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The German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) guidelines on psychosocial interventions for people with severe mental illness appraise the transferability of results of trials evaluating community-based mental health services to the German situation. This assessment has to draw on research results on factors determining effectiveness. This must be seen against the background of a lack of high-quality trials in Germany. The article discusses system, context and setting factors related to the transfer of evidence on community-based service models from other countries. These issues are discussed on the basis of evidence concerning the models of case management, assertive community treatment and community mental health teams. International differences in study findings are highlighted and the importance of treatment-as-usual in influencing study results is emphasized. The more control services including elements of community-based care there are and the less the pressure to reduce inpatient treatment (threshold to inpatient care admission), the smaller the relative effect sizes of innovative care models will be.In the absence of direct evidence, careful examination of transferability is required before introducing health care models. Research has revealed solid evidence for several factors influencing the effects of innovative community mental health care. Among key factors in the care of people with severe mental illness, home visits and joint team responsibility for both psychiatric and social care were identified. This evidence can facilitate the adaptation of successful mental health care models in Germany.

The World Health Organization (WHO) is revising the ICD-10 classification of mental and behavioural disorders, under the leadership of the Department of Mental Health and Substance Abuse and within the framework of the overall revision framework as directed by the World Health Assembly. This article describes WHO’s perspective and priorities for mental and behavioural disorders classification in ICD-11, based on the recommendations of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The WHO considers that the classification should be developed in consultation with stakeholders, which include WHO member countries, multidisciplinary health professionals, and users of mental health services and their families. Attention to the cultural framework must be a key element in defining future classification concepts. Uses of the ICD that must be considered include clinical applications, research, teaching and training, health statistics, and public health. The Advisory Group has determined that the current revision represents a particular opportunity to improve the classification’s clinical utility, particularly in global primary care settings where there is the greatest opportunity to identify people who need mental health treatment. Based on WHO’s mission and constitution, the usefulness of the classification in helping WHO member countries, particularly low- and middle-income countries, to reduce the disease burden associated with mental disorders is among the highest priorities for the revision. This article describes the foundation provided by the recommendations of the Advisory Group for the current phase of work.

In August 2002 the Japanese Society of Psychiatry and Neurology decided to rename the Japanese expression for schizophrenia from Sêshin Bunretsu Byô to Tôgô Shicchô Shô. Currently the psychiatric classification systems ICD-10 and DSM-IV are under revision. Against this background the Japanese process of renaming a psychiatric disorder is of high interest as far as the clinical, social and cultural implications of the new name are concerned.The authors give an overview of the Japanese process of renaming schizophrenia. Its background and realization are explained and the expectations of Japanese physicians, patients and their families related to the new name are analysed. Furthermore, its effects are evaluated. The aim of the paper is to clarify in how far the Japanese example may serve as a model for evaluating the possible implications that a renaming or nosological redefinition of schizophrenia might have in the course of the revision process of ICD 10 and DSM IV.

Psychische Krankheit ist kein Mythos, sondern – jenseits kultureller, politischer und weltanschaulicher Perspektiven – nachweisliche Realitat. In ihrem Ubergangsbereich sind psychische Krankheit und Gesundheit nicht scharf abgrenzbar, definitorisch sind sie aufeinander bezogen. Psychische Krankheit wird in ihren Erscheinungs- und Verlaufsformen, ihren Ursachen und Bedingungen mehrdimensional konzipiert und diagnostiziert. Pathobiologische, -psychologische und soziale Aspekte sind komplementar, objektive Indikatoren allerdings teilweise noch unzureichend entwickelt. Eindimensionale oder monokausale Theoriebildung ist uberholt; in der Forschung ist zwecks Hypothesenprufung oft ein reduktionistischer Ansatz, in der klinischen Praxis jedoch durchgehend eine integrative Sichtweise erforderlich. Grundsatzlich ist eine funktionale, auf normale Funktionsweisen und ihre Storungen ausgerichtete Betrachtungsweise anzustreben, die deskriptive Operationalisierungen moderner Klassifikationssysteme erganzt und rein nosologische Konzeptionen kontrastiert. Valide, empirisch geprufte oder prufbare atiopathogenetische Rahmenkonzepte und Krankheitsmodelle sind die Voraussetzung zur Entwicklung und Anwendung rationaler Therapie. Als allgemeines Modell zur integrativen Konzeptualisierung von Atiopathogenese , Disposition, auslosenden, aufrechterhaltenden und chronifizierenden sowie protektiven und therapeutischen Faktoren fur Krankheitsmanifestation und Verlauf kann heute das Vulnerabilitats-Stress-Coping-Modell gelten. Es besitzt heuristischen Wert fur die individuelle Psychoedukation und Therapieplanung wie fur die Ursachen-/Bedingungs- und Therapieforschung. Psychiatrische Forschung ist – in einem klar bestimmten begrifflichen Feld und unter Berucksichtigung strategischer wie methodischer Erfordernisse – multidisziplinar orientiert. Dies ruckt die Psychiatrie – im Kontext eines naturwissenschaftlich orientierten Weltbildes – naher an Psychologie, Sozialwissenschaften und Medizin; letzteres ist auch ein Beitrag zur immer noch unvollstandigen sozialen Gleichstellung von psychisch und somatisch Kranken.

