No abstract

Vocational rehabilitation programmes are an essential part in the treatment of people with chronic mental illness. Integration into work varies markedly while patients' satisfaction is comparably good. Competitive employment represents a realistic objective only for patients with high motivation and favourable preconditions.

SF-36 questionnaire is a useful instrument to monitor the health status and to evaluate treatment effects in drug addicts.

Work therapy is a widespread form of sociotherapy. In contrast to pharmacological and somatic forms of treatment, proof of efficacy is difficult to produce in multimodal therapy of schizophrenic patients on account of the many methodological problems involved. Within the framework of an extensive study on the vocational rehabilitation of mentally ill patients, we carried out a naturalistic follow-up study of 83 schizophrenic patients attending outpatient work therapy. The sample, which comprised 44 men and 38 women with a mean age of 35 years (+/- 8.5 years), can be seen as regionally representative. The courses of illness and rehabilitation were documented prospectively at annual follow-ups over a 3-year period. Most of the probands were chronically mentally ill patients with a history of frequent and long-term hospitalisation. At the end of the 3-year period, 22% of the patients were integrated into the open labour market, 26% were working in sheltered employment, 23% were still in work therapy, and 29% were unemployed. Two-thirds had achieved their stated rehabilitation objectives. The 3-year rehabilitation outcome was strongly dependent on the patients' subjective expectations. Other factors proving to be predictors of successful rehabilitation were less pronounced psychopathological symptoms (ADMP), better social functioning (GAS), a higher level of education and an early introduction to work therapy. Work therapy appears to have a favourable impact on hospitalisation rates.

The social implications and long term consequences of mental disorders regarding sick days at work, unemployment rates and early retirement are considerable. Outcome in psychiatric treatment should be measured not only by reduction of psychopathological symptoms and improvement of subjective well-being respectively quality of life but also by taking social integration into account. Job inclusion could become a crucial factor indicating successful therapy. It is remarkable that there has been so little focus on the links between reduction of psychopathological symptoms and competitive working skills. Hardly any studies exist evaluating for example psychopharmacological strategies referring to social outcome criteria. Without denying the progress that has been made, the classical paradigm of community psychiatry has reached its limits. Initial hopes of spontaneous social integration did not come true. Vocational rehabililitation sensu strictu is either aiming at the individual's work related skills (personal approach) or at reducing demands on the job (environmental approach) - in Germany being mostly realised at sheltered workshops. Thus most of the rehabilitation programmes are based on the traditional "train and place"-approach. There are some controlled studies about the new innovative supported employment programmes taking the reverse principle of "place and train" into account. These studies could show a clear superiority regarding the number of successfully integrated patients. Scientific evaluation of complex programmes is sophisticated but seems to be necessary for further developments in the field of general psychiatric therapies as well as for the legitimation of financial ressources needed. Foreseeing the perspective of social psychiatry a next substantial step could be the identification of social and functional outcome variables as a basis of validation of numerous therapy strategies.