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6 - The Mannheim Project
- from Part II - COMPREHENSIVE SERVICE EVALUATION PROJECTS
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- By Heinz Häfner, Central Institute of Mental Health, Wolfram An Der Heiden, Zentralinstitut für Seelische Gesundheit
- Edited by Helle Charlotte Knudsen, University of Copenhagen, Graham Thornicroft, Institute of Psychiatry, London
- Foreword by Norman Sartorius
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- Book:
- Mental Health Service Evaluation
- Published online:
- 05 August 2016
- Print publication:
- 14 March 1996, pp 82-95
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Summary
Introduction
After World War II psychiatry in Germany carried a terrible burden. From 1933 onwards the ideology of national socialism had disastrous consequences for the mentally ill. The eugenic laws demanded the compulsory sterilisation of every individual suffering from functional psychoses, familial epilepsy and familial retardation. The inhumanity culminated in the programme of euthanasia. Between 80 000 and 100 000 mentally ill people were killed. Some of the leading German psychiatrists had been actively involved in this programme.
Understandably, psychiatrists and psychiatric institutions thereafter met with a fundamental distrust. It took a long time until the problems of mental health care could again be brought before the public. Therefore, until 1970, German psychiatry was comparatively little influenced by the community psychiatry movement initiated in the United States, Britain and other European countries. As a consequence, the maximum of occupation of psychiatric beds, indicating the culmination of custodial care, was reached in Germany approximately 15 years later than in Great Britain or the United States.
Mental health care in Germany in the early 1960s was characterised by a sharp demarcation between inpatient and outpatient care. Ninety-seven per cent of all psychiatric beds were in mostly remote, large public hospitals, four of them with more than 4000 beds. The majority were in an obsolete state. The average length of stay was 215 days, 26% of the patients staying in hospital for more than 10 years. Only 3% of the psychiatric beds were located in units of general hospitals with a bed ratio of 1:12.6 and an average length of stay as short as 35 days. Outpatient psychiatric care rested almost completely with psychiatrists and psychotherapists in private practice. Among their clientele patients with severe mental disorders and socially disabled chronically mentally ill individuals in particular, as well as psychogeriatric patients, were considerably underrepresented. Complementary services, such as day hospitals, supervised homes and apartments, and sheltered workshops, were lacking almost completely, and there was no prospect of a change in this system, especially in the rehabilitation of dischargeable long-stay patients.
Provision of care for mentally ill old people was extremely deficient. In the mostly isolated mental hospitals somatic care to modern standards was impossible.
9 - Experimental and quasi-experimental design in evaluative research
- from Part III - METHODS: MEASUREMENT, STRATEGIES AND NEW APPROACHES
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- By Wolfram An Der Heiden, Zentralinstitut für Seelische Gesundheit
- Edited by Helle Charlotte Knudsen, University of Copenhagen, Graham Thornicroft, Institute of Psychiatry, London
- Foreword by Norman Sartorius
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- Book:
- Mental Health Service Evaluation
- Published online:
- 05 August 2016
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- 14 March 1996, pp 143-155
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Summary
Depending on the processes being assessed, the term ‘evaluative research’ is used for different approaches (Milne, 1987): ‘effort evaluation’ examines the relationship between the characteristics and activities of a programme or service (e.g. physician-patient ratio, utilisation of beds) and the money spent on it (e.g. for staff and equipment); ‘process evaluation’ is traditionally limited to a simple outline of services over time (number of patients, type and extent of services offered); ‘efficiency evaluation’ establishes the relationship between the cost of a service and the goal it aims to achieve; ‘client satisfaction evaluation’ examines the patients’ acceptance of treatment measures. ‘Outcome evaluation’ is the core of evaluative research; here, the result of a measure is the focus of the study. This approach is chosen when the effectiveness of interventions or services is to be examined. Outcome evaluation relates most directly to the primary goal of treatment, ‘which is to make the patient better’ (Schwartz et al.1973).