To examine depressive symptoms, their course during treatment, and influence on outcome.Weekly Calgary Depression Scale for Schizophrenia ratings were performed in 249 inpatients with schizophrenia. Early response was defined as a 20% reduction in the total score of the Positive and Negative Syndrome Scale for Schizophrenia from admission to week 2, response as a 50% reduction in the total score of the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) from admission to discharge and remission according to the consensus criteria.Thirty six per cent of the patients were depressed at admission, with 23% of them still being depressed at discharge. Depressed patients scored significantly higher on the PANSS negative and general psychopathology subscore, featured more impairments in subjective well-being (P0.0001) and functioning (P0.0001). They suffered from more suicidality (P = 0.0021), and had greater insight into their illness (P = 0.0105). No significant differences were found regarding early response, response, and remission.Patients with depressive symptoms should be monitored closely, given the burden of negative symptoms, their impairments in well-being and functioning and the threat of suicidality.

A total of 364 schizophrenic outpatients who were stabilized for 3 months on continuous neuroleptic therapy after discharge from the hospital were rated according to three different scales for depressive syndromes (Brief Psychiatric Rating Scale anxious depression factor, AMDP/depression, and the self-rating PD-S depression scale). Between 19.5% and 27.5% of the patients were rated as depressed, or 35.7%–42.8%, when mild depressive syndromes were included. There were low, but significant correlations between demographic or life-event data and depression scores on the self-rating scale, whereas fewer correlations were found on the observer ratings. No associations were found between social adjustment and depression. Moderate correlations were found between measures of the apathetic syndrome and depression ratings, while observer ratings showed higher correlations than the self-rating. High depression scores, especially in the observer ratings, correlated with scales for global psychopathological assessment (CGI, GAS). There were significant correlations between extrapyramidal rigidity and observer rating depression scores, whereas the total amount of neuroleptics given had no influence. These results are interpreted on the basis of hypotheses about depressive syndromes in schizophrenia.

In several German cities various programmes and initiatives have been conducted during recent years aimed at reducing the stigma attached to mental illness, especially schizophrenia. So far only single interventions in specific target groups have been evaluated but not their effectiveness in the general population.Two representative telephone surveys with repeated measurements were conducted in six German cities (n 7,225/4,622). Social distance towards people with schizophrenia and knowledge of antistigma projects were assessed.Between 2001 and 2004 the social distance toward persons with schizophrenia decreased in the general population. Persons familiar with antistigma projects or who lived in cities with such projects showed lower social distance.For the first time evidence has been found that antistigma interventions are successful in reducing the stigma attached to schizophrenia in the general population.

Introduction The revision of DSM-5 and the mental disorders chapter of ICD-11 are informed by concepts of mental disorders, which share some features, and some differences. Objectives To review the similarities and differences in concepts of ICD-11 and DSM-5 Aims By describing the classification of psychotic disorders, we exemplify the different conceptual approaches of both classification systems. Methods Review of the classification of psychotic disorders in DSM-5 and ICD-11 and the underlying concepts of mental disorders. Results Both systems take an anosological approach and base the classification of mental disorders on psychopathology, which takes centerstage in the clinical evaluation for classification purposes. A major difference is the role of functional impairments, which are mandatory in DSM-5, but not ICD-11. Time course criteria were harmonized and dimensional assessments were introduced in both systems. Differences in duration criteria lead to different approaches regarding brief psychotic disorders. Attenuated psychotic symptoms did not receive full diagnostic status. Conclusions Neither DSM-5 nor ICD-11 have introduced neurobiological or genetic factors into the classification of psychotic disorders. Both systems take steps towards dimensional symptom assessments, with different practical operationalizations. Some differences prevail regarding time course criteria and the handling of brief psychotic disorders, which may indicate different concepts of chronicity underlying these decisions. An important aspect was the non-inclusion of attenuated psychotic symptoms syndrome among the mental disorders, indicating that the border towards normality is still uncharted terrain in both classification systems and open for discussions about concepts of subclinical or otherwise dimensional ratings of subdiagnostic symptoms in the general population.

