BRIEFINGS Psychiatry in former East and West since reunification

Manfred Bauer

Discussion of the need to reform psychiatric equals the number admitted by state mental services in former West Germany started rela hospitals. Since all these departments are tively late. It was only in the late 1960s, when the located close to mostly urban communities, it is a government changed from the conservative safe assumption that today far more than half of Christian Democrats to a coalition of the Social all psychiatric patients can be treated in their Democratic and Liberal Parties, that psychiatry own community. became a public issue for the first time since The majority of these departments serve a World War II. Parliament appointed an expert defined catchment area in which chronic commission, which after four years gave a com patients are no longer sent to state mental hos prehensive report in which the inadequate care pitals but treated within the community. Almost of mentally ill patients was criticised. all of these facilities have sheltered workshops, The points of criticism were that the sheltered housing for psychiatric patients and in-patient treatment of the mentally ill was often also day-centres and well equipped out mostly provided by badly staffed and remotely patient services. So far no state mental hospital located large state mental hospitals, sometimes has been closed down but their number of with 2000 or more beds; psychiatric facilities beds has been reduced dramatically. Hospitals within the community were almost non-existent; which had 1500 beds 20 years ago have 400-500 out-patient services, especially for chronic men today, sometimes less than 300 beds. The first of tally ill patients, were insufficient; and psychi the state mental hospitals are expected to close atric treatment and care was mostly conducted before the year 2000. outside the general medical system. This development is not only supported by The expert commission proposed reforms that politicians and many young psychiatrists, but took into account internationally accepted stan demanded by newly organised groups of relatives dards and were modelled on the British system. of the mentally ill. This caused a public recog The main focus of the proposals was on the nition of psychiatry and a discussion about creation of community based facilities and the existing problems which speeded up the reforms link between in-patient and out-patient services, and helped psychiatry move towards the commu which until then had been strictly separated. The nity. However,there is still an ongoing discussion big state mental hospitals did not have out about the 'best way' among the profession. While patient departments and chronic mentally ill the reform-orientated, mostly younger doctors, patients stayed an unnecessarily long time in who work in the community think that progress hospital because there were no complementary is too slow, many hospital psychiatrists and and out-patient services within the community. administrators want to preserve the status quo. In West Germany this situation has improved They argue that psychiatric departments in significantly over the last 20 years. Between general hospitals and connected extramural and 1971 and 1994 almost 100 psychiatric depart out-patient séviceswillnot be able to treat every ments have been organised in general hospitals. patient and that state mental hospitals will still Most have about 80 beds and 20 places in day- be necessary in the future. They also think that care facilities. The number of psychiatric depart big hospitals are able to provide better care, since ments in general hospitals therefore exceeds the it requires a certain size of facility to provide 78 large state mental hospitals still in existence. specialised treatment for different groups of Including the 27 psychiatric university clinics, patients, e.g. depressive, schizophrenic, psycho- which are comparable to a psychiatric depart geriatric and alcohol or drug addicts. Neither the ment, there are currently 125 departments in the patients, their relatives nor the politicians share western parts of Germany with about 12,000 this view, so that steady progress towards more beds. The average duration of a patient's stay is community orientation and integration of psychi about 30 days and these facilities admit about atric services can be expected, although slower 120,000 patients annually, which approximately than in the past since public funding has

