gms | German Medical Science

GMS Psycho-Social-Medicine

Corporate journal of German scientific societies in psychosocial medicine

ISSN 1860-5214

The development of guidelines for the treatment of patients with mental disorders under particular consideration of rehabilitative aspects

Leitlinienentwicklung für die Behandlung von Patienten mit psychischen Störungen unter besonderer Berücksichtigung rehabilitativer Aspekte

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  • corresponding author Cathrin Büscher - Hamburg-Eppendorf University Clinic, Center for Psychosocial Medicine, Institute and Policlinic for Medical Psychology, Hamburg, Germany
  • author Birgit Watzke - Hamburg-Eppendorf University Clinic, Center for Psychosocial Medicine, Institute and Policlinic for Medical Psychology, Hamburg, Germany
  • author Uwe Koch - Hamburg-Eppendorf University Clinic, Center for Psychosocial Medicine, Institute and Policlinic for Medical Psychology, Hamburg, Germany
  • author Holger Schulz - Hamburg-Eppendorf University Clinic, Center for Psychosocial Medicine, Institute and Policlinic for Medical Psychology, Hamburg, Germany

Psycho-Social-Medicine 2004;1:Doc05

The electronic version of this article is the complete one and can be found online at:

Published: July 1, 2004

© 2004 Büscher et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Inpatient psychotherapeutic treatment is quite extensive in Germany. Three treatment systems (psychosomatic/psychotherapeutic healthcare, psychiatric/psychotherapeutic healthcare and rehabilitation of patients with mental disorders) exist relatively independently from one another. They show large areas of overlap, however, with regard to various criteria. This is due to the fact that, as opposed to many somatic illnesses, a clear distinction between acute-medical and rehabilitative elements cannot be made in the treatment of mental disorders.

Systematic treatment recommendations in the form of guidelines could aid in determining the optimal treatment form for patients.

The current development of guidelines for mental disorders will thus be presented and analyzed in this article. Particular focus will be placed on rehabilitative aspects. The presentation and analysis will take place using the example of guidelines written for panic disorders. Based on a national and international investigation of guidelines (internet, databases) 11 guidelines for panic disorder (2 German guidelines, 9 from English spoken countries; target group of 9 guidelines: general practitioners; recommendations concerning diagnostics /assessment and treatment) were analysed. The results demonstrate a considerable need for development as rehabilitative elements are only marginally mentioned in the guidelines up to now. Of the 16 rehabilitative elements being investigated, only two ("psycho education" and "pharmacotherapy of chronic illness in the long-term perspective") are considered more than once in the guidelines. Seven elements (e.g. "salutogenic aspects of the therapy/ measures for the maintenance of quality of life", "methods of long-term guidance") are not mentioned at all. Based on the results of the analyses performed, conclusions for the further development of guidelines will be presented for discussion.


Die stationäre psychotherapeutische Versorgung von Patienten ist in der Bundesrepublik Deutschland vergleichsweise gut ausgebaut. Drei Versorgungssysteme (die psychosomatisch/psychotherapeutische Krankenhausversorgung, die psychiatrisch/psychotherapeutische Krankenhausversorgung sowie die Rehabilitation von Patienten mit psychischen Störungen) bestehen relativ unabhängig voneinander. Sie zeigen aber dennoch hinsichtlich verschiedener Kriterien große Überschneidungsbereiche, da sich bei der Behandlung von psychischen Störungen - anders als bei vielen somatischen Erkrankungen - eine klare Unterscheidung in akutmedizinische und rehabilitative Elemente nicht vornehmen lässt.

Systematische Behandlungsempfehlungen in Form von Leitlinien könnten dazu beitragen, die optimale Behandlungsform für Patienten zu bestimmen.

