Reinhold Kilian

Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries

Abstract Objective To establish whether reinstitutionalisation is occurring in mental health care and, if so, with what variations between western European countries. Design Comparison of data on changes in service provision. Setting Six European countries with different traditions of mental health care that have all experienced deinstitutionalisation since the 1970s—England, Germany, Italy, the Netherlands, Spain, and Sweden. Outcome measures Changes in the number of forensic hospital beds, involuntary hospital admissions, places in supported housing, general psychiatric hospital beds, and general prison population between 1990-1 and 2002-3. Results Forensic beds and places in supported housing have increased in all countries, whereas changes in involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds has been reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing. The general prison population has substantially increased in all countries. Conclusions Reinstitutionalisation is taking place in European countries with different traditions of health care, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more important than changing morbidity and new methods of mental healthcare delivery.

Limits of meta-analysis: methylphenidate in the treatment of adult attention-deficit hyperactivity disorder.

Abstract Guidelines for the treatment of attention-deficit hyperactivity disorder (ADHD) in adults advocate methylphenidate as first-line treatment. The aim of this study was to review the effectiveness of methylphenidate treatment of adult ADHD and to examine the influence of methods on meta-analytic results. Electronic databases were searched to identify clinical trials comparing methylphenidate with placebo in the treatment of adult ADHD. Studies were summarised with meta-analytic methods. Subgroup analyses were conducted with respect to parallel group versus cross-over trials and self versus observer ratings. The relationship between dosage and effect size was explored by weighted regression analysis. The results were tested for publication bias, and several sensitivity analyses were performed. Findings and methods were compared with a previous meta-analysis. Eighteen studies met the inclusion criteria of which 16 were included in the meta-analysis. The overall effect size (d = 0.42) was significantly different from zero, but was only half the size expected on the basis of a previous meta-analysis. No significant differences could be observed in the subgroup analyses. The regression analysis showed no significant influence of mean daily dose on effect size. These results contradict findings of a previous meta-analysis and challenge guideline recommendations. Methodological issues in meta-analyses are discussed.

Is it worth investing in mental health promotion and prevention of mental illness? A systematic review of the evidence from economic evaluations

BackgroundWhile evidence on the cost of mental illness is growing, little is known about the cost-effectiveness of programmes in the areas of mental health promotion (MHP) and mental disorder prevention (MDP). The paper aims at identifying and assessing economic evaluations in both these areas to support evidence based prioritisation of resource allocation.MethodsA systematic review of health and non health related bibliographic databases, complemented by a hand search of key journals and analysis of grey literature has been carried out. Study characteristics and results were qualitatively summarised. Economic evaluations of programmes that address mental health outcome parameters directly, those that address relevant risk factors of mental illness, as well as suicide prevention interventions were included, while evaluations of drug therapies were excluded.Results14 studies fulfilled the inclusion criteria. They varied in terms of topic addressed, intervention used and study quality. Robust evidence on cost-effectiveness is still limited to a very small number of interventions with restricted scope for generalisability and transferability. The most favourable results are related to early childhood development programmes.ConclusionPrioritisation between MHP and MDP interventions requires more country and population-specific economic evaluations. There is also scope to retrospectively add economic analyses to existing effectiveness studies. The nature of promotion and prevention suggests that innovative approaches to economic evaluation that augment this with information on the challenges of implementation and uptake of interventions need further development.

Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care?

Objective:  To report recent findings regarding differences in the provision, cost and outcomes of mental health care in Europe, and to examine to what extent these studies can provide a basis for improvement of mental health services and use of findings across countries.

Health behavior in psychiatric in-patients compared with a German general population sample.

Objective:  To compare the health relevant behavior of psychiatric patients and the general population.

Factors contributing to frequent use of psychiatric inpatient services by schizophrenia patients.