Psychiatric Bulletin (1994), 18. 637-639 637 BRIEFINGS decreased from the level of the 1970s because German economy after reunification, unemploy of Germany's unification. There will also be ment rose sharply and almost all mentally ill regional differences because funding of health patients lost their jobs. Since the cost of housing care system falls within the jurisdiction of the 16 also rose sharply and apartments are scarce, it is Lander which have different opinions about the at present very difficult to develop a psychiatric structure of psychiatric care. The sparsely popu infrastructure comparable to West German stan lated , for example, plans to close its dards. However, there are promising initiatives only big state mental hospital by 1996 and to in East Germany, especially where psychiatric provide psychiatric beds only in general hospi departments in general hospitals have been tals. Densely populated Bavaria, by contrast, created. These departments are best able to adheres to the concept of large state mental create initiatives for community based psy hospitals, which have been modernised in recent chiatry because they are located in the com years. Here only a fewpsychiatric departments in munity and part of a general hospital better general hospitals have been created. accepted by the population than large state The mental health care system in former East mental hospitals, which still carry unpleasant Germany after WorldWar II was almost the same associations about the treatment of the mentally as in West Germany. It was also based mainly on ill. large psychiatric hospitals with 500 to 2000 A special concern among many Germans, and beds. Out-patient care took place in out-patient not only psychiatrists, after reunification was departments that were typical in former socialist whether in former East Germany there had been countries and there were no psychiatrists in an abuse of psychiatry comparable with the one private practice. These out-patient departments in the former Soviet Union. Four years after were intended to provide medical treatment as reunification this can be answered with 'no'. well as social care with a multiprofessional team Although there were frequent attempts in former of doctors, psychologists, social workers, nurses East Germany to employ psychiatrists politically, and other psycho-social professionals but rarely no case was found where a political dissident was functioned satisfactorily because of insufficient given a psychiatric diagnosis and treated accord staffing. Most of these out-patient departments ingly in a special psychiatric hospital. However, have since been closed down and many of the many psychiatrists who held senior posts as doctors who used to work there are now in office hospital directors and university professors had practice, with most in the cities and only very few either worked for the secret service (Stasi) or in the country. Compared to the former West provided them with medical information about German Länder,wherethere is one psychiatrist certain patients. When this was uncovered the for every 20,000 people, the rates in the former psychiatrists lost their posts and now work in East German Länderis 1:30,000. But in the office practice or private hospitals. The contro western parts of Germany there also exists a versy about the political involvement of psychia large number of psychologists and psychothera trists which was very heated only two years ago pists in office practice (about 1:10,000 popu has now almost disappeared since the problem lation) while in former East Germany this has been solved in this way. number is very small. In October 1993 a law came into effect that allows only the same number of doctors to start a Conclusions private practice as retire, which means that the number of psychiatrists in office practice will In terms of international comparisons, the West remain at the level of 1993. Therefore it will not German psychiatric reform took an intermediate be possible to improve the out-patient treatment path. With significant regional differences the of psychiatric patients through an increase in size of large state mental hospitals has signifi the number of psychiatrists in office practice. In cantly decreased, but none has been yet closed. this context it must be emphasised that many Almost 100 psychiatric departments in general German studies came to the conclusion that the hospitals have been created during the last 20 patients of psychiatrists in office practice differ years, most consisting of about 80 beds and a from patients treated in hospitals and therefore day hospital, and are responsible for a catch many communities established complementary ment area of about 150,000 inhabitants. This out-patient services especially for the treatment system works best in towns with 100,000- of chronic mentally ill patients. 150,000 inhabitants. Many places have suc Until German réunificationthere were almost ceeded in adding a variety of extramural and no sheltered workshops and other services offer- out-patient services (e.g. sheltered workshops, Ing rehabilitative care in East Germany. One sheltered housing, day-centres, out-patient reason was that many chronic mentally ill facilities, etc.) to their psychiatric infrastructure. patients were integrated into the regular job The relatively high number of psychiatrists market. During restructuring of the East (1:20,000 population) and psychologists/

638 Bauer BRIEFINGS

psychotherapists (1:10,000 population) in office hospitals will be the engine of this develop practice has also contributed to the situation ment. There already are promising attempts, that out-patient care of mentally ill patients mostly in medium-sized cities. Because financial within the community is satisfactory. Neverthe resources are more scarce and the political less, a number of old chronic mentally ill patients priorities of 1994 are different from 1974, this are still in psychiatric hospitals because up to process in the East will probably take longer now there were no adequate services within the than in West Germany. This means that in community for them. almost every area of society, the gap between In East Germany the reform of psychiatry West and East Germany will continue for many essentially started only after reunification. more years. Therefore the large state mental hospitals are still very prevalent there. An out-patient psychi M. Bauer, Professor, Städtische Kliniken atric infrastructure comparable to that in West , Psychiatrische Klinik, Starkenburg- Germany will slowly develop over the next few ring 66. 63069 Offenbach, Germany years. The psychiatric departments in general

East and west, old and new: the College tour of Germany

S.D. Martin, B. Bende, B. Breitner, M. Laker and F. Leslie

German psychiatry is emerging from a black past Health insurance organisations pay doctors in to a challenging future. Under the Nazis it Is their own practice every three months for their thought that about 100,000 psychiatric patients patient contacts and interventions with itemised were killed and 300,000 were compulsorily fees. Insurance organisations, together with local sterilised. Services for the mentally ill had also government, negotiate contracts with individ been adversely affected by two world wars and ual hospitals for in-patient treatment. Recent recession. For 50 years there was little pro research has shown 20% of the population have gress. By the 1970s, the government and other had insurance payments for some kind of mental institutions took more interest in mental health. health treatment. Community facilities began to appear such as Rehabilitation services, including addictions, day centres. Long-stay patients are now being are often funded by health insurance organis discharged from hospitals and asylums have ations and pension funds who, as purchasers, closed in some states. can restrict funding and prevent treatment. On 26 September 1993, a party of 26 psy chiatrists went on a week-long Study Tour to Northern Germany visiting Lübeck,Kiel,Rostock and Hamburg. It was admirably organised by Private practice Dr Cyril Davies from the British side and Dr Hospital psychiatrists see almost exclusively in- Alexander Boroffka from the German Association patients. Most out-patient treatment is provided for Psychiatry and Neurology. by specialists in their own practices in the com munity. Usually called 'private practice' the term is misleading as health insurance organisations Health insurance pay for treatment. The system allows patients to choose psychiatrists but they must usually It Is mandatory for anybody in training or em arrange their own follow-up after discharge from ployment in Germany to have health insurance. hospital. Unemployed people or those receiving social There is very little multidisciplinary team benefits are also included. work. Psychiatrists in their own practice are

College tour of Germani) 639 Psychiatry in former East and West Germany since reunification Manfred Bauer Psychiatric Bulletin 1994, 18:637-639. Access the most recent version at DOI: 10.1192/pb.18.10.637

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