Im vorliegenden Artikel wird deshalb die gegenwärtige Entwicklung von Leitlinien für psychische Störungen dargestellt und analysiert, wobei ein besonderer Schwerpunkt auf der Berücksichtigung von rehabilitativen Aspekten liegt. Dieses erfolgt am Beispiel von Leitlinien zur Panikstörung. Auf der Grundlage einer nationalen und internationalen Recherche (mittels Internet und unter Verwendung verschiedener Datenbanken) wurden 11 Leitlinien zur Behandlung der Panikstörung (2 deutschsprachige, 9 englischsprachige Leitlinien; Zielgruppe von 9 Leitlinien: Hausärzte; ausgesprochene Empfehlungen hinsichtlich Diagnostik, Assessment und Behandlung) analysiert. Die Ergebnisse machen einen beträchtlichen Entwicklungsbedarf deutlich, insofern als rehabilitationsspezifische Elemente in den Leitlinien nur randständig Erwähnung finden. Von den 16 rehabilitationsspezifischen Elementen, hinsichtlich derer die Leitlinien untersucht wurden, fanden nur zwei („Psychoedukation" sowie „Pharmakotherapie chronischer Erkrankungen unter Langzeitperspektive") mehr als einmal in den untersuchten Leitlinien Erwähnung. Sieben Elemente (wie z.B. „salutogenetische Aspekte der Therapie/Maßnahmen zum Erhalt der Lebensqualität" werden gar nicht angeführt.

Aus den Ergebnissen der erfolgten Analysen werden Schlussfolgerungen für die weitere Entwicklung von Leitlinien zur Diskussion gestellt.

Inpatient treatment of patients with mental disorders

"Mental disorders are impairments of the normal capacity of human experience and behavior which result in emotional, cognitive, behavioral, interpersonal and/or physical disabilities" ([1], p.19). The individual often experiences them as conditions which cannot be influenced or which may only be influenced to a minimal degree. They may be accompanied by substantial suffering, and are even connected to a considerably increased risk of death [2]. Examples of mental disorders include depression, anxiety disorders, alcohol or drug dependency, and schizophrenia.

Various options for obtaining professional assistance are available for people with mental disorders in Germany. Treatment most frequently takes the form of pharmacotherapy and/or psychotherapy. An international comparison has shown that Germany not only has a particularly extensive system of outpatient treatment (therapy practices, acute walk-in wards, information centers), and partial-inpatient care (day clinics), but also extensive inpatient treatment (hospitals, clinics) [1]. The available treatment is distributed among three treatment systems that are relatively independent of one another: psychosomatic/psychotherapeutic hospital treatment ("acute psychosomatics"), psychiatric/psychotherapeutic hospital treatment and the rehabilitation of patients with mental/psychosomatic disorders.

A comparison of the treatment capacities provides the following picture: A total of 135,000 patients with mental disorders (including addiction illnesses) were treated in rehabilitation measures provided by the German statutory pension insurance organizations in the year 2001 [3]. An additional 23,220 patients were treated with psychosomatic/psychotherapeutic measures, and 638,538 patients were treated in the framework of psychiatric/psychotherapeutic hospital care [4]. In all three areas, pharmacotherapy measures and psychotherapeutic procedures were generally performed. In the rehabilitation measures and psychosomatic/psychotherapeutic hospital treatment, psychotherapeutic procedures represent the central treatment approach. For the area of psychiatry and psychotherapy we estimate that approximately 180,000 patients receive psychotherapeutic treatment or secondary measures [5]. Similarities and differences of the three inpatient treatment systems mentioned above are summarized in table 1 [Tab. 1].

Concerning the two most frequent diagnostic groups, the similarity between the treatment systems psychiatric/ psychotherapeutic hospital treatment and rehabilitation of patients with mental/psychosomatic disorders is visible.

