RESUMEN
OBJECTIVE: To describe the ongoing process of German psychiatric reform and the structure and functioning of mental health services. METHOD: Information sources used include official reports describing mental health services, relevant publications related to organization and functioning of services. RESULTS: There has been far-reaching change in mental health care since the late 1960s: psychiatric hospitals have lost about 50% of their beds and one psychiatric hospital has been closed. One hundred and sixty-five general hospital psychiatric units have been built up. Out-patient, community and residential services have been developed. There is a lack of diversified residential and rehabilitation services, particularly for the most severely ill. Co-ordination of care is not always ensured, transfer of patients to remote nursing homes has occurred in some places. Carers and service users articulate their views to an increasing degree. CONCLUSION: Political and professional enthusiasm have been important in implementation of the German reform. Evolving it further will require major efforts.
Asunto(s)
Reforma de la Atención de Salud , Servicios de Salud Mental/organización & administración , Psiquiatría/organización & administración , Alemania , Humanos , Psiquiatría/legislación & jurisprudenciaRESUMEN
The reform of psychiatric services started in Germany in 1975 with the publication of the governmental "Enquete"-Report. In the area of housing for chronic patients the recommendations made 1975 have not been fulfilled. A greater number of chronic patients as planned live in institutionalised homes with little access to the community and shortcomings in the area of individual self determination. The process of deinstitutionalization of the old chronic patients from psychiatric hospitals has created new problems. Some 60,000 patients have been deinstitutionalized, but in some parts of the country to a considerable degree just by renaming parts of the hospital into a home for the disabled. There is a need for research on who lives where and how and efforts have to be made to change this situation by the development of more community centered and individualised forms of living as shown by many successfully working regions in the country.
Asunto(s)
Desinstitucionalización/métodos , Clausura de las Instituciones de Salud , Hospitales Psiquiátricos/organización & administración , Trastornos Mentales/rehabilitación , Calidad de Vida , Instituciones Residenciales/organización & administración , Enfermedad Crónica , Desinstitucionalización/tendencias , Alemania , Humanos , Instituciones Residenciales/tendenciasRESUMEN
Discussing drug abuse and the concept of "low-threshold" in the treatment of drug addicts, we investigated development of detoxification strategies in the Department of Psychiatry at Kaufbeuren during the last 10 years. In the following we describe 4 different phases of this development: In 1988 we admitted 34 opiate-dependent patients treated in general psychiatric units. In 1998 almost, 1,000 drug addicts were treated in specialised drug detoxification units. In the beginning we realised opiate detoxification treatment without medication. In the second phase we treated the subjects symptomatically. During the last four years we have been offering homologue opiate withdrawal with L-polamidone. Last year we extended the opiate detoxification treatment to the day hospital and outpatient setting. The comparative examination of patient moods during the so called qualified and the homologue splitted opiate withdrawal treatment shows amazing similarities regarding the oscillations, leaving out of account that the remarkable worsening after one week of drug assisted detoxification was seen one week later in the homologue splitted detoxification group.
Asunto(s)
Trastornos Relacionados con Opioides/rehabilitación , Admisión del Paciente , Atención Ambulatoria/estadística & datos numéricos , Alemania , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Hospitales de Distrito/estadística & datos numéricos , Humanos , Trastornos Relacionados con Opioides/epidemiología , Admisión del Paciente/estadística & datos numéricos , Servicio de Psiquiatría en Hospital/estadística & datos numéricos , Centros de Tratamiento de Abuso de Sustancias/estadística & datos numéricos , Resultado del TratamientoRESUMEN
We investigate the sociomedical effect of the development of Kaufbeuren's Psychogeriatric Center through the last six years by means of administrative and medical care variables. Whereas the number of admissions remained relatively stable, the medium duration of stay continuously decreased from 181 to 31 days--above all in favour of dementia--and the number of days hospital stay by 692%. The diagnosis with the greatest variation in number was the increase of depressive disorders to 31% of all admissions in 1998. Whereas the hospitalisation of patients initiated by general practitioners decreased by 12%, in the same period of time the number of admissions from our psychogeriatric outpatients' department increased by 16%. The number of admissions suggested by homes of the aged decreased, whereas the admission by patients' own initiative increased continuously. While the number of patients living in residential care decreased by 11%, the rate of patients living with their partners at home increased by 7%. These results point to the efficiency of community and visiting psychogeriatric care from both a patients' and an economically point of view.
