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DOI: 10.1055/s-0028-1090208
© Georg Thieme Verlag KG Stuttgart · New York
Da-Heim im Heim!?
Bedeutete Ent-Hospitalisierung auch Ent-Institutionalisierung?At Home in a Home?Did De-Hospitalisation Mean De-Institutionalisation?Publikationsverlauf
Publikationsdatum:
08. April 2009 (online)
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Zusammenfassung
Anliegen Die Ausgliederung chronisch psychisch Kranker aus Langzeitstationen wurde hinreichend evaluiert und gilt mittlerweile in der westlichen Welt als abgeschlossen. Methode In einer Literaturrecherche über „pubmed” wurden alle deutsch- und englischsprachigen Arbeiten der Jahre 1997–2007 ausgehoben, welche sich mit dem Thema der Deinstitutionalisierung auseinandersetzten. Ergebnisse Beinahe alle entlassenen Patienten wurden in Betreuungsformen mit 24-h-Betreuung transferiert; dieser Umstand änderte sich auch im längerfristigen Verlauf nicht. Schlussfolgerung Angesichts des auf die Entlassung folgenden Verlaufs muss auf die Gefahr der Trans-Institutionalisierung hingewiesen werden. Der Stand des Wissens zu bedürfnisgerechter Integration mit möglichst niederschwelligen Hilfsangeboten ist bisher sehr gering, woraus sich gegebener Forschungsbedarf ableiten lässt.
Abstract
Objectives In the last decades, long-time patients were systematically discharged from psychiatric hospitals in order to integrate this disadvantaged population into the community. This procedures where adequately evaluated and are regarded to be completed in the western world today. However, few evidence has been presented regarding the further course of integration following discharge from mental hospitals: was integration into community really successful or were patients permanently placed in sheltered housing staffed 24 hours 7 days a week. This review focuses on the question whether papers describing large deinstitutionalisation projects mention the level of institutional support in the years following discharge from hospital. Furthermore we tried to find out which parameters are dealt with when describing successful community integration. Methods „Pubmed” was searched for studies on deinstitutionalisation projects published between 1997 and 2007. Results The discharge from the mental hospital wards was in all studies described as successful, positive effects like an increased quality of life were found. However, studies describing the years following discharge mentioned that patients continuously stayed in sheltered housing with care offered 24 hours a day. Conclusion Reviewing the available data about the level of support regarding accommodation of former long time patients, the danger of „transinstitutionalisation” has to be pointed out. Evidence is lacking concerning support models tailored to the individual needs of the patients. Similarly, possible side effects of long-term stays in sheltered housing staffed 24 hours a day have not yet been established. Therefore, we see a need for further evaluation of different models of supported housing for former long-term hospitalised patients, as well as for new chronic mentally ill patients.
Schlüsselwörter
Enthospitalisierung - Entinstitutionalisierung - Schizophrenie - schwer psychisch krank
Key words
dehospitalisation - deinstitutionalisation - schizophrenia - severe mentally ill
Literatur
- 1 Lamb H R, Bachrach L L. Some Perspectives on Deinstitutionalization. Psychiatr Serv. 2001; 52 1039-1045
- 2 Priebe S, Gruyters T. The role of the helping alliance in psychiatric community care. A prospective study. J Nerv Ment Dis. 1993; 181 552-557
