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

In German mental health services, the ill-defined term "sociotherapy" has been used to designate nonmedical, social, and work-related components of the care process. Recently, a new component of outpatient/community mental health care called "sociotherapy" (according to Paragraph 37a of the Fifth German Social Code) which is funded by the public health insurance system has been introduced and is now in the process of being implemented. The paper describes (a) patients eligible for the service and (b) the aims and scope of this case management module. The key objectives are to motivate patients with schizophrenia to utilise mental health services and antipsychotic medication and to liaise with psychosocial services. Therefore, sociotherapy is distinct from (a) multidisciplinary inpatient care for people with severe mental illness, (b) assertive community treatment, (c) community care provided by social workers or community psychiatric nurses, and (d) family interventions. So far there has been little evaluation of sociotherapy.     

Has the public taken notice of psychiatric reform? The image of psychiatric hospitals in Germany 1990–2011

Purpose

In the context of mental health care reform in Germany, psychiatric hospitals have been transformed in terms of their infrastructure, staffing levels and therapeutic culture. The question arises as to what extent these improvements had an impact on the public image of these institutions.

Methods

In 1990 and 2011, population surveys were conducted in the “old” states of Germany, using the same sampling procedure, interview mode and measures.

Results

Over the last two decades, attitudes toward psychiatric hospitals have improved considerably. This improvement was particularly pronounced among those who had been in treatment for mental health problems. The public is now more inclined to regard psychiatric hospitals as similar to other hospitals, more ready to expect effective treatment in psychiatric hospitals, and less inclined to support the stereotype that psychiatric hospitals are primarily places where patients are locked away. However, there was a stronger tendency to agree with the notion that psychiatric hospitals are necessary to protect society from persons with mental illness.

Conclusions

The improvement of psychiatric care seems to pay off as regards the image of psychiatric hospitals among the general public. Further efforts are necessary to reduce the stigma attached to mentally ill people.     

The differential effectiveness of psychosocial and biogenetic causal explanations in reducing negative attitudes toward "mental illness"

Given the apparent failure of the "mental illness is an illness like any other" approach to reducing negative stereotypes of people with mental health problems, the differential effects of biogenetic and psychosocial explanations of psychiatric symptoms were evaluated. Attitude measures were administered to young New Zealand adults before and after a video portraying a young man with psychotic symptoms followed by either biogenetic or psychosocial explanations. Consistent with previous studies, the "medical model" approach significantly increased perceptions of dangerousness and unpredictability. Following the psychosocial explanation there was a slight but statistically insignificant improvement in attitudes. Participants who knew users of psychiatric services, or who had used services themselves, had more positive attitudes than other participants. It is recommended that destigmatization programs minimize efforts to persuade the public that mental health problems are biogenetic illnesses, and focus instead on increasing exposure to users of mental health services. Further research is required to determine whether such exposure should include life histories, so as to highlight the psychosocial causes of mental health problems.     

Psychiatric Patients' Rights and Users Groups

The rules of the public health field in France and relations between the different actors have undergone a swift evolution in recent years. At the heart of these changes lies the question of patients' rights, among which are the patient's right to information on his or her state of health. Simultaneously, the role of patients groups has grown steadily, giving them a voice and the recognition of both professionals and users of the health system, whom they accompany in the "empowerment" over their health. Over the past 10 years the two main associations in the French mental health field (FNAPSY and UNAFAM) have progressively become a source to health administrators and services of propositions and innovative initiatives to improve the care of people suffering from mental illness. It is no longer possible to ignore their demands, be it on the level of government mental health policy or in psychiatric care units. This article presents a brief history of the role of users in the French mental health field, a presentation of the main demands of user groups and their relatives, and some concrete examples that show the long road ahead toward health democracy in French psychiatry.     