Asunto(s)
Servicios de Salud para Ancianos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Trastornos Mentales/epidemiología , Admisión del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Enfermedad de Alzheimer/epidemiología , Enfermedad de Alzheimer/terapia , Centros Comunitarios de Salud Mental/estadística & datos numéricos , Femenino , Alemania/epidemiología , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Humanos , Masculino , Trastornos Mentales/terapia , Grupo de Atención al Paciente/estadística & datos numéricos , Revisión de Utilización de RecursosRESUMEN
A meta-analysis was carried out on 53 cases of dementia praecox (DP) and 134 cases of manic-depressive insanity (MDI) originally diagnosed by Kraepelin or his collaborators in Munich in 1908. The original case material was coded in terms of Present State Examination syndromes and analysed statistically for internal consistency and discrimination between the two diagnostic entities. Kraepelin's DP and MDI were found to define homogeneous groups of disorders which could be clearly distinguished from one another. A CATEGO re-classification of the cases revealed an 80.2% concordance rate between Kraepelin's diagnoses and ICD-9. Cluster analysis of the original data reproduced closely Kraepelin's dichotomous classification of the psychoses but suggested that DP was a narrower concept than schizophrenia today, while MDI was a composite group including both 'typical' manic-depressive illnesses and schizoaffective disorders.
Asunto(s)
Trastorno Bipolar/historia , Esquizofrenia/historia , Adulto , Trastorno Bipolar/clasificación , Análisis por Conglomerados , Femenino , Alemania , Historia del Siglo XX , Humanos , Masculino , Escalas de Valoración Psiquiátrica , Esquizofrenia/clasificación , Psicología del Esquizofrénico , Terminología como AsuntoRESUMEN
Patients and nurses assessed the social atmosphere in two psychiatric acute care units and their behavior was recorded before and after the observation ward and the residential ward were transformed into two fully functioning admission wards, avoiding transference of patients. Consequently, the initially high amount of isolated behavior decreased, social behavior and outdoor activities increased. For the patients, however, the stereotype of a psychiatric acute care unit does not change so soon because of their higher aspiration levels and their uncertainty about the treatment concept. As the new structures increasingly are filled with life, "environmental therapy" aimed at the patients' involvement gains a great importance.
Asunto(s)
Actitud del Personal de Salud , Hospitalización , Trastornos Mentales/psicología , Satisfacción del Paciente , Medio Social , Adulto , Arquitectura y Construcción de Instituciones de Salud , Femenino , Humanos , Trastornos Mentales/terapia , Persona de Mediana Edad , Relaciones Profesional-Paciente , Garantía de la Calidad de Atención de Salud , Conducta SocialRESUMEN
Personality disorders, the most important category of section F6, were studied in the ICD-10 field trial. The overall Kappa values for interrater reliability of section F6 is 0.64, for personality disorders 0.61 and for dyssocial personality 0.73. These results are very close to those of the DSM-III field trials. Subjective assessments of feasibility, suitability and goodness of fit demonstrate good acceptance of the diagnostic guidelines by the clinicians. A comparison of ICD-9, DSM-III and ICD-10 diagnoses yielded broad agreement for diagnoses of personality disorders with overlapping Kappa values of 0.91 and 0.94. The acceptance and reliability of the new classification could be increased by a number of improvements and the planned introduction of a multiaxial system.
Asunto(s)
Conducta , Trastornos de la Personalidad/diagnóstico , Adulto , Humanos , Estudios Multicéntricos como Asunto , Trastornos de la Personalidad/psicologíaRESUMEN
The 1987 draft of ICD-10 presents many new aspects of the psychiatric diagnostic evaluation. Some were readily accepted by the participants of the field study, including: the purely descriptive approach with the abautonment of many theoretical concepts; the more operationalized descriptions of the diagnoses; similarity in structure and terms to DSM-III-R. Others proved controversial: extension of the term dementia to include even mild and moderately severe organic psychosyndromes; inclusion of all forms of depression in one chapter, and their subdivisioning only by severity; different time criteria for the diagnosis of schizophrenia in DSM-III-R (6 months) and ICD-10 (1 month). Considerable criticism was levelled at the overly long and often tediously formulated text, and the lack of didactic organisation. A number of examples of translation difficulties are given, and the differences between a too literal and a technically correct equivalent translation disu-used.