The treatment of patients with mental disorders is characterized by high rates of comorbidity, by the complexity of the disorders' pathology and by a variety of problems resulting from the disorder as well as by many differing treatment approaches. The three areas overlap considerably in their spectrum of diagnosis. Affective disorders, disorders resulting from the use of psychotropic substances, and anxiety disorders represent the most frequent treatment indications within both the hospital treatment setting and rehabilitation measures. Various criteria applied in somatic medicine to separate rehabilitative treatment from hospital treatment, such as goals, date of treatment initiation, degree of the risk of personal injury, and the need for intensive medical monitoring, can only be applied to the setting of mental disorders to a limited degree [6], [7]: For example, measures such as the reintegration of mentally ill persons also form an essential component of hospital treatment, since many mental disorders are accompanied by a limitation of psychosocial functions. On the whole it is therefore hardly surprising, that a generally accepted solution to the issue of assigning various treatment settings is not yet available.

As opposed to curative medicine, the focus in rehabilitation is not placed primarily on the treatment of the cause of illness and the elimination of the resulting damage to a patient's health, but rather on the consequences of an illness or health impairment. Rehabilitation aims for an optimization of the adaptation to disorders and symptoms that are caused by the illness or the therapy [8]. In accordance with a theoretical model of rehabilitation, assistance with coping processes is at the center of the treatment [9]. Impairments to capacity and participation in social and occupational settings are important areas of focus with the treatment. It encompasses all measures by which a permanent disability can be avoided or at least reduced - for the sake of independent participation in all areas of life.

In order to meet the specific demands of rehabilitative diagnostics and therapy, a further classification system, the ICF (International Classification of Functioning, Disability and Health, WHO 2001) was developed as a supplement to the ICD-10 (International Classification of Diseases). Its predecessor is the International Classification of Impairments, Disabilities and Handicaps (ICIDH). The ICF is made up of four sub-classifications: physical function, physical structure, activities/participation, and environmental factors. It does not serve as a statistical classification of illnesses and related health problems, as does the ICD-10 classification system, but rather as a systematic classification of the results of illness with regard to functional capacity and disability in various areas of life (cf. Deutsches Institut für Medizinische

Dokumentation und Information (German Institute for Medical Documentation and Information) - DIMIDI, URL: Moreover, the ICF not only documents the disabilities that emerge as a result of illness, but also individual resources that are available to the patient.

The goal of current research is to implement the ICF and derivable, operationalized instruments into clinical practice. A specific compilation will be made of those categories of the ICF classification system ("core sets") that are characteristic for the functional restrictions seen in the defined illnesses [10].

As in other areas of medical treatment, the development of guidelines has also begun for the inpatient treatment of patients with mental disorders in recent years. These endeavors are found in all three of the above mentioned healthcare systems. They are in various stages of development and are progressing relatively independently from one another. Since guidelines are primarily oriented towards diagnoses and since the spectrum of diagnoses among the patients treated in these three treatment areas shows considerable overlap, coinciding developments are inevitable. If the development and implementation of guidelines within a treatment area contribute to the making of empirically based decisions by all persons involved in the treatment process, then the use of guidelines for the inpatient treatment of mental disorders could be a way to base controversial discussions about tasks and responsibilities (not presented here in depth) on more rational arguments.

In the following sections, the state of the development of guidelines for the treatment of patients with mental disorders will be characterized and current initiatives for the specific treatment area of rehabilitation will be presented. Furthermore, an initial approach to the creation of basic principles for the development of guidelines especially for the rehabilitation of patients with mental disorders will be introduced. Initial results from an exemplified analysis of 11 guidelines for panic disorders will follow, and conclusions for the further development of guidelines will be derived from this.

Guidelines for the treatment of patients with mental disorders

Definition and current developments

Guidelines can be defined as "written recommendations or systematically developed decision making aids for diagnosis and treatment (...), that are founded on epidemiological and scientific studies (evidence based) as well as expert knowledge (clinical experience)" ([11], p. 391, also cp. [12]) To exemplify a possible construction of a guideline, in the following the table of contents of the exemplary guideline edited by the American Psychiatric Association is given [Tab. 2].

In the treatment, guidelines can play an important, supportive role as "decision making pathways" for prevention, diagnosis, therapy, rehabilitation, and aftercare. Furthermore, they can contribute to explicit specifications for the treatment's setting and requirements through a processing of the available, empirical knowledge on the basis of consensual expert assessments. However, to a certain extent guidelines also reflect the characteristics of the particular health care system they are subjected to.