Abstract.Background:Although present findings about frequent users of psychiatric inpatient services vary from study to study, some potentially important predictors of frequent use were extracted. The purpose of this study was to examine the potentially contributory factors of frequent use of psychiatric inpatient services by schizophrenia patients and to test the influence single factors have in an overall model.Methods:A total of 307 schizophrenia patients were interviewed five times with intervals of 6 months. Data were collected about service receipt and health care costs, strength of primary diagnosis and comorbidities, as well as about patients’ needs for care and satisfaction with care. Patients with three or more psychiatric admissions within a 30-month period were defined as frequent users.Results:According to this criterion, 12% of the study population were frequent users. Compared with ordinary users, these patients accounted for significantly higher costs in hospital- and community-based care. Important predictors for frequent use of psychiatric inpatient services were the number of previous hospitalizations and current scores of psychopathology. In addition, a longitudinal analysis showed the importance of social factors for the use of psychiatric inpatient care. Therefore, a number of the frequent users’ multiple admissions could also be caused by social problems.Conclusions:The mental health system should, thus, provide well-directed community-based resources, which give frequent users support to solve their social problems.

Quality of Life of Spouses of Mentally Ill People

Background: Spouses of people with mental disorder experience various forms of objective and subjective burden. This should negatively affect their quality of life. However, until now no single study has addressed this question. Aims: To investigate the quality of life of spouses of people with schizophrenia, depression or anxiety disorders. Method: Spouses of patients suffering from schizophrenia (n 1/4 45), depression (n 1/4 49) and anxiety disorders (n 1/4 39) were consecutively recruited from out-patient services in the city of Leipzig. Quality of life was assessed by means of the WHOQOL-BREF, a self-administered questionnaire developed by the World Health Organisation. Results: Compared with the general population, the quality of life of the spouses of mentally ill people was lower in the domains ‘psychological well-being’ and ‘social relationships’. There was a significant association between the patients functional level and the spouses quality of life. Conclusions: Better treatment, professional support and participation in self-help and advocacy groups may help to improve the quality of life of spouses of mentally ill people.

Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment.

Längle G, Steinert T, Weiser P, Schepp W, Jaeger S, Pfiffner C, Frasch K, Eschweiler GW, Messer T, Croissant D, Becker T, Kilian R. Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment.

The European Schizophrenia Cohort (EuroSC): a naturalistic prognostic and economic study.

BackgroundSchizophrenia has a variety of clinical profiles, disabilities and outcomes requiring responsive management and the devotion of considerable resources. The primary objective of the European Schizophrenia Cohort (EuroSC) is to relate the types of treatment and methods of care to clinical outcome. Secondary objectives include the assessment of treatment needs in relation to outcome, the calculation of resource consumption associated with different methods of care, and the identification of prognostic factors.MethodEuroSC is a naturalistic follow-up of a cohort of people aged 18 to 64 years, suffering from schizophrenia and in contact with secondary psychiatric services. The study was done in nine European centres, in France (N=288), Germany (N=618), and Britain (N=302). Participants were interviewed at 6-monthly intervals for a total of 2 years. This initial paper describes the methods used and presents clinical and social baseline data.ResultsThe clinical and socio-demographic differences between patients from the different countries were small. However, patients from Britain were considerably more likely than their continental counterparts to have a history of homelessness, rooflessness or imprisonment, even when social and clinical differences between the samples were controlled.ConclusionsThe samples were largely similar in clinical terms. Thus, the social differences between the samples seem likely to be due more to the societal context and may reflect relatively benign situations in the continental locations of our study.

Issues in conducting cross-cultural research: implementation of an agreed international procotol designed by the WHOQOL Group for the conduct of focus groups eliciting the quality of life of older adults

Multi-centre and cross-cultural research require the use of common protocols if the results are to be either pooled or compared. All too often adherence to protocols is not discussed in reports and where it is reported poor adherence is frequently noted. This paper discusses the use of international guidelines developed by WHOQOL Field Centres to conduct and report focus groups aimed at eliciting key concepts of quality of life among older adults. This was the first step in the development of the WHOQOL-OLD instrument. Although there was overall adherence to the agreed guidelines, there were some differences in the level of reporting, even after participating Field Centres had the opportunity to explain their reports. The reasons for these discrepancies are reported. It is concluded that because of local situations, it is difficult to achieve identical implementation of multi-centre cross-cultural protocols and that the highest standards of auditing are required if findings are to be compared. Suggestions for how such protocols can be improved are given.