Providing better care to severely mentally ill people with psychosocial therapies

A current DGPPN-S3 guideline provides impulses for healthcare and healthcare research

The severely mentally ill represent an important group in the care of the mentally ill. The blatant lack of care initiated the Psychiatry Enquete 40 years ago, and in fact most of these patients are now cared for in a multi-professional and community-based manner. Nevertheless, the severely mentally ill participate insufficiently or not at all in the current enormous increase in knowledge in the field of psychosocial treatment options. The right to a hospital bed, specialist treatment and access to all available psychopharmacological substances are important but not sufficient for the treatment of the severely mentally ill (Kilian 2014). Access to evidence-based outpatient psychosocial forms of treatment, such as acute treatment at home [home treatment], family-related psychoeducation or supported employment [supported employment], depends to this day on more or less random constellations of laypeople, politicians, those affected, psychiatric... Experts and activities from municipalities, independent organizations or other actors (Kilian 2014). However, in addition to somatic treatments (e.g. psychotropic drugs) and psychotherapeutic interventions, psychosocial therapies are an important and central pillar in the treatment of people with serious mental illnesses. They are mainly aimed at improving the individual possibilities of those affected to live in their social environment and to participate in social life and to enable inclusion.

>> That is why the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) has launched the evidence- and consensus-based S3 guideline “Psychosocial therapies for serious mental illnesses”. The guideline has three special features:
(1) the guideline covers diagnoses,
(2) presents a system of very heterogeneous psychosocial interventions and
(3) locates these interventions in the German care system within the framework of a matrix chapter and at the same time shows examples of good practice.
This makes it a German-language standard work. The guideline is intended to improve care practice for people with serious mental illnesses (DGPPN 2013).
Who exactly is meant? The everyday work of many people working in psychiatric and psychosocial care is determined by this patient group, i.e. people with serious mental illnesses. Across diagnoses, it concerns people who are impaired by psychological symptoms for a long time, experience significant limitations in their social functioning and make intensive use of the help system (Ruggeri et al. 2000). Those affected may suffer from various mental disorders (schizophrenia and other severe mental illnesses from the schizophrenic spectrum, severe affective disorders, severe personality disorders or severe anxiety and obsessive-compulsive disorders).
What is meant by psychosocial interventions? Psychosocial therapies include a number of very different interventions that are systematized in the guideline. One area is so-called system interventions, which involve organizing and providing care services in a specific way. These are usually complex interventions such as acute treatment in the home environment, case management or work rehabilitation. There is an enormous increase in knowledge and high-quality evidence, especially in the area of complex care interventions. Another area is so-called individual interventions, such as psychoeducation or artistic therapies. These can be used in various settings (outpatient area, day clinic, ward). In addition, fundamental aspects of psychosocial action are addressed (therapeutic relationship, milieu therapy and recovery) and concepts such as self-help, self-management and peer counseling are taken into account.
Overview of evidence and recommendations
Table 1 provides an overview of the most important recommendation areas, the evidence and the corresponding recommendation strengths. The best evidence to date is for multi-professional community psychiatric and team-based treatment approaches as well as for psychoeducation involving relatives and social skills training (Table 1).
In a wealth of high-quality studies and meta-
Analyzes have shown that community psychiatric team-oriented approaches, such as “community mental health teams”, “home treatment” teams and “assertive community treatment” teams, reduce inpatient treatment and treatment times as well as treatment terminations compared to conventional community-based treatment without a multiprofessional team can improve treatment satisfaction among patients and relatives (Murphy et al. 2012; Malone et al. 2007; Dieterich et al. 2010). Characteristics of social inclusion, particularly in the areas of living and work, can be significantly positively influenced by long-term support of those affected through outreach and follow-up multiprofessional treatment (“assertive community treatment”) (Dieterich et al. 2010). In addition to providing needs-oriented and flexible treatment at every point in the treatment process, the main task of the multi-professional community psychiatric teams is, above all, the team's shared responsibility for the health and psychosocial care of those affected in order to ensure treatment continuity. In the field of work rehabilitation, there are numerous randomized controlled studies and systematic reviews that show the superiority of the “supported employment” approach over standard treatment and also “pre-vocational training” (preparatory work training, for example in rehabilitation facilities) (Bond et al. 2008). Most studies were conducted in the USA and the generalizability to German economic conditions has been questioned. Since the guidelines were published, the evidence has expanded: There is now a current study from Switzerland that clearly favors “supported employment” even under Western European economic conditions compared to classic approaches to vocational rehabilitation (Hoffmann et al. 2012).
There are a large number of studies on the effectiveness of psychoeducation, including those from Germany. Convincing effects for severely mentally ill people can be found primarily for psychoeducational treatment approaches involving family members. Systematic reviews and meta-analyses invariably show reduced relapse risks and an associated lower probability of inpatient readmission rates (Pharoah et al. 2010; Pitschel-Walz et al. 2001). There are also indications of reduced symptom severity, improved medication compliance and a higher level of social functioning. Family-oriented psychoeducational interventions also show positive effects on the acquisition of knowledge and the stress experienced by relatives and contribute to an improved family climate. Social skills training, so far primarily examined in people with schizophrenic disorder, also shows clear effects on improved social skills and a higher probability of greater social adaptation (Gühne et al. 2012). Far less evidence could be identified for other interventions or methodological weaknesses do not currently allow a strong recommendation. In the area of artistic therapies, for example, there is currently a manageable number of randomized controlled studies based on predominantly small samples. The observation periods are often short and the intervention approaches are heterogeneous, e.g. In some cases, active control interventions are missing. A reliable statement about the effectiveness of artistic therapies for people with serious mental illnesses therefore seems premature. However, the results available so far provide almost uniform evidence that the additional use of various approaches to artistic therapies (music, art, drama and dance therapy) in addition to conventional treatment can reduce the negative symptoms of schizophrenic illnesses (Mössler et al. 2011; Ruddy /Milnes 2005).
There is a need for further research in the areas of artistic therapies, occupational therapy and sports and exercise therapy approaches. But even in the area of supported living, no statement can currently be made based on scientific evidence as to which form of living is particularly suitable for which patient. What is certain, however, is that long-term hospitalization is associated with negative effects (Kallert et al. 2007) (see Table 1).
Implementation and impulses for health services research
Announcement of the guidelines to users: It is obvious that the dissemination of knowledge to the intended target group through appropriate measures and their availability is a prerequisite for further action steps. The S3 guideline “Psychosocial therapies for serious mental illnesses” is therefore available as a book (DGPPN 2013a) and as open access on the Internet in long and short versions. In addition, open access training materials for all chapters of the guidelines with Power Point slides were developed for download (DGPPN 2013b). In addition, the contents of the guidelines were disseminated in numerous specialist journals and at national and international congresses and work meetings. Although publicity is necessary, we know that it alone has little impact. We therefore consider a central step to be the publication of a patient and relatives version with the collaboration of users as a book (Gühne et al. 2014) and as a free e-version (DGPPN 2013b). The patient guideline is supplemented by an ultra-short or waiting room version, for which a comprehensive dissemination concept was developed.
Transferring effective interventions into care practice: Implementation measures should begin with a systematic contrast of the current care situation with the guideline recommendations (“translational gap” or the evidence-practice gap). The starting point must be the severely mentally ill person. According to Bramesfeld et al. The focus is on the following three questions (Bramesfeld et al. 2014):
(1) Which psychosocial therapies are currently being used by clients? Psychosocial care is based in the community and only works with the cooperation of regional service providers. The region is therefore an important unit of analysis for three variables:
(a) the regional care structures (e.g. who offers psychosocial help in the region?)
(b) the processes (e.g. What kind of psychosocial care do severely mentally ill people actually receive? Do severely mentally ill people across the board have the opportunity to benefit from individual effective interventions such as psychoeducation or social skills training? What is the access to innovative treatment approaches such as acute treatment at home (home treatment) or the consistent outreach services (“assertive community treatment”)?
(c) the results (relevant endpoints and thus parameters of the quality of results of psychosocial care include objective criteria such as institutionalization, retirement, starting work, hospital admissions as well as subjective criteria such as health-related quality of life or recovery). These questions are the starting point for further implementation measures. For example, innovative treatment models are currently only established in a few places. Examples include home treatment teams in Frankfurt, Krefeld, Günzburg and elsewhere or the Assertive Community Treatment Team for the care of psychotic patients at the University Hospital Hamburg-Eppendorf (Munz et al. 2011; Lambert et al. 2010).
(2) What are the characteristics of clients seeking mental health care? Questions of under-, over- and incorrect care need to be addressed. Who uses care services, when and to what extent? What barriers exist in the event of non-use? How can changing needs be met at different points in the course of treatment?
(3) Which structures and processes promote implementation of the guidelines, where are the barriers? Here, regions in which the guideline is successfully implemented can be compared with regions in which this is less successful. The opportunities and barriers to widespread implementation need to be identified in more detail. In addition, it must be asked which attitudes and attitudes of the practitioners and users lead to psychosocial therapy in accordance with the guidelines. Behavioral theoretical models are available here (Ajzen 1991) that show opportunities and barriers to changing attitudes.