Inpatient treatment is the most costly sector of treatment for depressive disorders in Germany. However, little is known about which patient and hospital characteristics contribute to costs of inpatient episodes.To take part in this study, patients had to fullfill criteria for ICD-10 diagnosis of F31.3-F31.5, F32, F33, F34.1, F43.20, or F43.21. Episodes were recorded between September 9 2001 and March 3 2003 in ten hospitals in three German states. Inpatient records of 1,202 persons were analysed. Multiple regression analysis was performed to identify significant patient predictors of cost per inpatient episode, and the predictive function of hospital characteristics was analysed by applying hierarchical linear modeling.Patient characteristics at admission could not explain a substantial part of the variance in episode costs. Better prediction was possible including variables from the whole treatment process. Also, conditions for admission and patient-related factors did not well explain cost differences between hospitals, but characteristics of the whole treatment were.For predicting costs of inpatient depressive episodes, the complete course treatment has to be considered. As in the physiologic sector, therapeutic and diagnostic procedures have a great effect on cost prediction.

Public relations activities of the German Research Network on Schizophrenia (GRNS) have shown that there is a demand for more information about schizophrenia disorder. This confirms international research findings that relatives of schizophrenia patients are particularly in need of information and support. In response, the GRNS has maintained a telephone hotline since 2001. The hotline is manned by clinical experts, psychiatrists, or psychologists once a week. The telephone calls are documented in a systematic manner. From 2001 to 2003, 3,909 calls were registered. This volume exceeds the limit of the hotline's resources. The telephone hotline is mainly used by relatives of psychotic patients. Most questions relate to the symptoms of schizophrenia and pharmaceutical treatment. The need for emotional support is also a high motivational factor for dialing the hotline number. The telephone hotline seems to be a worthwhile addition to the already existing crisis telephones and should be maintained even after public funding of the network expires.

The positive effect of greater adherence to evidence-based guidelines on possibilities of optimizing diagnosis and therapy has been shown various times. Electronic systems for interactive support and systematization of physicians' decision-making represent a relatively new method for implementing guidelines. Introducing the "schizophrenia module", newly developed decision support software is presented combining electronic data processing-based, quality-oriented documentation and interactive decision support in the outpatient treatment for schizophrenic disorders. Structure, functionality, and options of use are presented. Besides classic measures of quality management (benchmarking), electronic decision support systems can contribute to improve process quality and outcome in the treatment of mental diseases.

Patient outcome and guideline conformity in inpatient schizophrenia treatment was systematically evaluated and compared with 597 patients across seven psychiatric hospitals. Patient structure and treatment processes showed a great variability between hospitals. Patient characteristics, especially mental state, and the chronicity of the disease were the strongest predictors of clinical outcome. Outcome evaluation using quality indicators is only possible after case-mix adjustment taking into account prognostic factors. A poorer average clinical outcome was associated with lower guideline conformity in a variety of treatment domains. After case-mix adjustment, benchmarking is an opportunity to improve quality of treatment and promote guideline conformity.

Several quality assurance initiatives in health care have been undertaken during the past years. The next step consists of systematically combining single initiatives in order to built up a strategic quality management.In a German multicenter study, the quality of inpatient depression treatment was measured in ten psychiatric hospitals. Half of the hospitals received comparative feedback on their individual results in comparison to the other hospitals (bench marking). Those bench markings were used by each hospital as a statistic basis for in-house quality work, to improve the quality of depression treatment.According to hospital differences concerning procedure and outcome, different goals were chosen. There were also differences with respect to structural characteristics, strategies, and outcome. The feedback from participants about data-based quality circles in general and the availability of bench-marking data was positive. The necessity of carefully choosing quality circle members and professional moderation became obvious.Data-based quality circles including bench-marking have proven to be useful for quality management in inpatient depression care.

In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.