The development of medical guidelines in Germany is currently being coordinated by the Ärztliches Zentrum für Qualität in der Medizin (Physician Center for Quality in Medicine) - ÄZQ. The Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (Association of the Scientific Medical Societies) - AWMF in Germany performs a scientific advisory function. The ÄZQ is member of the Guideline International Network (GIN; so that international coordination and cooperation, e.g. harmonization of methodologies, can be fostered.

The development of guidelines takes place in a three-staged process: Guidelines of the lowest level of development ("S1") were prepared by a representative group of experts from the individual specialist societies and adopted in an informal consensus process. When the consensus process takes place in accordance with a predetermined procedure (nominal group process, consensus conference, delphi conference) rather than informally, then a preexisting guideline from level S1 is reassigned to the next higher development level of "S2". Guidelines with all components of a systematic development (logical structure of clinical algorithms, consensus, evidence base, decision analyses and outcome analyses) are at development level "S3" (cf. AWMF, URL:

The AWMF website currently offers a total of about 1600 scientifically founded medical guidelines in the German language, at various levels of development. Guidelines for the treatment of patients with mental disorders make up a small part of these at about 2%. These guidelines are drawn up by medical societies from the fields of "psychiatry, psychotherapy and neurology" as well as the field of "psychotherapy and psychosomatics". The participation of psychological societies is still small. The first field ("psychiatry, psychotherapy and neurology") has recently published updated guidelines for the treatment of anxiety disorders, eating disorders, affective illnesses, and dementia as well as two guidelines for the acute treatment of substance induced disorders. The latter two guidelines fulfill the criteria of development level 2, whereas the four first groups of guidelines meet the requirements of development level 1 of the AWMF's methodic recommendations. The second field ("psychotherapy and psychosomatics") has currently put forth guidelines for somatoform disorders, posttraumatic stress reactions, personality disorders, psychotherapy of depression, and factitious disorders. The first three of these groups of guidelines are at development level 2, the last one at development level 1. The remaining six groups of guidelines from this field do not primarily refer to the disorders diagnosed in chapter V (mental and behavioral disorders) of the ICD-10, but rather they refer for the most part to psychosocial aspects in the treatment of somatic illnesses.

This overview shows that numerous different initiatives for the development of guidelines can also be listed for the area of mental disorders. At the same time, it also makes clear the continuing need for development of further guidelines. As shown above, it is characteristic for the area of mental disorders that a clear distinction between acute medical care and rehabilitative treatment measures is hardly possible. The following section will therefore address the degree to which elements specific to rehabilitation are already accounted for in the corresponding guidelines.

According to present knowledge, there is no national guideline that has been specifically tailored to the rehabilitation setting in the area of mental disorders. As the existence of a specific and extensive (inpatient) system of rehabilitation is a distinctive feature of the German health care system, international guidelines do not state this issue explicitly either. National approaches to the development of guidelines for rehabilitation in general have arisen in recent years. In this context the project "System Guidelines for Psychosomatic Rehabilitation" under the initiative of the Deutsche Gesellschaft für klinische Psychotherapie und Psychosomatische Rehabilitation (German Society for Clinical Psychotherapy and Psychosomatic Rehabilitation) - DGPR [13], the guideline project of the Bundesversicherungsanstalt für Angestellte (German Federal Insurance Institute for Employees) - BfA and the Ärztliches Zentrum für Qualität in der Medizin (Physician Center for Quality in Medicine) - ÄZQ, as well as a specific task group appointed by the guideline commission of the Deutsche Gesellschaft für Rehabilitationswissenschaften (German Society for Rehabilitation Sciences) - DGRW are to be mentioned.