- 3 Kaiser W, Priebe S, Hoffmann K. et al . Subjektive Lebensqualität bei Patienten mit chronischer Schizophrenie. Nervenarzt. 1996; 67 572-582
- 4 Kaiser W, Priebe S, Barr W. Profiles of subjective quality of life in schizophrenic in- and out-patient samples. Psychiatry Res. 1997; 66 153-166
- 5 Zerssen D von, León C A, Möller H J. et al . Care Strategies for Schizophrenic Patients in a Transcultural Comparison. Compr Psychiatry. 1990; 31 398-408
- 6 Svensson B, Hansson L. Patient satisfaction with inpatient psychiatric care. The influence of personality traits, diagnosis and perceived coercion. Acta Psychiatr Scand. 1994; 90 379-384
- 7 Barry M M, Crosby C. Qualtity of life as an evaluative measure in assessing the impact of community care on people with long-term psychiatric disorders. Br J Psychiatry. 1996; 168 210-216
- 8 Knudsen H C, Krasnik A, Jessen-Petersen B. et al . Patients in the care of private psychiatric practitioners. Comparison with public hospital patients and the background districts' population. Soc Psychiatry Psychiatr Epidemiol. 1992; 27 156-160
- 9 Holley L H, Jeffers B, Hodges P. Potential for community relocation among residents of Alberta's psychiatric facilities: a needs assessment. Can J Psychiatry. 1997; 42 750-757
- 10 Holley H L, Hodges P, Jeffers B. Moving psychiatric patients from hospital to community: views of patients, providers, and families. Psychiatr Serv. 1998; 49 513-517
- 11 Steinkamp G, Netz P, Werner B. Ambulante Versorgung psychisch gestörter älterer Menschen – Eine vergleichende empirische Untersuchung von zwei Versorgungsregionen. Gesundheitswesen. 1996; 58, Sonderheft 2 132-138
- 12 Francis V M, Vesey P, Lowe G. The closure of a long-stay psychiatric hospital: a longitudinal study of patients' behaviour. Soc Psychiatry Psychiatr Epidemiol. 1994; 29 184-189
- 13 Thornicroft G, Bebbington P, Leff J. Outcomes for long-term patients one year after discharge from a psychiatric hospital. Psychatr Serv. 2005; 56 1416-1422
- 14 Lesage A D, Morissette R, Fortier L. et al . Downsizing psychiatric hospitals: needs for care and services of current and discharged long- stay inpatients. Can J Psychiatry. 2000; 45 526-531
- 15 Shipley K, Hilborn B, Hanselt A. et al . Patient satisfaction: a valid index of quality of care in a psychiatric service. Acta Psychiatr Scand. 2000; 101 330-333
- 16 Räsänen S, Hakko H, Herva A. et al . Community placement of long-stay psychiatric patients in northern Finland. Psychiatr Serv. 2000; 51 383-385
- 17 Rothbard A B, Schinnar A P, Hadley T P. et al . Cost comparison of state hospital and community-based care for seriously mentally ill adults. Am J Psychiatry. 1998; 155 523-529
- 18 Rothbard A B, Kuno F, Schinnar A P. et al . Service utilization and cost of community care for discharged state hospital patients: A 3-year follow-up study. Am J Psychiatry. 1999; 156 920-927
- 19 Sytema S, Burgess P, Tansella M. Does community care decrease length of stay and risk of rehospitalization in new patients with schizophrenia disorders? A comparative case registers study in Groningen, the Netherlands; Victoria, Australia; and South Verona, Italy. Sizophr Bull. 2002; 28 273-281
- 20 Tansella M, Amaddeo F, Burti L. et al . Evaluating a community-based mental health service focusing on severe mental illness. The Verona experience. Acta Psychiatr Scand. 2006; 113 (Suppl. 429) 90-94
- 21 Trieman N, Leff J, Glover G. Outcome of long stay psychiatric patients resettled in the community: prospective cohort study. BMJ. 1999; 319 13-16