In a mental health care system many events occur at the same time. So at first sight it seems rather arbitrary to assume that of all things happening one event ‘treatment’ is causally related to another event ‘outcome’, for example absence or presence of schizophrenic symptoms at a given point in time. Many factors besides treatment may influence psychopathological status. It is well known that the mere incidence or correlation of two events does not tell anything about which is the cause and which is the effect, whether two events are mutual interdependent or whether they are both dependent upon an unknown third variable (Simon, 1976). Chains of cause and effect are not observable in principle; it is also impossible to verify a causal relationship empirically. The testing of a causal hypothesis rather results by ruling out rival explanations for an effect (Kraak, 1966; Cook & Campbell, 1979).
According to Kenny (1979) three commonly accepted conditions must hold for a scientist to claim that the event X causes the event Y:
Temporal precedence of the cause: for X to cause Y, X must precede Y in time; such temporal precedence means a causal relationship is asymmetric.
2 - Background and goals of evaluative research in community psychiatry
- from Part I - INTRODUCTION
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- By Heinz Häfner, Central Institute of Mental Health, Wolfram An Der Heiden, Zentralinstitut für Seelische Gesundheit
- Edited by Helle Charlotte Knudsen, University of Copenhagen, Graham Thornicroft, Institute of Psychiatry, London
- Foreword by Norman Sartorius
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- Book:
- Mental Health Service Evaluation
- Published online:
- 05 August 2016
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- 14 March 1996, pp 19-36
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Summary
Introduction
Evaluative research in community psychiatry is one of the most difficult areas of psychiatric research. This is due to: (1) multiple conditions of care and complex measures of intervention; (2) difficulties in finding appropriate criteria and indicators of outcome (especially in assessing quality of life); (3) difficulties in measuring and controlling for relevant intervening variables; and (4) different methods and practices of data collection. As a result, it is hard to ensure both internal and external validity of the results obtained, that is, to isolate the reasons for observed changes and also to apply the results to other populations, services or community care systems. Indeed, many reviews and attempts at a meta-evaluation of studies on the effectiveness of community care (Renshaw et al.,1988; Hafner & an der Heiden, 1989) have been faced with the following problems: the patient groups studied differed in their profiles of needs for care, the underlying social and institutional conditions of the programmes and services were hardly comparable and intervening variables, such as severity of illness and the patients’ skills levels, were not taken sufficiently into account.
An additional hindrance to transnational comparative studies is the lack of comparable national databases or health information systems providing background information for a given structure of mental health care. In addition, there are differences in the organisation of health care, social and welfare systems as well as in the level of implementation of community care. As a consequence, the WHO Regional Office for Europe in its transnational comparative 10-year assessments of mental health care in the European member states included only a few crude indicators of community psychiatric care, such as number of psychiatric units in general hospitals, bed capacity and number of outpatient and day-care units (May, 1976; Freeman et al. 1985). Such an approach naturally harbours fewer errors, but also narrows the range of relevant results.
The present chapter deals with some core questions of evaluative research in psychiatry. In the first part the objectives of psychiatric care and treatment will be discussed. Rather than providing a list of operational criteria for assessing effectiveness in the evaluation of outcome, the chapter focuses on the objectives explicitly determined or merely implied by the changed assumptions, principles and value judgements in the field of community care.
The Evaluation of Mental Health Care Systems
- Heinz Häfner, Wolfram an der Heiden
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- Journal:
- The British Journal of Psychiatry / Volume 155 / Issue 1 / July 1989
- Published online by Cambridge University Press:
- 02 January 2018, pp. 12-17
- Print publication:
- July 1989
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While the demand for deinstitutionalisation, strongly supported by the economic aspect of the issue, has resulted in a steep decline in the number of psychiatric beds in many Western countries, the evaluation of extramural psychiatric care has several difficulties, including that of proving effectiveness without experimental control of confounding influences. For a cohort of schizophrenic patients we investigated the impact of outpatient psychiatric treatment on length of stay in hospital and length of stay in the community. Outpatient care had a significant influence on read mission, but no effect on the length of inpatient treatment. While the average cost of community care was less than half that of traditional hospital care, in 6% of the patients this threshold value of continued inpatient care was exceeded. There also seems to be a non-monetary threshold, above which community care is no longer appropriate.