A Community Approach to Helping Disabled Children in Jamaica

Private sector hospitals are the main provider of mental health care in Japan. More than four-fifths of psychiatric beds are privately owned. Unlike Western countries, private sector hospitals in Japan serve all citizens enrolled in the universal public health insurance system. Private sector hospitals in Japan are only allowed to be nonprofit corporations. Mental health system is still inpatient oriented. Mental health professionals have recognized the importance of movements toward community mental health, but changes have been slow. The shortage of social resources in the community is one reason why many patients have experienced prolonged inpatient care unnecessarily. Although the Ministry of Health, Labor, and Welfare has declared its commitment to mental health reform, it is very difficult to establish public community mental health system from scratch because of financial problems. The Japanese mental health system received only 0.38 percent of the gross domestic product in funding. In Japan, some hold an overly optimistic view that hospitalization costs can be cut by transferring inpatients to residential community care facilities and that the savings generated can be used to pay for acute psychiatric care. However, this proposition is unfeasible because hospitalization costs have been reduced to a level equal to or below that of residential care costs in the other developed countries. Japan has established a system called hospital ward specialization. Under this system, psychiatric wards have been divided into units specializing in various areas of care. This system is not helping to decrease the number of hospital beds or the inpatient populations and has been found to be hindering deinstitutionalization in Japan. It will be necessary in the future to transition from a medical fee-for-service system that promotes long-term hospitalization and large-scale expansion to one in which downsizing correlates with better financial results.     

Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995

OBJECTIVE: The study examined patterns of care for persons with mental illness in nursing homes in the United States from 1985 to 1995. During that period resident populations in public mental hospitals declined, and legislation aimed at diverting psychiatric patients from nursing homes was enacted. METHODS: Estimates of the number of current residents with a mental illness diagnosis and those with a severe mental illness were derived from the 1985 and 1995 National Nursing Home Surveys and the 1987 and 1996 Medical Expenditure Surveys. Trends by age group and changes in the mentally ill population over this period were assessed. RESULTS: The number of nursing home residents diagnosed with dementia-related illnesses and depressive illnesses increased, but the number with schizophrenia-related diagnoses declined. The most substantial declines occurred among residents under age 65; more than 60 percent fewer had any primary psychiatric diagnosis or severe mental illness. CONCLUSIONS: These findings suggest a reduced role for nursing homes in caring for persons with severe mental illness, especially those who are young and do not have comorbid physical conditions. Overall, it appears that nursing homes play a relatively minor role in the present system of mental health services for all but elderly persons with dementia.     

Public attitudes toward psychiatric treatment

Aim In order to examine whether there is a relationship between the state of mental health care and the acceptance of psychiatry, public attitudes toward psychiatric treatment in three countries where the reform of mental health care has progressed to a different degree will be compared. Methods Population surveys on public beliefs about mental illness and attitudes toward psychiatric treatment were conducted in Bratislava, Slovak Republic, and Novosibirsk, Russia. The data were compared with those from a population survey that had recently been carried out in Germany. In all three surveys, the same sampling procedure and fully structured interview were applied. Results Although respondents from all three countries were equally inclined to seek help from mental health professionals, those from Bratislava and Novosibirsk tended to recommend more frequently to address other medical or nonmedical professionals or members of the lay support system. In all three countries, psychotherapy was the most favored treatment modality, followed by psychotropic medication. Although natural remedies were more frequently recommended in Bratislava and Novosibirsk, meditation/yoga was more popular among the German public. Across all three countries, the endorsement of a brain disease as cause was associated with a greater willingness to seek help from medical professionals (psychiatrist, GP). Respondents who adopted biological causes tended to recommend psychotropic medication more frequently. Conclusion In countries with less developed mental health care systems, there appears to be a tendency of the public toward more frequently relying on helping sources outside the mental health sector and on traditional “alternative” treatment methods. However, it is our prognosis that with the progress of reforms observed, differences may further decrease.     

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

Background   There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.
Method   A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.
Results   People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.
Conclusions   Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.     

A review of the interplay between tuberculosis and mental health

Aims

Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/substance abuse and migrant status leading to frequent comorbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness.

Methods

A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. In total 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data.

Results

Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses, such as depression, may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects and some medications such as rifampicin may reduce the effective doses of anti-psychotics y their enzyme induction actions. Treatment with agents such as cycloserine has been associated with depression, and there have been reported cases of psychosis with most anti-tuberculous agents. Mental illness and substance abuse may also affect compliance with treatment, with attendant public health concerns.

Conclusions

As a result of the common co-morbidity of mental illness and tuberculosis, it is probable that physicians will encounter previously undiagnosed mental illness among patients with tuberculosis. Similarly, psychiatrists are likely to meet tuberculosis among their patients. It is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.     