- 22 Salokangas R K, Saarinen S. Deinstitutionalization and schizophrenia in Finland: I. discharged patients and their care. Schizophr Bull. 1998; 24 457-467
- 23 Honkonen T, Saarinen S, Salokangas R K. Deinstitutionalization and schizophrenia in Finland: II. discharged patients and their psychosocial functioning. Schizophr Bull. 1999; 25 543-551
- 24 Leff J, Szmidla A. Evaluation of a special rehabilitation programme for patients who are difficult to place. Soc Psychiatry Psychiatr Epidemiol. 2002; 37 532-536
- 25 Hansson L, Björkman T, Priebe S. Are important patient-rated outcomes in community mental health care explained by only one factor?. Acta Psychiatr Scand. 2007; 116 113-118
- 26 Leiße M, Kallert T W. Social integration and the quality of life of schizophrenic patients in different types of complementary care. Eur Psychiatry. 2000; 15 450-460
- 27 Spancken E. Rheinische Kliniken Bedburg-Hau: Auswertung eines Enthospitalisierungsprogramms unter besonderer Berücksichtigung der schwierigen bzw. neuen chronisch Kranken. Krankenhauspsychiatrie. 2001; 12, Sonderheft 2 79-84
- 28 Konrad M. Enthospitalisierung als Aufgabe eines kliniknahen Pflegeheims. Krankenhauspsychiatrie. 2001; 12, Sonderheft 2 85-89
- 29 Heilemann H. Enthospitalisierung in den neuen Bundesländern am Beispiel des Sächsischen Krankenhauses für Psychiatrie und Neurologie Arnsdorf. Eine Zwischenbilanz nach 10 Jahren. Krankenhauspsychiatrie. 2001; 12, Sonderheft 2 90-94
- 30 Stich J. Enthospitalisierung älterer psychisch kranker Menschen am Beispiel einer ehemaligen Langzeitstation des Bezirkskrankenhauses Bayreuth. 1989–1993
- 31 Moos M, Stich J, Rossow D. et al . Enthospitalisierung am BKH Bayreuth – Aktuelle Situation schwer chronisch psychisch kranker Menschen. Krankenhauspsychiatrie. 2001; 12, Sonderheft 2 110-115
- 32 Arvidsson H. Met an unmet needs of severely mentally ill persons. The psychiatric care reform in Sweden. Soc Psychiatry Psychiatr Epidemiol. 2003; 38 373-379
- 33 Thornicroft G, Strathdee G, Phelan M. et al . Rationale and design. PRiSM Psychosis Study I. Br J Psychiatry. 1998; 173 363-370
- 34 Becker T, Holloway F, McCrone P. et al . Evolving service interventions in Nunhead and Norwood. PRiSM Psychosis Study 2. Br J Psychiatry. 1998; 173 371-375
- 35 Johnson S, Leese M, Brooks L. et al . Frequency and predictors of adverse events. PRiSM Psychosis Study 3. Br J Psychiatry. 1998; 173 376-384
- 36 McCrone P, Thornicroft G, Phelan M. et al . Utilisation and costs of community mental health services. PRiSM Psychosis Study 5. Br J Psychiatry. 1998; 173 391-398
- 37 Becker T, Leese M, McCrone P. et al . Impact of community mental health services on users' social networks. PRiSM Psychosis Study 7. Br J Psychiatry. 1998; 173 404-409
- 38 Leese M, Johnson S, Slade M. et al . User perspective on needs and satisfaction with mental health services. PRiSM Psychosis Study 8. Br J Psychiatry. 1998; 173 409-415
- 39 Taylor R E, Leese M, Clarkson P. et al . Quality of life outcomes for intensive versus standard community mental health services. PRiSM Psychosis Study 9. Br J Psychiatry. 1998; 173 416-422
- 40 Thornicroft G, Wykes T, Holloway F. et al . From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study 10. Br J Psychiatry. 1998; 173 423-427
- 41 Ruggeri M, Biggeri A, Rucci P. et al . Multivariate analysis of outcome of mental health care using graphical chain models. The South-Verona Outcome Project 1. Psychol Med. 1998; 28 1421-1431
