Who cares for the newborn when the mother is hospitalized with severe postpartum depression? What do caregiving relatives do when they become so mentally ill that only a stay in hospital seems to help? Who cares for someone who needs intensive psychiatric help but dreads clinics? Every year almost 800,000 people are treated as inpatients in a psychiatric ward. For many, getting there is a hurdle.
There has been an alternative to the ward for them for five years: ward-equivalent treatment, or staff for short. The therapy, even for seriously ill patients, takes place entirely at home. Revolutionary, one might think. It’s high time, say experts: “From a German perspective, this is new and special, but such outreach offers are well known internationally,” says Andreas Bechdolf, chief physician at the clinic for psychiatry, psychotherapy and psychosomatics at the Vivantes Clinic at Urban in Berlin. His facility also offers staff, and he is also in charge of the first nationwide survey on the effectiveness of the new care model. “In Great Britain, Ireland and the Netherlands, home treatment for mentally ill people in crisis has been around for more than 50 years, in some cases,” he emphasizes. From the studies there, we know how useful and effective care at home is.
The demand is also growing in this country – from the sick, their relatives, but also from psychiatric clinics. Nationwide, 50 of the approximately 400 clinics now offer their psychiatric patients crisis care at home. At least one member of the team comes on home visits seven days a week. Depending on your needs, this includes specialists, nurses, psychotherapists and occupational therapists. On average, the visit lasts an hour. There is a 24-hour on-call service and often a short call in the evening to make sure everything is ok. A staff can replace the time on the ward or continue an inpatient stay in your own four walls.
“The health insurance companies fear that we are treating less severe cases here than can otherwise be found in a psychiatric ward. But that is not true,” emphasizes psychiatry professor Gerhard Längle, deputy managing director of the ZfP Südwurttemberg supply association. Of course, home treatment has its limits. People who want to take their own lives, like aggressive people, cannot initially be cared for at home. Those who do not stick to agreements and do not ask for help when things get tricky need a different therapeutic framework. The psychiatric team is also unable to care for people at home who also have serious physical illnesses that require a great deal of care. But apart from that, the patients are not very different.
Längle and colleagues compared patients at home with those on the ward for an investigation: “The severity of the diseases was identical.” However, in the home setting, it is only about patients who are being treated voluntarily and not about those who are forcibly admitted.
But Stäb can also be an option to prevent forced admissions. The psychiatrist Eva Ketisch, who heads the ward-equivalent treatment at the Kbo-Isar-Amper-Klinikum in Munich, reports on this: “I know a few patients who used to always have to be on the ward and were sometimes treated under duress, and today only in crises be cared for at home,” she says. For example, you might think of a man who suffers from schizoaffective disorder. Whenever he got into a manic, i.e. strongly emotionally agitated phase, he was eventually taken to the clinic by force. He was once treated by staff. Since then he has not been forcibly admitted. “He calls us now when he’s feeling very bad, and then we treat him intensively at home,” says Ketisch.
The teams now also see patients who previously could not be treated at all
The psychiatrist and her two staff teams are now also seeing sick people who were previously hidden from them, such as those people who have not left the house for months or even years because they have severe fears or are extremely listless. Therapy in your own four walls can finally reach these people.
Gerhard Längle also reports on this. “Going to a psychiatric ward means not only immediate help for those affected, but also a lot of restlessness and being close to strangers. Not everyone wants that,” he says. Others have had bad experiences in psychiatry, for example with coercive measures such as restraint or isolation. These people do not want to go to such a facility again – and still urgently need help. He had already experienced tears of joy when he offered a patient to be treated at home with his team.
Working with people in their home environment also changes the view of those affected. Practitioners and patients tend to meet as equals. “The contact is much more balanced when we go to the patients’ homes than when we treat them in the clinic,” says Eva Ketisch. Stäb is also changing the way she works: “In the clinic, for example, I focus on someone’s psychotic experience. But with the person at home, I see what they can do and where everyday deficits lie.” Does anyone open their mail regularly or do they have letters from two years ago lying around? Can someone still run their household or is the rubbish piling up? “It’s precisely at these points that you can get a grip. Open the mail together, take out the garbage: that’s part of the therapy,” says Ketisch.
The fact that the treatment is virtually tailor-made has particularly great advantages for some patient groups, such as young mothers. Only recently, Ketisch’s team cared for the mother of a newborn who had massive suicidal thoughts. She initially had to be treated on the ward. After three days in the facility, the woman was stable enough to continue treatment at home – and to take care of her baby. The treatment lasted six weeks. Mother and child are doing well.
With home treatment, the social environment can also be more closely involved. “Before we treat someone in Stäb, we naturally check whether no child is at risk and whether all family members agree that the treatment can take place at home,” says Längle. For him, the advantages are obvious: “With therapy at home, we can deal with conflict issues much better. Take, for example, an addict who has been to the clinic 10 to 15 times. He knows everything and everyone Loop in therapy. He no longer benefits from it,” explains Längle. But if the problems were in everyday life, Stäb could make the difference here. Ketisch adds: “At the same time, we are more likely to see what the illness is doing to the relatives in the home environment, and we can intervene and help here.”
Those cared for at home had fewer symptoms and a better quality of life than the inpatients
Studies should now underpin these experiences. The Berlin psychiatrist Andreas Bechdolf therefore initiated the active study together with ten other clinics and clinic groups in Germany. From Berlin to Munich, they compare patients who are treated at home with those who are cared for on the ward, even a year later. The investigation is not expected to be completed until the fall of this year, however the first preliminary findings the researchers are positive: “The therapy in Stäb was broken off less often and the patients felt more involved in the treatment,” reports Bechdolf from his data set in Berlin. Gerhard Längle also reports higher satisfaction among patients at home than among those on the ward in the participating centers of his clinic network in Baden-Württemberg. “80 percent of the patients who were in staff want to be treated the same way again next time,” he says.
One review paper with findings from model projects in Germany as well as acute home care in Austria and Switzerland shows further positive effects: Those treated at home afterwards had fewer symptoms and a better quality of life than those treated in hospital. They were more likely to find work again and appear to be less likely to have to return to a psychiatric ward.
There are now patients in the 50 clinics with staff who have already received intensive psychiatric treatment several times but have never been to a ward. Instead, she drank tea with the specialist at the living room table and sat down in her own chair for the psychotherapy.