The stigma attaching to mental illness and psychiatry, and the resulting discrimination of people with mental disorders are major obstacles to early and successful treatment. The current antistigma program "Open the Doors" of the World Psychiatric Association, currently being implemented in 26 countries is aimed at reducing the stigma attached to, and discrimination against, schizophrenia. Since 1999 the program has been running in 7 project centers in Germany. Information programs for the public, and measures aimed at specific target groups will, it is hoped, improve knowledge about the causes, nature and therapeutic options in schizophrenic disorders, and break down prejudices and negative attitudes, thus facilitating the social rehabilitation of those affected.

In the outpatient treatment of depression, the potential of diagnostic and therapeutic methods is seldom exhausted resulting in variable quality of treatment and partly insufficient cost effectiveness. Implementation of a guideline-oriented reimbursement system seems to be an option to improve quality of treatment. Corresponding incentive systems have been outlined and evaluated for the health care of somatic diseases such as diabetes. Acting on these experiences, an attempt was made to utilize them for the area of psychiatric disorders. Taking depression as an example, a model for a quality-oriented, guideline-based reimbursement system for general and specialist practice is presented.

Die pharmakologische Langzeitbehandlung mit dem Ziel der Prophylaxe schizophrener Reexazerbationen gehort zu den bestgesicherten Behandlungsformen psychischer Erkrankungen. Entscheidendenden Beitrag dazu lieferte die Entwicklung und systematische Evaluation verschiedener Behandlungsstrategien mit Neuroleptika. Durch eine konsequente Weiterentwicklung sind nicht nur Substanzen mit optimiertem Wirkungs-/Nebenwirkungsprofil entstanden, sondern die Forschung auf diesem Gebiet hat auch zur Vertiefung atiopathogenetischer Kenntnisse gefuhrt. Ausgehend von dem Vulnerabilitats-Stress-Coping-(VSC-)Modell sind unter Einbeziehung psycho-sozialer und rehabilitativer Ansatze umfassende Therapiestrategien entstanden, die die sekundare und tertiare Pravention deutlich verbessert haben. Mittlerweile liegen zumindest teilweise empirisch validierte Konzepte zu Entstehung und Verlauf vor, die einen Zuschnitt der Behandlung auf individuelle Erfordernisse ermoglichen. Im Sinne einer Evidenz-basierten Medizin hat diese Entwicklung zur Formulierung von Therapieleitlinien gefuhrt, die die Umsetzung des wissenschaftlichen Kenntnisstandes in die Praxis und die Behandlungsplanung fordern sollen (Gaebel, 1999; Mellman et al, 2001). Im Folgenden werden die wesentlichen differentiellen Ansatze zur neuroleptischen Rezidivprophylaxe schizo phrener Psychosen dargestellt.

Attitudes of the urban population in Germany towards people with mental illness were investigated in this study. The results are compared with those of attitude surveys conducted by other research centres participating in the World Psychiatric Association's (WPA) global anti-stigma-programme "Fighting Stigma and Discrimination because of Schizophrenia - Open the Doors" (WPA 1998).A total of 7246 German-speaking persons aged 16 and over were interviewed in private households in six German cities by telephone using a standardised questionnaire. The respondents were asked about their knowledge in regard to schizophrenia, their social distance towards people with schizophrenia and estimations of the social stigmatisation of mental patients in general.33.1 % of the interviewees were able to name causes of schizophrenia. 76.5 % of the interviewees believe that people with schizophrenia often or very often need prescription drugs to control their symptoms. 81.1 % believe that most people would pass over the job application of a former mental patient in favour of another applicant.Improvements in the education of the public about mental illnesses and provision of the opportunity for personal contact with mentally ill people are considered to be important measures for promoting the acceptance of the mentally ill by the public.

Die Rheinischen Kliniken Dusseldorf als psychiatrisch-psychotherapeutische Versorgungsinstitution sind zugleich Universitatsklinik mit Aufgaben in Forschung und Lehre. 1876 als Rheinische Provinzial-Heil- und Pflegeanstalt gegrundet, sind sie seit 1923 mit der damaligen Medizinischen Akademie verbunden, die aus der 1907 errichteten Dusseldorfer Akademie fur praktische Medizin hervorgegangen war, 1965 in Universitat Dusseldorf umgewandelt und 1988 in Heinrich-Heine-Universitat Dusseldorf umbenannt wurde. Die Klinik und Poliklinik fur Psychiatrie und Psychotherapie ist fur die psychiatrisch-psychotherapeutische Regionalversorgung des Bezirks Dusseldorf Mitte-Sud mit ca. 520.000 Einwohnern zustandig (sektorisierte Pflichtversorgung). Die enge Verknupfung von Versorgung, Forschung und Lehre ist eine der Besonderheiten der Rheinischen Kliniken Dusseldorf. An kaum einem anderen Standort sonst in Deutschland bestehen vergleichbare Moglichkeiten, Patienten mit einem breit-gefacherten Spektrum an psychischen Erkrankungen — mit ihrer Einwilligung — in Forschung und Lehre einzubeziehen. Dadurch konnen nicht nur wichtige For-schungsergebnisse an reprasentativen Patientengruppen gewonnen und diesen Patienten auch wieder zuteil werden, sondern es kann auch eine klinisch breit fundierte Aus-, Fort- und Weiterbildung vermittelt werden.