Specific characteristics must be considered in the development of guidelines for the rehabilitation of patients with mental disorders: The rehabilitative treatment of patients with mental disorders is multi-professional and interdisciplinary. Guidelines that are developed must therefore be valid for as many different treatment professions as possible, and address topics of as many different aspects of interdisciplinary cooperation as possible. Guidelines are evidence based by definition. A particular problem in the development of guidelines, however, can be seen in the fact that an expansion of rehabilitation-science oriented research has only begun in recent years. The fundamentals for evidence based recommendations are thus not yet available to the necessary extent in all subsections.

On the one hand this creates a need for the development of guidelines that are specifically oriented towards the rehabilitation of patients with mental disorders. On the other hand, it is also a source for difficulties in the development of such guidelines. One possible approach to such a development will be outlined in the following section. The primary procedure in this presentation will be to observe and evaluate existing guidelines. In addition to a general evaluation, emphasis will be placed on the appropriateness of the formulation of guidelines as well as on the rehabilitative aspects that are mentioned in the guidelines.

A scientific description and evaluation of guidelines requires defined criteria that are to be used in the evaluation. Two evaluation instruments will thus be introduced in the following section that each relate to both the stated general evaluation dimension as well as to the evaluation of rehabilitation specific elements. On the basis of these instruments, an exemplified analysis of guidelines will take place for a defined, described mental disorder, that of panic disorder.

General criteria for guideline evaluation

It is commonly accepted that the effectiveness of a guideline depends on its quality (e.g. [14], [15], [16]). Not all previously published guidelines have adhered to unified standards of quality in their development. The clearinghouse established by the ÄZQ enables the development and application of standards, which are unified both in regard to their creation as well as to their use in the evaluation of guidelines.

In order to describe and evaluate guidelines with specific regard to the treatment of patients with mental disorders, an instrument is needed with which the appropriateness of the guidelines - i.e. their formal, content oriented and methodic aspects - can be assessed. In order to specify individual categories of this instrument, the authors have given great detail to establishing which categories are necessary for the description and evaluation of guidelines for mental disorders. The checklist for the generic evaluation of guidelines published by the ÄZQ [17] - which is an adaption of the "Criteria for the Appraisal for National Guidelines" of the Scottish Intercollegiate Guidelines Network [18] - provided a basis of orientation. The formal aspects in particular could be adopted in large part from the ÄZQ checklist - in a somewhat modified form. In order to create an economical instrument for the evaluation of the quality of guidelines for treating mental disorders, first analyses served as the basis for an abridged form that includes those criteria, which are theoretically the most significant and display the greatest variance. The criteria for the abridged version are listed in Table 3 [Tab. 3]. The following example analysis refers to this abridged version of the instrument.

Rehabilitation specific criteria for guideline evaluation

The second focus of analysis is on those aspects of the selected guidelines that are specific to setting, and here in particular those specific to rehabilitation. The ÄZQ checklist for the assessment of the appropriateness of guidelines includes very few criteria for the evaluation of aspects that are potentially specific to rehabilitation. This corresponds, however, to the limited amount of attention given to rehabilitative content in the guidelines published by the AWMF to date: Less than 1% includes information concerning rehabilitative treatment elements [19].

As with the generic evaluation of guidelines, the analysis of guidelines with regard to their rehabilitation specific elements requires the compilation of appropriate criteria. A possible approach to the development of rehabilitation specific aspects and content in guidelines can be found in the Guideline Clearing Report for Depression published by the ÄZQ. Clearing reports by the ÄZQ serve to improve the quality of guidelines. In addition to the formal, content oriented and methodic evaluation of guidelines that have been researched for the treatment of defined disorders, they include recommendations for future guidelines based on the analysis of previous guidelines [20]. The Guideline Clearing Report for Depression contains a collection of rehabilitation specific criteria that the authors have determined guidelines should address. The terminology of the Clearing Report is strongly aligned with the one used in the ICF. Fifteen of these criteria were selected for the first example of an analysis of guidelines for the treatment of panic disorders [Tab. 4].