Asunto(s)
Trastornos Mentales/clasificación , Adolescente , Adulto , Conducta , Niño , Preescolar , Humanos , Discapacidad Intelectual/clasificación , Discapacidad Intelectual/psicología , Lenguaje , Trastornos Mentales/inducido químicamente , Trastornos Mentales/psicología , Trastornos del Humor/clasificación , Trastornos del Humor/psicología , Estudios Multicéntricos como Asunto , Trastornos Neurocognitivos/clasificación , Trastornos Neurocognitivos/psicología , Trastornos Neuróticos/clasificación , Trastornos Neuróticos/psicología , Trastornos de la Personalidad/clasificación , Trastornos de la Personalidad/psicología , Escalas de Valoración Psiquiátrica , Proyectos de Investigación , Esquizofrenia/clasificación , Trastorno de la Personalidad Esquizotípica/clasificación , Trastorno de la Personalidad Esquizotípica/psicología , Trastornos Somatomorfos/clasificación , Trastornos Somatomorfos/psicología , Estrés Psicológico/complicaciones , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
On the basis of the results of the field trial, the most important classificatory innovations of ICD-10, together with their advantages and disadvantages are described. The initial good acceptance of the new system could be further improved by structural modifications, such as a uniform and systematic description of the individual diagnostic categories. Criticism of content was focused on affective and neurotic disorders and adult personality disorders. When it is introduced, the psychiatric chapter of ICD-10 will surpass most of the hitherto existing psychiatric classification systems in size, differentiation and international testing.
Asunto(s)
Trastornos Mentales/clasificación , Adolescente , Adulto , Conducta , Niño , Preescolar , Humanos , Discapacidad Intelectual/clasificación , Discapacidad Intelectual/psicología , Trastornos Mentales/psicología , Trastornos del Humor/clasificación , Trastornos del Humor/psicología , Estudios Multicéntricos como Asunto , Trastornos Neurocognitivos/clasificación , Trastornos Neurocognitivos/psicología , Trastornos Neuróticos/clasificación , Trastornos Neuróticos/psicología , Trastornos de la Personalidad/clasificación , Trastornos de la Personalidad/psicología , Esquizofrenia/clasificación , Trastorno de la Personalidad Esquizotípica/clasificación , Trastorno de la Personalidad Esquizotípica/psicología , Trastornos Somatomorfos/clasificación , Trastornos Somatomorfos/psicología , Estrés Psicológico/complicaciones , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
The advent of more explicit diagnostic criteria and the growing interest in "lifetime" rates of mental disorders has made imperative an accurate determination of time-related diagnostic criteria. We used data from two independent test-retest studies of the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI) to study the reliability of different time-related questions in these fully standardized diagnostic interviews. With two exceptions (anxiety disorders and alcohol-related questions), the test-retest reliability of most time-related questions in both interviews was judged to be satisfactorily high. Furthermore, the validity of time-related questions in the DIS (age at symptom onset, duration and frequency of illness episodes) was examined by comparing them with detailed "consensus" ratings done independently by different clinicians for 207 former psychiatric inpatients. A surprisingly high concordance was found for former psychotic patients except for those still severely disturbed at the follow-up investigation. Some severe restrictions were also found for nonpsychotic disorders with regard to judgment of the age at onset of phobias, panic attacks, and depression. For a more valid assessment of time-related symptom information, the use of specific memory aids is suggested.
Asunto(s)
Memoria , Trastornos Mentales/diagnóstico , Recuerdo Mental , Escalas de Valoración Psiquiátrica , Adulto , Factores de Edad , Femenino , Estudios de Seguimiento , Hospitalización , Humanos , Masculino , Manuales como Asunto/normas , Trastornos Mentales/psicología , Psicometría , Factores de TiempoRESUMEN
The reliability of DSM-III diagnoses using an expanded version of the Diagnostic Interview Schedule (DIS), called the Composite International Diagnostic Interview (CIDI), was evaluated by examining 60 psychiatric inpatients on a test-retest basis. Acceptable agreement coefficients of (kappa) 0.5 or above were found for all but two disorders: dysthymic disorder and generalized anxiety disorder. The subclassification of DSM-III affective disorders also revealed some discrepancies between the test and the retest interviews. When compared with results from earlier versions of the DIS, diagnostic reliability was found to have improved for the DSM-III anxiety disorders in particular. These improvements can possibly be attributed to some changes in the wording of the respective items of this section. Several reasons for lowered test-retest reliability are discussed.