In a research project of the German Research Network on Schizophrenia, public attitudes towards people with schizophrenia were studied within a public education project. In six German cities, 7,246 persons aged 16 or older were interviewed in a telephone survey. Knowledge of schizophrenia, social distance, and proposals for activities to improve the public acceptance of mentally ill persons were inquired. Most of the persons interviewed expressed positive attitudes towards people with schizophrenia. Better public education about mental illnesses and the opportunity for closer contact to mentally ill persons were rated as important to improve the public acceptance of these individuals.

The main aim of the study was the evaluation of out-patient behavioural approaches in alcohol dependence. Additionally, the persistence of treatment effects and the impact of psychiatric comorbidity in long-term follow-up was examined.A total of 120 patients were randomly assigned to non-specific supportive therapy or to two different behavioural therapy programmes (coping skills training and cognitive therapy) each comprising 26 weekly sessions; the follow-up period lasted 2 years.Patients undergoing behavioural therapy showed a consistent trend towards higher abstinence rates; significant differences between the two behavioural strategies could not be established. Moreover, the results indicate a reduced ability of cognitive impaired patients to cope with short-time abstinence violations and at a reduced benefit from behavioural techniques for patients with severe personality disorders.Behavioural treatment yielded long-lasting effects and met high acceptance; yet, still in need of improvement is the development of specific programmes for high-risk patients.

Adverse neuropsychiatric effects under interferon treatment have often been reported. However, the pathogenetic mechanisms have not yet been fully explored. Most frequent are affective disorders, but psychotic decompensations can also occur, as reported in the following case. Thus, taking a detailed psychiatric history is required before starting a therapy with interferon, since past and current psychiatric disorders might imply an increased risk for psychiatric adverse effects.

Schizophrenia is a mental illness that is often chronic and can severely compromise day-to-day life. In Germany, some 800,000 people--that is, almost 1% of the population--will suffer from schizophrenia during the course of their lives. In almost 50% of schizophrenics treatment is virtually exclusively in the hands of their family doctors. For this reason, thorough familiarity with the diagnosis and treatment of this condition, in particular with more recent therapeutic options is essential for the family doctor. Despite the fact that the disease often remains chronic, the prognosis has been considerably improved by the introduction of new therapeutic approaches.

Die Bezeichnung Psychiatrie fur Seelenheilkunde geht auf Johann Christian Reil zuruck, Verfasser des ersten psychiatrischen Lehrbuches Rhapsodien uber die Anwendung der psychischen Kurmethode auf Geisteszerruttungen von 1803 [18]. Schulen und Schwerpunkte in der historischen Entwicklung der Psychiatric, wie die moraltheologischen Lehren der Psychiker, die hirnpathologischen Sichtweisen der Somatiker, die Psychoanalyse, Psychopharmakologie, Biologische Psychiatric, Sozialpsychiatrie oder Neurowissenschaften bewegen sich seit dem 19. Jahrhundert, in dem sich Universitatspsychiatrie und Versorgungspsychiatrie (zum Nachteil beider) getrennt haben [15], im wesentlichen zwischen den Polen biologischer und psychosozialer Konzeptualisierung psychischer Erkrankungen - im Wechselschritt hin zu einer Komplementierung und Verschrankung der einzelnen Perspektiven. So stand beispielsweise der Jahreskongress 2001 der American Psychiatric Association (APA) unter dem Motto „Mind meets brain “ [1]. Die verschiedenen, in der Geschichte oft genug verabsolutierten Teilperspektiven psychischen Krankseins, entwickeln sich erkennbar aufeinander zu, und es setzt sich zunehmend die Erkenntnis durch, dass eine Psychiatric ohne Seele, aber auch ohne Gehirn an der Sache vorbeigeht und der Komplexitat psy-chischer Storungen nicht gerecht wird.

