[Sociotherapy in German social law. Indication, contents, and aspects of public health]

Sozialmedizinische Interventionen in der Richtlinienpsychotherapie

Hintergrund

Viele psychische Störungen nehmen einen Langzeitverlauf und gehen daher mit sozialen und beruflichen Teilhabeeinschränkungen einher. Dies gilt auch für Patienten in der Richtlinienpsychotherapie. Um eine ganzheitliche Versorgung zu gewährleisten, sind u. a. sozialmedizinische Interventionen erforderlich, wozu die Koordinierung mit anderen Therapeuten, Kontakte zum Arbeitgeber oder zu arbeitsrelevanten Institutionen, häusliche und freizeitbezogene Hilfen oder soziale Unterstützungsmaßnahmen gehören. Es stellt sich die Frage, welche derartigen sozialmedizinischen Interventionen zum Repertoire von Richtlinienpsychotherapeuten in ihrem Arbeitsalltag gehören.

Material und Methoden

Es wurden 131 psychologische Psychotherapeuten gebeten, anhand eines Glossars mit 38 sozialmedizinischen Interventionen anzugeben, welche davon sie in ihrer täglichen Praxis anwenden.

Ergebnisse

Alle Maßnahmen kamen zur Anwendung. Im Durchschnitt gaben die Therapeuten an, dass ihnen von den 38 Interventionen eine nicht bekannt war, sie mit ca. 14 Interventionen nach eigener Einschätzung nie, mit 8 weniger als einmal/Jahr, mit 8 einmal/Jahr und mit 6 einmal/Quartal befasst waren.

Schlussfolgerung

Die vorliegenden Daten zeigen, dass sozialmedizinische Interventionen zum Repertoire vieler Psychotherapeuten gehören. Allerdings finden sich Unterschiede zwischen den Therapeuten, hinsichtlich des Bekanntheitsgrads und der Anwendung sozialmedizinischer Interventionen. Das weist auf Optimierungspotenziale in der Ausbildung, Organisation und Vergütung hin.

Evaluation of an integrated care program for schizophrenia: concept and study design

Concept and design of an independent scientific evaluation of different pathways of care for schizophrenia patients in Germany with respect to effectiveness and efficiency are presented. In this prospective, observational study, schizophrenia patients receiving an integrated care treatment, the intervention group (IG), are compared with patients under routine care conditions treated by the same physician (first control group, CG 1). A second control group (CG 2) of patients treated by office-based psychiatrists not participating in the integrated care program will be recruited and their data compared with the two other groups. The total amount of psychiatric hospital days after 12 months is defined as primary outcome parameter. Secondary outcome parameters comprise the frequency of psychiatric inpatient readmissions, severity of schizophrenia symptoms, remission rates and quality of life. Patients undergo assessments at baseline, month 6 and 12 using standardized and experimental questionnaires. Routine data of a regional German social health insurance fund complement information on included patients. Additionally, a cost-effectiveness and cost-utility analysis will be performed. Until now, 137 psychiatrists included 980 patients in the integrated care project in Lower Saxony, Germany, and 47 psychiatrists (IG and both CGs) are willing to participate in the independent evaluation. For the first time, a prospective observational controlled evaluation study of a countrywide integrated care project planning to recruit 500 schizophrenia patients has started using comprehensive assessments as well as routine data of a social health insurance fund.

Prevention of rehospitalization in schizophrenia: results of an integrated care project in Germany

The goal of this study was to prevent rehospitalizations and thus to optimize satisfaction with treatment and quality of life in patients suffering by schizophrenia or schizoaffective disorder. A complex intervention with improved cooperation between in- and outpatient services was applied to 46 "high utilizing" patients after discharge from inpatient care during an intervention phase of 6 months. The study was controlled by a matched group of 47 patients receiving treatment as usual. The intervention was based on a computerized decision support module. Eight psychiatrists in private practices were supplied with this software to obtain guideline-based recommendations according to current psychopathology and clinical state. Suggested complex interventions by the software included psychoeducation, social competence group therapy, integrated psychological therapy, computer-based cognitive training, coping skills training, sociotherapy, nursing care, home visits, social-worker care, assistance to family members, and the use of an emergency call-in line. A local hospital project team arranged specifically suggested interventions. We intended to accomplish a reduction of rehospitalization rates by 50% in the intervention group within a 12-month follow-up phase. Satisfaction with treatment, subjective quality of life, and treatment costs in terms of daily inpatient costs were compared between both groups. Moderator variables such as socio-demographical aspects or influences of certain interventions to rehospitalization rate were analyzed. The sample included patients more seriously ill than originally expected. Subjects in the control group (CG) were older (46 years) than those subjects in the intervention group (IG) (40 years). Other sociodemographical aspects (sex, family status, level of education, and number of former hospitalizations) showed no differences between both groups. The rehospitalization rate and the mean length of inpatient treatment were reduced to nearly 50% in the intervention group. The rate of readmissions increased in the control group, leading to a difference of 23% between both groups. The most important factor to favorably influence rehospitalization rates was the participation in coping skills training. There was an increase in patient satisfaction with treatment, while the subjective quality of life remained constant. Since these improvements were accomplished with lower costs (in terms of inpatient care), cost effectiveness was higher in the IG than in the CG. The most important single factor to favorably influence rehospitalization rates was the participation in coping skills training. Only the guideline consistent complex therapies as common intervention caused the significant overall result. Thereby, satisfaction with treatment increased considerably during the 6 months of intervention and remained constant during 12 months of follow up. The model project described is an important step to gain evidence and experience with integrated care for patients with schizophrenia.

[Care requirements for severe mental disorders. Scientific evidence for integration of clinical psychiatry and community psychiatry]

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.