Deinstitutionalization and psychiatric reform in Spain

The transformation of psychiatric care which has been carried out in Spain since the 1980s, under the name of “Psychiatric Reform”, had produced as it most significant achievements: (i) the development of a new organizational structure for mental health care, (ii) the integration of psychiatric patients in the general health care system, (iii) the creation of an extensive community network of mental health centers, and (iv) the adoption by the general public of more positive attitudes towards mental illness and its treatment and the passing of legislative measures aimed at improving the civil rights of these patients. However, the application of the Psychiatric Reform has followed an uneven course in Spain as a whole, with marked differences between the different autonomous communities. The main deficiency has been in the development of intermediate community services and programs to rehabilitate and resettle patients in the community. With regard to deinstitutionalization, the results have also been insufficient and it is still possible to observe a strong tendency, within the system, to maintain the old mental hospitals for both long-term and short-term illness care. Finally, the analysis of the Spanish experience has revealed that (i) many of the criticisms leveled at deinstitutionalization are not aimed at its “conceptual core” but stem from its inadequate implementation, and (ii) it is wrong to equate deinstitutionalization and psychiatric reform with closure of psychiatric hospitals, without the awareness that this process is far more complex.     

The role of general hospitals in the privatization of inpatient treatment for serious mental illness.

For almost three decades, many have regarded general hospital psychiatric units as the most appropriate setting for acute treatment of persons with serious mental illness who were once treated mostly in state hospitals. The extent to which this transfer has taken place and the differences between public and private general hospitals have been unclear. Using data from the 1988 National Mental Health Facilities Study and published data from the 1970s, the authors found that nearly half of all general hospitals providing psychiatric services treat persons with serious mental illness. Significant differences in case and payer mix were observed between public and private general hospitals, although these differences were smaller than in the 1970s. The findings suggest increased involvement by private general hospitals in treating patients reimbursed by public payers, but the findings also indicate that persons with serious mental illness and those using Medicaid are still more prevalent in public general hospitals than in private ones.     

Psychiatric emergency services and the system of care

OBJECTIVE: Admissions to psychiatric emergency services have frequently been cited as a gauge of how well a mental health system manages behavioral disorders. However, few measurements of the longitudinal association between psychiatric emergencies and characteristics of a mental health system have been described. The purpose of this study was to assess whether weekly admissions to psychiatric emergency services would increase when outpatient services were reduced, whether weekly admissions would increase when greater effort was made to identify and treat persons with acute mental illness, and whether weekly admissions would decrease when emergency services were enhanced to include postrelease case management. METHODS: Time-series methods were applied to approximately 29,010 admissions to three psychiatric emergency services of the San Francisco Department of Public Health over a 180-week period. RESULTS: Reduced outpatient services, efforts to identify acutely ill persons, and changes in emergency services themselves were found to affect admissions to emergency services. However, community events such as extreme weather, holidays, job loss, and the scheduling of receipt of income also affected the workload of the emergency service. CONCLUSIONS: The causes and course of mental illness inextricably tie a psychiatric emergency service to the overall mental health system and to events in the community it serves. These connections make it possible for managers to anticipate the use of emergency services and to detect disruptions in the remainder of the mental health services systems.     

Attitudes Toward Community Mental Health Care: The Contact Paradox Revisited

Contact with people with mental illness is considered to be a promising strategy to change stigmatizing attitudes. This study examines the underlying mechanisms of the association between contact and attitudes toward community mental health care. Data are derived from the 2009 survey “Stigma in a Global Context—Belgian Mental Health Study”, using the Community Mental Health Ideology-scale. Results show that people who received mental health treatment themselves or have a family member who has been treated for mental health problems report more tolerant attitudes toward community mental health care than people with public contact with people with mental illness. Besides, the perception of the effectiveness of the treatment seems to matter too. Furthermore, emotions arising from public contact are associated with attitudes toward community mental health care. The degree of intimacy and the characteristics of the contact relationship clarify the association between contact and attitudes toward community mental health care.     

Treatment prospects for persons with severe mental illness in an urban county jail

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.     

Health histories of juvenile offenders and a matched control group in Saskatchewan,Canada

A great deal of public and academic concern has been directed towards juvenile criminal involvement. In efforts to predict and control criminal behaviour, various explanations have been forwarded. A review of the literature indicates that a number of physical and psychiatric characteristics are hypothesised to be related to subsequent criminal activity. This study examines the health histories of 1647 young offenders and a matched control group of non-offenders. Information for the two groups was extracted from the records of various branches of the Saskatchewan Department of Health which contained historical data on hospital admissions and separations, outpatients services, and mental health services. Five health categories have been focused upon: trauma to the central nervous system; perinatal problems; psychiatric contacts; indicators of child abuse; and a general history of illness. A select number of health variables representing these categories were drawn from the available records and compared between the groups. Preliminary findings regarding the relationship of these health variables with juvenile justice system contacts indicated only weak or non-significant associations. One or more follow-up reports are anticipated.     