In the following section, an exemplified analysis of selected guidelines for the treatment of a defined disorder (panic disorder) will be performed with regard to formal, content oriented, methodic, and setting specific aspects. These analyses will be performed using the above mentioned criteria catalogs for appropriateness and setting specific orientation.

Example of an analysis of guidelines for panic disorder with regard to generic and setting specific elements

Currently, the following five diagnostic groups (based on the ICD-10) are those most frequently treated in inpatient rehabilitation of patients with mental/psychosomatic disorders: depressive disorders (F32-34.1), anxiety disorders (F40-41), reaction to severe stress and adjustment disorders (F43), somatoform disorders (F45) and personality disorders (F60-61) [21]. A national and international investigation of guidelines for these disorders leads to the identification of more than 100 guidelines [Tab. 5]. It is evident that the number of guidelines available for the treatment of these mental illnesses clearly varies depending on the given disorder: Guidelines for depressive disorders are by far the most frequent; the number of guidelines for reaction to severe stress and adjustment disorders, on the other hand, is comparatively low.

The exemplified analysis described in the following passage was performed with guidelines for panic disorders (F41.0). The selection of this well described disorder from the group of anxiety disorders was made, firstly, since an initial investigation showed that a sufficient number of guidelines for this disorder were available (11 of the 14 identified guidelines were available for analysis; 3 were excluded because they were identical to the guideline published by the American Psychiatric Association - APA). Furthermore, they had not yet been the objects of other research according to the current state of knowledge. The individual guidelines are presented in Table 6 [Tab. 6] together with the institutions or organizations that developed them.

The selected guidelines for panic disorders were examined with reference to the rehabilitation of patients with mental/psychosomatic disorders. As mentioned in the section "Rehabilitation specific criteria for guideline evaluation", this was done with regard to their appropriateness as well as the relevance of their content. The basis for this example analysis was the abridged version of the generic catalog (as described in Table 3 [Tab. 3]) and the rehabilitation specific criteria catalog. Table 7 [Tab. 7] presents the most important results of the generic analyses.

It can be seen in Table 7 [Tab. 7] that the guidelines evaluated are primarily English texts that were published by psychiatric or other medical organizations. The majority of the target group consists of general practitioners or other professionals active in primary care. With regard to the therapy recommendations made in the individual guidelines, it can be seen that the documented evidence provided in the pharmacological recommendations is more precise and detailed than that of the psychotherapeutic recommendations. Data concerning consensus processes were given in less than half of the examined guidelines. In some of the guidelines, however, it is mentioned that the detailed description of the consensus procedure is available in the unabridged version of the reference guide.

The analysis of the guidelines for panic disorders with regard to rehabilitation specific elements shows firstly, that the categories selected for an evaluation in this first analysis are in general fundamentally appropriate and applicable. However, it also becomes clear that about half of the categories could be only chosen once, and that, with the exception of two categories, corresponding aspects were only found for each of these categories in one guideline. The guidelines of the American Psychiatric Association - APA and the New Zealand Guidelines Group - NZGG are to be highlighted here, since they contain information concerning a larger number of the categories. The categories "epidemiology of the course of chronic illnesses", "differential diagnosis of the course of chronic illnesses", "diagnosis of a lack of functioning, activity or social participation", "description of limitations to functional capacity in conjunction with the illness", "psychotherapy of chronic illnesses in the long-term perspective", as well as "description of an intensive therapy in chronic illnesses" are each addressed in one of the 11 examined guidelines. The categories "classification of types of long-term courses of illness", "conditions, form and effects of activity and social participation disorders", "criteria for occupational incapacity and impairment of functional capacity", "prognosis for gainful employment", "methods of long-term guidance", "integration of acute treatment and rehabilitation care and inpatient, partial inpatient and outpatient rehabilitation", and the criterion of the "salutogenic aspects of the therapy and measures for the maintenance of quality of life" are, on the other hand, not mentioned in the guidelines examined.