- 42 Lasalvia A, Ruggeri M, Mazzi M A. et al . The perception of needs for care in staff and patients in community-based mental health services. The South-Verona Outcome Project 3. Acta Psychiatr Scand. 2000; 102 366-375
- 43 Ruggeri M, Warner R, Bisoffi G. et al . Subjective and objective dimensions of quality of life in psychiatric patients: a factor analytical approach. The South Verona Outcome Project 4. Br J Psychiatry. 2001; 178 268-275
- 44 Ruggeri M, Gater R, Bisoffi G. et al . Determinants of subjective quality of life in patients attending community-based mental health services. The South-Verona Outcome Project 5. Acta Psychiatr Scand. 2002; 105 131-140
- 45 Lasalvia A, Ruggeri M, Santolini N. Subjective quality of life: its relationship with clinician-rated and patient-rated psychopathology. The South-Verona Outcome Project 6. Psychother Psychosom. 2002; 71 275-284
- 46 Ruggeri M, Pacati P, Goldberg D. Neurotics are dissatisfied with life, but not with services. The South Verona Outcome Project 7. Gen Hosp Psychiat. 2003; 25 338-344
- 47 Ruggeri M, Leese M, Slade M. et al . Demographic, clinical, social and service variables associated with higher needs for care in community psychiatric service patients. The South Verona Outcome Project 8. Soc Psychiatry Psychiatr Epidemiol. 2004; 39 60-68
- 48 Ruggeri M, Bisoffi G, Lasalvia A. et al . A longitudinal evaluation of two-year outcome in a community-bades mental health service using graphical chain models. The South-Verona Outcome Project 9. Int J Methods Psychiatr Res. 2004; 13 10-23
- 49 Hansson L, Middelboe T, Merinder L. et al . Predictors of subjective Quality of Life in Schizophrenic Patients living in the Community. A Nordic Multicentre Study. Int J Soc Psychiatry. 1999; 45 247-258
- 50 Sörgaard K W, Hansson L, Heikkilä J. et al . Predictors of social relations in persons with schizophrenia living in the community: a Nordic multicentre study. Soc Psychiatry Psychiatr Epidemiol. 2001; 36 13-19
- 51 Levy E, Shefler G, Loewenthal U. et al . Characteristics of schizophrenia residents and staff rejection in community mental health hostels. Isr J Psychiatry Relat Sci. 2005; 42 23-32
- 52 de Souza L A, Coutinho E S. The quality of life of people with schizophrenia living in the community in Rio de Janeiro. Brazil Soc Psychiatry Psychiatr Epidemiol. 2006; 41 347-356
- 53 Leiße M, Kallert T W. Normative needs for community-based psychiatric care of patients with schizophrenia in different residential settings. Psychiatr Res. 2003; 118 223-233
- 54 Henderson C, Phelan M, Loftus L. et al . Comparison of patient satisfaction with community-based vs. hospital psychiatric services. Acta Psychiatr Scand. 1999; 99 188-195
- 55 Harrison-Read P, Lucas B, Tyrer P. et al . Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough. Psychol Med. 2002; 32 403-416
- 56 Petersen L, Nordentoft M, Jeppesen P. et al . Improving 1-year outcome in first-episode psychsis. OPUS trial. Br J Psychiatry. 2005; 187 (Suppl. 48) 98-103
- 57 Killaspy H, Bebbington P, Bilzard R. et al . The REACT study: randomised evaluation of assertive community treatment in north London. Br Med J. 2006; 332 815-820
- 58 Sytema S, Wunderink L, Bloemers W. et al . Assertive community treatment in the Netherlands: a randomized controlled trial. Acta Psychiatr Scand. 2007; 116 105-112
- 59 Essock S M, Mueser K T, Drake R E. et al . Comparison of ACT and standard case management for delivering integrated treatment for co-coccurring disorders. Psychiatr Serv. 2006; 57 185-196