In spite of the increasing interest in outpatient treatment programmes for alcohol dependents, there still exist only a few experimental studies on this issue. Moreover, the interaction between abstinence and sociodemographic factors has been only rarely explored. In this study, the efficiency of different behaviour therapy strategies was examined: 120 patients were randomly assigned to nonspecific supportive therapy or to 2 forms of behavioural therapy (coping skills training and cognitive therapy). Behavioural treatment comprised 26 weekly sessions; follow-up examinations took place every 6 months over 2 years. Patients undergoing behavioural therapy showed less drop outs and significantly higher rates of abstinence and also of reemployment and satisfaction with their job situation compared to those under supportive treatment. At the same time, the employment status proved to be a valid predictor of treatment success, whereas there was only a weak (negative) impact of an existing partnership on abstinence. Statistically significant differences between the 2 behavioural therapy strategies could be established in neither respect.

Schizophrenia is a relapsing disorder. The main goal of neuroleptic long-term treatment is relapse prevention, which is empirically well proven. Availability of different kinds of treatment strategies including new antipsychotic drugs with improved risk/benefit profile allow long-term treatment to be individually tailored. Treatment guidelines developed mainly by the scientific medical societies can help the practitioner in making the right decisions.

This paper summarizes current knowledge about course and outcome in schizophrenia by selecting particular information and by drawing conclusions in the light of theoretical and methodological considerations, in order to illustrate future research strategies, as well as to consider novel targets of treatment.Based on examples from the literature the concepts of course and outcome as well as intervening factors of course and outcome are discussed by considering study results within their methodological and theoretical framework restrictions.The heterogeneity of the disorder, manifest in its variable phenomenology, illness course, treatment response and outcome, complicates research but at the same time offers clues to elucidate the heterogeneity of aetiology and pathogenesis. The search for intervening factors and predictors is of particular interest in order to explore the illness mechanisms.Future research should focus on the biopsychosocial determinants of course and outcome in methodologically improved long-term studies.

With increasing CT examinations of the cerebrum, the discovery of basal ganglia calcification becomes more frequent. In order to correlate these calcifications to the symptoms believed to be accompanied with Fahr's disease 2318 cranial CT scans were examined. There was an overall incidence of basal ganglia calcification of 12.5%. The most frequent location was the globus pallidus (96.4%). In the examined population there was no correlation found between the calcifications and symptoms having been described with striopallidentate calcifications.

In spite of the increasing interest in out-patient treatment programmes for alcoholics, there still exist only a few experimental studies on this issue. In this still ongoing study the efficacy of different behaviour therapy strategies is to be examined.One hundred and twenty patients were assigned randomly to non-specific supportive therapy or to two forms of behavioural therapy (coping skills training and cognitive therapy). Behavioural treatment comprised 26 weekly sessions; follow-up examinations will take place every 6 months over 2 years.Patients undergoing behavioural therapy showed less drop-outs and significantly higher rates of abstinence compared with supportive treatment. Nevertheless, statistically significant differences between the two behavioural therapy strategies could not be established so far.Preliminary results demonstrate the feasibility and efficacy of behaviour therapy programmes in the out-patient treatment of alcoholism. Furthermore, they stress the importance of professional psychiatric and psychotherapeutic engagement in the field of addiction.

Attempts to regulate the quality of clinical practice date back as far as medicine itself. The Hippocratic Oath includes as fundamental principles that doctors should use their ability and judgement to benefit patients as much as they can and that they should refrain from any harmful or mischievous course of action. Safeguarding and improving existing standards of practice is now accepted as a central priority. The introduction of measures aimed at quality assurance (QA) is in part a response to the growth of knowledge and to increasing specialisation. However, it also reflects increased public scepticism about medical practice and, last but not least, pressures to contain costs because of increasingly restricted resources in public sector health services (Eichhorn 1997).

The treatment of patients with schizophrenic disorders is based on clear, empirically derived principles. Guidelines for treatment may be found in a number of published works (see below; Gaebel, in press). In countries with a structured health care sector, schizophrenic patients are treated in a system comprising multiple components. The psychiatrist is not necessarily the caregiver of first resort for such patients, but is, as a practically universal rule, consulted as a specialist - at least upon the initial presentation of the illness - and directs further treatment measures, in whatever component of the mental health care system they may take place. In the context of multidiscipHnary treatment, the psychiatrist bears the ultimate responsibility for the development and implementation of an overall treatment plan.