Routine HIV testing for the severely mentally ill: considerations and cautions

The last few decades have brought major changes in both mental health laws and AIDS public health laws. The author first examines the impact of the HIV epidemic on those with severe and persistent mental illness. He then discusses how changes in public health laws have affected those infected with HIV and how changes in mental health laws have affected those with mental illness. People suffering from severe mental illness are increasingly being held legally responsible for their personal actions. At the same time, AIDS public health laws have begun to change so that those infected with HIV enjoy less legal protection and have more personal responsibility for transmitting the virus to others than in the recent past. The author then considers what impact the convergence of these legal changes is likely to have on the growing population of people with mental illness who are infected with HIV. The article concludes with some practical recommendations concerning HIV assessment and treatment in individuals with severe and persistent mental illness.     

Mental health care in Fiji

Fiji is one of the largest island nations in the South Pacific. It is multicultural and has an economy based on tourism and sugar production. Like many developing countries Fiji faces the double burden of communicable and non‐communicable diseases as well as a third emerging burden of accidents and injuries. Fiji lacks data on the national prevalence and burden of disease of mental disorders. Using World Health Organization estimates there is over a 90% treatment gap for mental disorders. Contributing to this treatment gap are the misconceptions and stigma surrounding mental illness leading people to seek alternative treatments. Fiji's mental health services were established in 1884, comprising a single ward to care for mentally ill expatriates. Services have since expanded to include a 136‐bed inpatient facility (St. Giles Hospital), which provides outpatient, psychosocial rehabilitative and community psychiatric services. Mental health services remain centralized at St. Giles, with follow‐up in the community supported by a well‐established public health hierarchy and by medical personnel at the divisional hospitals. St. Giles is also responsible for conducting mental health awareness and training for health workers and the public and provides input at a national level for mental health policy, plans and legislation. Psychiatric training is available at the undergraduate nursing and medical levels. The Fiji School of Medicine is in the process of developing a postgraduate psychiatric program. With its limited resources Fiji needs to integrate mental health services into the general and public health systems to achieve a comprehensive and integrated mental health system.     

The public image of psychiatrists

The image of psychiatry is directly related to the knowledge that the public has of psychiatry and to the psychiatrists role as a "public informer". The time has come for psychiatrists to organize and have their opinions on all aspects of the mental health care system and mental illness heard in the media. After a review of different causes of the negative public image of psychiatrists, the reasons for which psychiatrists need to change their public image are outlined with some suggestions for increase public recognition. The importance of developing more research on the effect of mass media on the mental health care system is also outlined.     

Implementation of monitoring and management guidelines for second-generation antipsychotics

It has long been known that psychiatric patients experience increased morbidity and mortality associated with a range of physical disorders. Lifestyle, inadequate health care, and a variety of other factors all contribute to the poor physical health of people with severe mental illness. Second-generation antipsychotics have gained widespread acceptance for the management of patients with schizophrenia and other forms of severe mental illness. While demonstrating several advantages over first-generation antipsychotics, second-generation antipsychotics have been found to cause or exacerbate several metabolic disorders, including diabetes, obesity, dyslipidemia, and metabolic syndrome. These disorders are closely linked and consistently associated with the development of cardiovascular disease, with varying prevalence rates depending on the second-generation antipsychotic used. As a result, several authoritative guidelines have been developed for the monitoring and management of metabolic disturbances in schizophrenia and other forms of severe mental illness. Specifically, the guidelines and recommendations generated from the Mount Sinai Conference on Medical Monitoring and the American Diabetes Association/American Psychiatric Association Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes call for a more integrated and cooperative approach between primary care physicians and mental health care providers to improve the quality of health care for people with severe mental illness. By routinely performing physical health monitoring, referrals, and/or treatment for patients with schizophrenia and other forms of severe mental illness, mental health care providers can take a lead role in transforming the current system of fragmented mental and physical health services into a system focused on early intervention, wellness, and recovery.