Asunto(s)
Manuales como Asunto , Trastornos Mentales/diagnóstico , Escalas de Valoración Psiquiátrica , Adulto , Agorafobia/diagnóstico , Trastornos de Ansiedad/diagnóstico , Trastorno Bipolar/diagnóstico , Trastorno Depresivo/diagnóstico , Femenino , Humanos , Masculino , Trastornos Mentales/clasificación , Psicometría , Esquizofrenia/diagnósticoRESUMEN
The perception and recognition of faces, mimic expression and gestures were investigated in normal subjects and schizophrenic patients by means of a movie test described in a previous report (Berndl et al. 1986). The error scores were compared with results from a semi-quantitative evaluation of psychopathological symptoms and with some data from the case histories. The overall error scores found in the three groups of schizophrenic patients (paranoic, hebephrenic, schizo-affective) were significantly increased (7-fold) over those of normals. No significant difference in the distribution of the error scores in the three different patient groups was found. In 10 different sub-tests following the movie the deficiencies found in the schizophrenic patients were analysed in detail. The error score for the averbal test was on average higher in paranoic patients than in the two other groups of patients, while the opposite was true for the error scores found in the verbal tests. Age and sex had some impact on the test results. In normals, female subjects were somewhat better than male. In schizophrenic patients the reverse was true. Thus female patients were more affected by the disease than male patients with respect to the task performance. The correlation between duration of the disease and error score was small; less than 10% of the error scores could be attributed to factors related to the duration of illness. Evaluation of psychopathological symptoms indicated that the stronger the schizophrenic defect, the higher the error score, but again this relationship was responsible for not more than 10% of the errors. The estimated degree of acute psychosis and overall sum of psychopathological abnormalities as scored in a semi-quantitative exploration did not correlate with the error score, but with each other. Similarly, treatment with psychopharmaceuticals, previous misuse of drugs or of alcohol had practically no effect on the outcome of the test data. The analysis of performance and test data of schizophrenic patients indicated that our findings are most likely not due to a "non-specific" impairment of cognitive function in schizophrenia, but point to a fairly selective defect in elementary cognitive visual functions necessary for averbal social communication. Some possible explanations of the data are discussed in relation to neuropsychological and neurophysiological findings on "face-specific" cortical areas located in the primate temporal lobe.
Asunto(s)
Gestos , Cinésica , Películas Cinematográficas , Trastornos de la Percepción/fisiopatología , Psicología del Esquizofrénico , Adulto , Cara , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
An unselected series of 100 psychiatric inpatient admissions were interviewed at admission by a psychiatrist using the German version of the PSE (Present State Examination), with a second psychiatrist as an observer. The diagnostic agreement between the two project psychiatrists was considerably higher than the agreement between clinicians and CATEGO, a computerised diagnostic system based on PSE data. The disagreements are discussed.
Asunto(s)
Diagnóstico por Computador , Trastornos Mentales/diagnóstico , Escalas de Valoración Psiquiátrica , Estudios de Evaluación como Asunto , HumanosRESUMEN
The proposals for the classification of psychiatric disorders made at the Psychiatric Clinic of the University of Munich reflect the development of psychiatric nosology during this century. Kraepelin modified self-critically his classification several times and was attacked by his successor Bumke, who proposed a descriptive "Syndromlehre" but later initiated a period of acceptance of the concept of disease entities lasting until the beginning of the seventies, when the concept of multiaxial classifications came into wider discussion.
Asunto(s)
Hospitales Psiquiátricos/historia , Trastornos Mentales/diagnóstico , Psiquiatría/historia , Alemania , Historia del Siglo XIX , Historia del Siglo XX , Humanos , Trastornos Mentales/clasificaciónRESUMEN
The AMDP-System is a documentation system for psychiatric data widely in use in the German-speaking countries. A summary of results of a multicentered study of interrater agreement of the Psychopathology Scale is presented. A new index of rater agreement was tested and the notion is discussed that the judgement of the presence and the absence of a symptom are two different processes with different reliability.
Asunto(s)
Trastornos Mentales/diagnóstico , Pruebas Psicológicas , Alemania Occidental , Humanos , Trastornos Mentales/psicología , Trastornos del Humor/diagnóstico , Trastornos Neurocognitivos/diagnóstico , Psicometría , Esquizofrenia/diagnósticoRESUMEN
A factor analytic study of the Psychopathology Scale and the Somatic Symptoms Scale of the AMDP System in reported. The random sample was comprised of 1166 psychiatric inpatients, and the resulting factors are compared with other factor analytic studies based on the AMDP System. The study concluded that the AMDP scales have a stable factorial structure, but more exact comparative methods of factorial structure should be applied in future studies.