[Implementation of the principle of supported employment in Germany : Position paper of a task force of the DGPPN]

The effects of mental diseases on the employment and working situation can be substantial. They are one of the main reasons for inability to work and reduced earning capacity. Against this background the question arises about suitable occupational reintegration measures for people with severe mental illnesses. In recent years, the principle of supported employment has been internationally shown to be increasingly more successful. In this context mentally ill people are primarily placed at a position of the first employment market and supported on-site by a job coach. This concept is inclusive, individual and evidence based. Despite proven effectiveness, it has so far been insufficiently implemented in German-speaking regions. In the future it will be a matter of considering the individual needs for assistance of mentally ill people more intensively than previously and to respond with functional and in a best-case scenario, multiprofessional and flexible offers.

Classification of parasuicide by cluster analysis. Types of suicidal behaviour, therapeutic and prognostic implications

A classification of suicidal behaviour was derived by cluster analysis from descriptive data on parasuicide patients. The grouping was meaningful in terms of clinical interpretation and had both therapeutic and prognostic implications. The sample was broken down into three groups, identified as repeated, serious and non-serious attempts. The repeated attempters had the worst prognosis at 1-year follow-up. When the sample was classified into five groups according to seriousness of the attempts, the repeater and non-serious groups were retained, while the serious attempts were split into three subtypes, which differed on nosological characteristics, treatment disposal and outcome. An excessively high successful suicide rate was found in a small group of elderly attempters.

[Treatment of patients following attempted suicide within the scope of a liaison service]

Only few patients after suicide attempt are examined by a psychiatrist. In order to intensify the primary psychiatric care of suicide attempters, a psychiatric liaison scheme was established at an intensive care unit of the Technical University, Munich. The main advantages are: A psychiatrist talks with every suicide attempter; the psychiatrist and the medical staff are better informed about the suicidal act and the personality of the suicide attempter because of close cooperation; there is more time for diagnostic and psychotherapeutic activities; suicide risk diminishes while staying on the medical ward. If a psychiatric liaison scheme cannot be established it should be tried to change ward atmosphere by advising the medical staff and offering emotional support.

[Description of sociodemographic and psychiatric data of 295 patients following attempted suicide by poisoning--inpatient treatment within the scope of a psychiatric liaison service at an internal medicine clinic of a large municipal hospital]

295 attempted suicides with intoxication are described by sociodemographic, biographic, and psychiatric characteristics. The patients were hospitalized for detoxification, and after clearing up interviewed by a psychiatrist working in the hospital as a liaison-psychiatrist. The patients did not differ essentially from patients treated in the emergency unit of another general hospital of the city in terms of basic social data. The patients--65% women, 35% men--are young (up to 40 years), 39% had already attempted suicide before the index-time. 41% came from "broken homes", 40% had one or more psychiatric disease(s) in their families. 56% were diagnosed as "psychiatrically ill", second diagnosis was in 33.5% abuse of alcohol/drugs. The referal offer to the patients for the time after discharge from emergency unit is described in detail. Just 12% of the patients were treated in a psychiatric hospital, after-care in an ambulatory setting seemed to be sufficient for most of the other patients. 20% were not offered any after-care. Patients with addiction and psychosis were sent to institutions specialized for these diagnoses.

[On the problem of the "Seriousness" of suicide attempts]

In 15.3% of 295 hospitalized suicide attempters (94% with intoxication) severe intoxication that would have had a lethal outcome without medical treatment was significantly associated with previously described factors characterizing persons who committed suicide. A strong death wish (47.3%), as judged by physicians, was highly associated with almost the same factors. A high degree of physical harm and a firm intention to die correlated significantly with the intensity of care during hospitalization and after discharge from the emergency unit.

[Comparative study of 295 patients with first and repeated suicide attempts]

After their first suicide attempts 169 patients were compared to 109 repeated suicide attempters regarding sociodemographical, biographical, and psychopathological variables. The differences between the groups characterize the repeaters as persons with more broken-home situations in childhood and youth and with more tension and instability in private and occupational relationships. These patients received more psychiatric or psychotherapeutic treatment, were more often classified as suffering from a personality disorder or addiction and their prognosis was estimated less favourable. These findings are consistent with the results of other investigations. Questions of typological interpretation and practical consequences are discussed.

[Care of patients after attempted suicide: tasks, problems and possibilities of improvement]

Inpatient and post-inpatient psychiatric/psychotherapeutic treatment of suicides poses a considerable number of problems which have to be handled by the institutions concerned: These problems are formidable because of the high incidence of attempted suicides and the considerable amount of work necessarily involved in caring for such persons. Care should by no means be restricted to the acute crisis; attempts should also be directed by preventing relapses and at improving the overall psychopathological status and social readjustment. The present manner in which suicides are looked after has quite a number of drawbacks, e.g. insufficient attention is paid to the requirements of the inpatient; patients fail to refer to the hospital during the period of their post-suicide attempt care; the incidence of "dropouts" during outpatient aftercare is very high; there is insufficient cooperation between the persons and institutions involved in the care programme. Improvements are presented which have been successfully tried out in practice.