- 60 Ryu Y, Mizuno M, Sakuma K. et al . Deinstitutionalization of long-stay patients with schizophrenia: the 2-year social and clinical outcome of a comprehensive intervention program in Japan. Aust N Z J Psychiatry. 2006; 40 462-470
- 61 Priebe S, Hoffmann K, Isermann M. et al . Klinische Merkmale langzeithospitalisierter Patienten. Teil 1 der Berliner Enthospitalisierungsstudie. Psychiat Prax. 1996; 23 15-20
- 62 Hoffmann K, Priebe S, Isermann M. et al . Lebensqualität, Bedürfnisse und Behandlungsbewertung langzeithospitalisierter Patienten. Teil II der Berliner Enthospitalisierungsstudie. Psychiat Prax. 1997; 24 221-226
- 63 Kaiser W, Hoffmann K, Isermann M. et al . Behandlerprognosen und Entlassungen nach zwei Jahren. Teil III der Berliner Enthospitalisierungsstudie. Psychiat Prax. 1998; 25 67-71
- 64 Hoffmann K, Isermann M, Kaiser W. et al . Lebensqualität im Verlauf der Enthospitalisierung. Teil IV der Berliner Enthospitalisierungsstudie. Psychiat Prax. 2000; 27 183-188
- 65 Kaiser W, Hoffmann K, Isermann M. et al . Langzeitpatienten im Betreuten Wohnen nach der Enthospitalisierung. Teil V der Berliner Enthospitalisierungsstudie. Psychiat Prax. 2001; 28 235-243
- 66 Priebe S, Hoffmann K, Isermann M. et al . Do long-term hospitalised patients benefit from discharge into the community?. Soc Psychiatry Epidemiol. 2002; 37 387-392
- 67 Haberfellner E M, Grausgruber A, Grausgruber-Berner R. et al . Die Enthospitalisierung psychiatrischer Langzeitpatienten in Oberösterrreich – soziodemografische und klinische Daten. Psychiat Prax. 2004; 31 192-197
- 68 Haberfellner E M, Grausgruber A, Grausgruber-Berner R. et al . Der Versorgungsbedarf ehemaliger psychiatrischer Langzeitpatienten. Psychiat Prax. 2006; 33 23-29
- 69 Haberfellner E M, Grausgruber A, Grausgruber-Berner R. et al . Die Enthospitalisierung ehemaliger psychiatrischer Langzeitpatienten in Oberösterreich – Inanspruchnahme von Versorgungsleistungen und Kosten der außerstationären Versorgung. Psychiat Prax. 2006; 33 74-80
- 70 Franz M, Meyer T, Ehlers F. et al . Schizophrene Patienten, die trotz Dekaden der Enthospitalisierung in den psychiatrischen Krankenhäusern verblieben sind. Teil 1 der Hessischen Enthospitalisierungsstudie. Psychiat Prax. 2002; 29 245-250
- 71 Meyer T, Franz M, Gallhofer B. Subgruppen und Prognose besonders schwer zu enthospitalisierender schizophrener Langzeitpatienten: Eine Differenzierung des „harten Kerns”. Teil 2 der Hessischen Enthospitalisierungsstudie. Psychiat Prax. 2002; 29 301-305
- 72 Franz M, Meyer T, Gallhofer B. Subjektive Lebensqualität schwer chronifizierter schizophrener Langzeitpatienten. Teil 3 der Hessischen Enthospitalisierungsstudie. Psychiat Prax. 2002; 29 306-310
- 73 Franz M, Meyer T, Ehlers F. et al . Schwer chronisch kranke schizophrene Langzeitpatienten. Welche Merkmale beeinflussen den Prozess der Enthospitalisierung? Teil 4 der Hessischen Enthospitalisierungsstudie. Krankenhauspsychiatrie. 2001; 12, Sonderheft 2 95-100
- 74 Kallert T W, Stoll A, Leiße M. et al . Der Enthospitalisierungsprozess des psychiatrischen Heimbereichs eines ehemaligen Großkrankenhauses aus Patienten- und Mitarbeitersicht. Fortschr Neurol Psychiat. 2004; 72 446-459
- 75 Rössler W, Salize H J, Cucciaro G. et al . Does the place of treatment influence the quality of life of schizophrenics?. Acta Psychiatr Scand. 1999; 100 142-148
- 76 Zissi A, Barry M M. From Leros asylum to community-based facilities: levels of functioning and quality of life among hostel residents in Greece. Int J Soc Psychiatry. 1997; 43 104-115
