Nonadherence with the recommendations of health care providers results in reduced quality of health, poorer social adjustment, and tremendous strain on our already fragile health care economy. This study includes 283 patients evaluated by the Psychiatric Emergency Service (PES) in the emergency room of an 800-bed medical center in an urban setting in the Northeastern United States. Adherence in this study was operationally defined as attending the first outpatient follow-up appointment after referral from the emergency room. Baseline levels of adherence with treatment recommendations were determined in a first group. Patients seen in a second group received a reminder letter as a treatment prompt. In a third group, a set of five Likert Scale questions evaluated the patient's perception of their experience in the emergency room and rated the availability of social supports. Objective aspects of patient care such as the length of time waiting for treatment in the emergency room and length of the interval before the first appointment were also recorded. Other variables such as insurance type, referral site and history of prior treatment at the referral site were studied. Data analysis revealed that the interventions of receiving a reminder letter and completing a questionnaire concerning the emergency room experience both were associated with increased adherence. Several aspects of patient care were also significantly associated with increased adherence, including waiting shorter periods for evaluation, and waiting fewer weeks for the first outpatient appointment. Increased adherence was associated with referral to HMO clinics and private practitioners as compared to referrals to community clinics. Having insurance also was associated with increased adherence, ranked in the following order: HMO insurance, commercial insurance, Medicare, and Medicaid, with the uninsured population having the lowest adherence rates. A history of prior treatment at the referral clinic, being satisfied with emergency room treatment, feeling in need of treatment, and having social supports for treatment all were significantly associated with outpatient referral adherence.

This study examined whether the concept of desired outcome in community programs serving adults with psychiatric disorders was a unitary or multifaceted concept and whether, if multifaceted, subject stakeholder group membership or variables of sex, education, age or attitudes were related to subject preferences for types of outcome. A literature review and focus groups were used to establish a broad range of potential outcomes and 47 subjects from six stakeholder groups (clients, family members, direct care staff, directors of programs serving clients with serious psychiatric disorders, DMH personnel who made service funding decisions, and taxpayers) sorted the 82 outcomes in order of their perceived importance. Subject responses were factor analyzed and a five factor solution was interpreted as indicating concerns for (1) increased client self determination, (2) risk reduction and stability, (3) provision for basic needs, (4) increasingly responsible and integrated community living, and (5) increased autonomy through skill development and symptom reduction. Stakeholder group membership was the only subject variable significantly correlated with subject differences in loading on the five identified factors. It was concluded that these differences had important implications for the ability of stakeholder groups to interact productively. That is, if individuals with differing views on the proper goals of the community mental health system fail to understand the nature of their differences conflict and distrust will continue and a coherent sense of mission for the community system will be impossible to attain. The author asserts that it is important for stakeholders to recognize the legitimacy of, and basis for, the views of others with whom they are attempting to work. Steps recommended to use these findings to improve the quality of practice in the field include: acknowledgment of conflicts inherent in differing points of view, clarifying the extent to which custodial care and social control of those with psychiatric disorders are primary functions of the community system, resolution of legal and ethical issues inherent in "ensuring" the care and safety (as defined by others) of those with psychiatric disorders, specification by funders of outcome priorities, and greater use of outcome measurement in program evaluation.

Wartezeiten von durchschnittlich mehreren Monaten sind auch nach Inkrafttreten des Psychotherapeutengesetzes in der deutschen Psychotherapieversorgung die Regel. Behandlungsbedürftige Störungen, für die ein Behandlungswunsch besteht, unversorgt zu lassen, ist weder unter ethischen, noch praktischen und therapeutischen Gesichtspunkten vertretbar. Aus diesem Grund schlagen viele Praktiker ihren wartenden Patienten niedrigschwellige Selbsthilfeangebote vor, die von psychoedukativen Informationen über Bibliotherapie bis zu Gruppenangeboten reichen. Die vorliegende Arbeit gibt einen Überblick über verschiedene Möglichkeiten, wartende Psychotherapiepatienten gut auf die bevorstehende Therapie vorzubereiten und während der Wartezeit zugleich sekundäre Prävention zu betreiben. Hierbei muss nach unserer Einschätzung vor allem die Maxime gelten, dass die vorgeschlagenen Maßnahmen mit dem Rational der darauf folgenden Therapie vereinbar sein sollten. / Even after the new psychotherapy law has been implemented, waiting times of several months remain rather common in the German mental health care system. For ethical, practical, and therapeutic reasons, however, patients who are in serious need of treatment should not be left unattended. Many practitioners therefore suggest self-help treatments such as psychoeducational information, bibliotherapy, or supportive groups to their waiting patients. The present study provides an overview on possibilities of preparing waiting psychotherapy patients for their upcoming therapy as well as implementing secondary prevention during the waiting time. As a basic, we suggest that the proposed methods should be in line with the treatment rationale of the subsequent therapy. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.