The current framework conditions in the German fragmented system of organizing and financing social and health services also represent a particular barrier (Bramesfeld et al. 2014; Kilian 2014), which is particularly difficult when implementing complex, multi-professional and cross-sectoral (outpatient vs. inpatient, financing by various service providers). Examples of good practice for establishing such innovative treatment models within the framework of integrative care models show that a lot is possible even under the current framework conditions, although the new version of §§ 140ff. of SGB V does not resolve the fragmentation. Attractive visions of the future for the professionally based design of psychiatric-psychotherapeutic care, such as the functional basic model of community psychiatric care, must be brought into greater discussion (Steinhart/Wienberg 2014).
Implementing guidelines is not trivial, especially for complex psychosocial interventions. Although there is consensus that the translation of evidence into care practice needs to be accelerated, Thornicroft et al. (2011) that implementation research in psychiatry is still in its infancy. This is underlined by a recent Cochrane review that examined studies on the effectiveness of guideline implementation strategies in psychiatric care, but was only able to include a few studies and did not allow any valid conclusions to be drawn (Barbui et al. 2014). With the same efforts and funding as basic research is translated into clinical research, the findings of clinical research must be implemented into healthcare practice in order to ultimately improve patient care. Health services research is essential for this last and very important step in the translation chain. Health services research must evaluatively accompany and support the implementation of guidelines in which evidence is collected and converted into recommendations (Nothacker et al. 2013). Our society has a special responsibility for the seriously mentally ill and their participation in advances in knowledge and evidence-based care. <<