- 77 Leff J, Trieman N. Long stay patients discharged from psychiatric hospitals. Social and clinical outcomes after five years in the community: the TAPS Project 46. Br J Psychiatry. 2000; 176 217-223
- 78 Trieman N, Leff J. The TAPS Project. 36: The Most Difficult to Place Long-Stay Psychiatric In-patients. Outcome One Year After Relocation. Br J Psychiatry. 1996; 169 289-292
- 79 Trieman N, Smith H E, Kendal R. et al . The TAPS Project 41: Homes for life? Residential stability five years after hospital discharge. Community Ment Hlt J. 1998; 34 407-417
- 80 Trieman N, Hughes J, Leff J. The TAPS Project 42: the last to leave hospital – a profile of residual long-stay populations and plans for their resettlement. Acta Psychiatr Scand. 1998; 98 354-359
- 81 Trieman N, Leff J. Long-term outcome of long-stay psychiatric in-patients considered unsuitable to live in the community. TAPS Project 44. Br J Psychiatry. 2002; 181 428-432
- 82 Leff J, Triemann N. Long-stay patients discharged form psychiatric hospitals. Social and clinical outcomes after five years in the community. The TAPS Project 46. Br J Psychiatry. 2000; 176 217-223
- 83 Hobbs C, Tennant C, Rosen A. et al . Deinstitutionalisation for long-term mental illness: a 2-year clinical evaluation. Aust N Z J Psychiatry. 2000; 34 476-483
- 84 Hobbs C, Newton L, Tennant C. et al . Deinstitutionalization for long-term mental illness: a 6-year evaluation. Australian and New Zealand Journal of Psychiatry. 2002; 36 60-66
- 85 Trauer T, Farhall J, Newton R. et al . From long-stay psychiatric hospital to Community Care Unit: evaluation at 1 year. Soc Psychiatry Psychiatr Epidemiol. 2001; 36 416-419
- 86 Barbato A, D'Avanzo B, Rocca G. et al . A study of long-stay patients resettled in the community after closure of a psychiatric hospital in Italy. Psychiatr Serv. 2004; 55 67-70
-
87 Katschnig H, Angermeyer M C.
Quality of life in depression. In: Katschnig H et al., Hrsg Quality of life in mental disorders. Chichester; John Wiley & Sons 1997: 137-147 - 88 Holley H L, Hodges P, Jeffers B. Moving Psychiatric Patients From Hospital to Community: Views of Patients, Providers, and Families. Psychiatr Serv. 1998; 49 513-517
- 89 Eikelmann B. Grenzen der Deinstitutionalisierung? – Die Sicht der Fachklinik. Psychiat Prax. 2000; 27, Sonderheft 2 53-58
- 90 Priebe S, Turner T. Reinstitutionalisation in mental health care. Br Med J. 2003; 326 173-176
- 91 Priebe S. Institutionalisation revisited – with and without walls. Acta Psychiatr Scand. 2004; 110 81-82
- 92 Killaspy H. From the asylum to community care: learning from experience. Br Med Bull. 2006; 79 and 80 245-258
- 93 Jähnel M, Rehm S, Pausch S. et al . Untersuchungen zur Lebensqualität im heimangebundenen betreuten Wohnen für chronisch psychisch Kranke. Psychiat Prax. 2007; 34, Supplement 1 S136-S137
- 94 Priebe S, Frottier P, Gaddini A. et al . Mental health care institutions in nine European countries, 2002 to 2006. Psychiatr Serv. 2008; 59 570-573
- 95 Priebe S, Badeconyi A, Fioritti A. et al . Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ. 2005; 330 123-126
-
96 Hoffmann C.
Enthospitalisierung oder Umhospitalisierung? – am Beispiel der Neuen Länder. In: Theunissen G Enthospitalisierung – ein Etikettenschwindel? Neue Studien, Erkenntnisse und Perspektiven der Behindertenhilfe. Bad Heilbrunn; Klinkhardt 1998: 109-153 - 97 Hambrecht M. Gemeindepsychiatrie im 21. Jahrhundert. Psychiat Prax. 2007; 34 263-265
Univ.-Doz. Dr. Stefan Frühwald
Psychosozialer Dienst der Caritas St. Pölten
Dr. Karl Renner Prom. 12
3100 St. Pölten, Österreich
eMail: psd.fruehwald@stpoelten.caritas.at