenia or schizoaffective disorder were assessed in 7 psychiatric hospitals. Data were collected between 2001 and 2002. For those patients (N = 847) with an antipsychotic prescription at discharge, t tests and covariance and logistic regression analyses were used to evaluate the relationship between demographic and clinical characteristics and antipsychotic switching. Results: Patients switched from FGAs to SGAs had fewer previous psychiatric admissions, a shorter illness duration, fewer substance disorders, and a higher probability of working in a competitive setting but more pronounced symptoms than those maintained on treatment with FGAs. Mental state and social functioning after case-mix adjustment were more favorable in the group switched to SGA monotherapy but not in those patients administered FGAs and SGAs concurrently at discharge. Logistic regression controlling for demographic and clinical variables revealed that a short disease duration (p

The aim of this study was to estimate costs accrued by the health care of children with asthma in comparison to children with atopic eczema and seasonal rhinitis and to investigate cost determinants. From the multicenter cohort study (MAS-90), we selected children with an asthma, atopic eczema and/or seasonal rhinitis diagnosis during the first 8 years of life, and overall 8-year health care utilization was estimated retrospectively by reviewing medical records. Asthma treatment (n = 76) incurs an average cost of 627 US dollars per year, 44% due to hospital stays. Atopic eczema treatment (n = 91) cost on average 219 US dollars and seasonal rhinitis (n = 69) 57 US dollars per year. In asthma and atopic eczema, costs increase significantly with disease severity. Allergy diagnostics use accounts for only 1% of total costs. Costs for asthma and atopic eczema treatment are highest in those years when topical steroids are used for the first time, but decrease with every further year of steroid use. A remarkable 25% of asthmatic children with severe symptoms were not treated according to national guidelines, so that most steroid treatment was initiated during the first hospital stay. In the case of asthma, total direct costs increased until the 3rd year of the disease, and then decreased with further years of diagnosis, while steroid use continued to increase. These results indicate a 'learning effect' in the treatment of asthma and atopic eczema for each patient as well as considerable cost-saving potential by preventing severe asthma. Moreover, the importance of considering cost-driving factors and using cohort or longitudinal designs in cost-of-illness approaches is emphasized.