In comparison to this, the categories "psycho education" and "pharmacotherapy of chronic illness in the long-term perspective" are more frequently present in the guidelines examined. They are mentioned in three and four guideline groups, respectively. The recommendations for education in the framework of intervention are formulated very generally or integrated into cited behavioral therapy treatment recommendations. The recommendations for the psychotherapy and pharmacotherapy of chronic illnesses in the long-term perspective are not very precise and are formulated in very vague fashion.

These results of the analysis on guidelines for panic disorders with regard to rehabilitation specific aspects are in alignment with those that are described in the above mentioned Guideline Clearing Report for Depression ([20], cf. The authors of the clearing report consider it to be problematic that essential rehabilitation aspects were not mentioned or were only given marginal consideration in the guidelines for depression that they analyzed. Moreover, they suggest that the focus of the treatment recommendations most frequently lies in acute treatment and not in the treatment of chronic illnesses. They suggest that this is also the case for the base of evidence provided for the individual recommendations, which is significantly more extensive and precise for the acute treatment setting.

Summary and conclusions

In the treatment of mental disorders, and as opposed to many somatic illnesses, a clear distinction between acute medical and rehabilitative elements cannot be made. At the same time, national health care analyses show that a substantial number of patients is treated in the inpatient setting not only in the hospital care system, but also in the area of medical rehabilitation, resulting in a significant overlap of the diagnostic spectrum.

With regard to the existing overlap in the three inpatient health care sectors, the establishment of guidelines could contribute to the clearing of the individual areas of responsibility.

Guidelines present a path of decision making for those providing treatment, as well as for the patients, by offering evidence-based treatment recommendations.

These points lead to the conclusion that it may be sensible to examine 1) which guidelines of which quality are already available for the treatment of patients with mental disorders and 2) to what degree do these guidelines address elements specific to rehabilitation.

It is necessary to be able to use appropriate criteria catalogs in an evaluation of these two questions.

A criteria catalog was thus created for the evaluation of generic aspects, closely based on the checklist of the ÄZQ.

The ascertainment of rehabilitation specific aspects took place on the basis of criteria from a clearing report published by the ÄZQ.

An initial example analysis of guidelines for panic disorders shows that an evaluation of these guidelines by means of the catalog used is fundamentally possible. Moreover, it also becomes clear that a considerable need for development still exists with regard to addressing the content of the examined aspects specific to rehabilitation.

The examination of whether this estimation is only valid for the example of guidelines for panic disorders examined here, or whether they are valid in general for guidelines that concern the most frequently treated diagnoses in patients with mental disorders is still incomplete. However, results of the German Clearing Report Depression [22] and own further analyses of guidelines for somatoform disorders [23] are in line with the findings and (preliminary) conclusions presented here.

Subject to the results of this examination, we consider the following two points to be necessary:

First, making the rehabilitation specific criteria more precise through the inclusion of consensus guided expert assessment must be a continual process. For this process, it is important to get involved experts of the three inpatient health care sectors.

Besides a generic specification of rehabilitative elements as pursuit at the moment it also seems to be relevant to differentiate these elements for specific diagnostic groups. Current research [24] aiming to define limitations to functional capacity in the context of specific disorders on the basis of the ICF could be very helpful for such developments.

Second, the evidence based fundament must be further expanded and more strongly considered in the development of guidelines. The results of our analysis indicate that in the guidelines, recommendations specific for rehabilitative diagnostics/ treatments - if mentioned at all - are often formulated very generally and without an evidence based reference. Therefore more extensive empirical research strategies seem to be necessary for these aspects, especially designs linking defined clinical situations (with patients with specific clinical characteristics) and rehabilitative treatment elements to treatment outcome. This increase of empirical knowledge could serve then as a basis for the optimization of current guidelines in respect to rehabilitative treatment elements for patients with mental disorders.


The presented data is collected within the framework of the project "Conditions and strategies for the development of guidelines for the rehabilitation of patients with psychiatric and psychosomatic disorders" financed by the Verband Deutscher Rentenversicherungsträger (Federation of German Pension Insurance Institutes) - VDR.


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