A German psychiatric care program aiming to improve patients’ compliance – Patients’ view

Abstract

Noncompliance is a worldwide problem in medical care, leading to prolonged recovery times and rehospitalizations. Especially in the field of psychiatry, consistent therapy compliance is crucial. Hence the Munich Integrated Care program for patients suffering from psychiatric disorders aims at improving patients’ compliance. To bring to light participants' personal experiences with the program, we conducted group interviews that we evaluated using qualitative methods. We shed light on what aspects make a psychiatric health care program so valuable in the eyes of its participants that it can develop its effect as a relapse-preventive agent. We found that in this program, patients experienced safety, stability, support, hope, motivation and understanding.

Introduction

In the therapy of chronically ill patients, non-compliance is a massive problem worldwide (1), concerning also psychiatric illnesses like depression or schizophrenia. In average, only 50% of patients living in developed countries can adhere to their recommended regimens, which affects not only the individual`s quality of life, but also the economy (therapy costs, non-productive time, etc.).

For that reason, in 2005 an Integrated Care program in Munich, Germany, was founded by the psychiatric department of the Klinikum rechts der Isar of the Technische Universität München in union with the “Arbeitsgruppe Münchner Nervenärzte und Psychiater” and the “Landesverband Bayern der Betriebskrankenkassen”, designed as an aftercare-tool for patients with an ICD-10 F2 or F3 diagnosis. The Integrated Care program set its goal on increasing their patients’ compliance. Compliance can be considered a necessary means of avoiding relapse. In this work with the special psychiatric background, we define compliance not only as the taking of medication, but also as sticking to a consistent aftercare regimen after acute intervention with regular visits to the doctor, work on personal social skills, understanding of the body's own warning signals for signs of a disease relapse and timely seeking of help in such a case. Important elements of the program that aim at improving patients’ compliance are regular courses such as relaxation classes, courses to improve social skills, regular contact with doctors, and exchange with other patients. In psychoeducational courses patients learn about their disease and how to recognize relapses. The program is characterized by a proactive setting (telephone reminders of appointments, active contact in case of prolonged absence) and 24-hour availability in emergency situations.

In 2014, Hamann et al. could already show the program`s success in terms of reducing overall inpatients days by 75% compared to the time before taking part in the program (2). To find out about the exact modalities of how the program manages to improve patients’ compliance, we got in close contact with participants.

Methods

To get detailed information about patients’ experiences regarding the program, we conducted focus group interviews. The interviews were planned by a team of psychiatrists of the Klinik und Poliklinik für Psychiatrie und Psychotherapie at the Klinikum rechts der Isar. Within the framework of a widespread study, we talked, among other stakeholders, to patients visiting the program at the time of our survey. They were separated for their main diagnosis including either schizophrenia / schizoaffective psychosis (ICD-10: F20 / F25) or depression / bipolar disorder (ICD-10: F3) as well as for their supposed compliance (compliant vs. non-compliant). Participating patients gave written informed consent about the interviews being audio-taped, anonymized, and used for the study. The transcripts were analysed using qualitative content analysis as shown by Mayring (3). Some of the most important findings of our analysis are shown in this article.

Results

The results that we found during our broad study are extensive. In this paper we decided to narrow down on content concerning the program's value in the eyes of patients.

In the following, we present the main themes of patients’ views and feelings towards the program Table 1. shows formal data about the patients interviewed.

Table 1.

Participants of conducted interviews [N = 17].

Age [years]	M = 52,6 SD = 11,5
Gender	7 female, 10 male
Diagnosis (number of patients)	Schizophrenia (10), Affective disorder (7)
Compliance (number of patients)	compliant (9), non-compliant (8)
Length of participation [years]	M = 7,6 SD = 4,1

Main themes describing the experience of the Integrated Care program by the participating patients

Enrichment of patients` everyday lives through activities, contacts and structureVisiting the program helped improve patients’ everyday life: attending the program`s courses and offerings helped them being active again. They were happy to have a place to go to, contact to other people with similar problems and overall more structure in life.

Safety Patients stressed that the integrated care program was a place they could feel sheltered and secure.

Stability Patients also addressed that by attending the program, they were able to (re-)gain their personal stability. This was due to the structure the program gave to their daily life, different courses that focused on mindfulness or the possibility of contacting the program whenever needed.

Support Patients frequently talked about the great support they experienced through the program. Whenever necessary, they could reach out for the program's team and require help in difficult situations or just talk to someone when in need.

Assistance in personal enhancements By attending the program and it`s courses, patients could work on their personal skills. They learned how to cope with critical, socially challenging situations or how to be active in their daily lives.

Hope and motivation Patients emphasized that by visiting the program, they could find new hope and motivation to master life.

Not being left alone Patients also stressed that at any time of the day, they could find an open ear in the program. This gave them a feeling of not being left alone in troubled times and thus could help to keep them from slipping into a new crisis.

Belonging and being in good hands Patients also addressed their feeling of being comfortable and sheltered when visiting the Integrated Care program.  It felt like family to them, many patients agreed.

Trust Beyond the familial feeling people experienced in the program, patients also talked about being able to give and find trust in the team members and fellow patients.

Appreciation A frequently addressed topic was the feeling of being appreciated. Patients talked about how the program`s team cared for them, took their time, and made them feel like they matter.

Understanding Patients emphasized that in the program they could always talk openly and without fear, because they could be sure that the program was a safe place to talk. Patients felt accepted and taken seriously.

Voluntariness Above all, patients stressed the fact that whenever they visited the program or took part in courses or offerings, they felt like doing so on their own behalf, without any pressure. Many patients agreed to highly appreciate the voluntariness of the program.

Conclusion

One of the prevailing aims of the Integrated Care Program is the improvement of compliance with the goal of a reduction of disease relapses and associated hospitalizations. Hamann et al. (2) could already show a significant success in terms of reduction of cost and overall days spent in hospital. In this study the reasons for Hamann`s results could comprehensively be substantiated with content for the first time. We were able to uncover elements of the program that patients value and thus keep them in the program, so that the program can have its compliance-promoting and relapse-preventing effect.

Potential limiting factors can be found in the sampling of patients, in the interview situation and in the dynamics of a group interview. Above all, the underlaying subjectivity of all qualitative methods remains a limiting factor.

Ethical considerations

The study received ethical approval from the Ethics Committee at the Technische Universität München (Nr 01VSF16004).

Funding

The study was funded by the German Innovationsfonds (Grant number 01VSF16004).

Acknowledgments

The authors would like to thank Prof. Linde for his advice and help. Thanks also go to the team of the Integrated Care for organizing the interviews, as well as to the team of the Qualitative Werkstatt of the LMU München for their input concerning the qualitative part of this study.