Passionate about our services Social and Rehabilitation Psychiatry Richard Laugharne Peninsula...

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Social and Rehabilitation Psychiatry

Richard LaugharnePeninsula MRCPsych Course 2013

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Truth about dangerous mental patients let out to

kill•http://www.telegraph.co.uk/news/uknews/crime/10358251/Truth-about-dangerous-mental-patients-let-out-to-kill.html by Andrew Gilligan 9:00PM BST 05 Oct 2013

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Tyrer 2013“society alternates between embracing community psychiatry as an inclusive and positive way of treating the mentally ill, and an exclusive psychiatry at other times, when those with mental illness are perceived as dangerous….and detained in institutions”

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History of psychiatric services Moral treatment Asylums: the invention of the psychiatrist Outpatients and voluntary care Day hospitals, deinstitutionalisation and resettlement Community care and ‘recovery’ Specialist teams: Assertive Outreach, EIT, HTT Reinstitutionalisation Community treatment orders DISCUSS ASYLUMS

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The asylum eraWhat happened to the mentally ill before the

asylum era?Moral treatment: Pinel, TukeTwo eras of asylum building in 1830s and 1880sPositive aspectsNegative aspects recognised early

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Problems with asylumsOvercrowdingLoss of individuality: GoffmanNeglectStigmatisationOutpatients 1890sVoluntary patients 1930s

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New developments in 20th century

Adolf Meyer: knowledge of patient as an individual, more to assessment than diagnosis

Therapeutic communities in WW2Day hospitalsCommunity mental health teams

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The Three Hospitals StudyThree large asylums with different care regimesClinical and social functioning differed and

closely associated with these regimesIn schizophrenia, the course of the disorder is

affected by the social environment(Wing and Brown 1961)

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DeinstitutionalisationPsychiatric inpatients one third in 1990

compared to 1950International phenomenon‘Unholy alliance between therapeutic liberals

and fiscal conservatives’Less ill patients first

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TAPS Study

Leff 1997Patients in two large London asylumsBaseline clinical and social functioning‘Stayers’ and ‘leavers’5 years follow up

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TAPS outcomesFew patients admitted permanentlyMany had repeated short acute admissionsNearly all preferred being out in the

communityAlmost none vagrant or lost to FUSmall number need institutional care

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StigmaAsylums – out of sight, out of mindPoor understanding – fantasies and mythsMedia distortionFears of violence: increased risk, little change

since 1950Taylor and Gunn 1999

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Combating StigmaUnderstand illnessesUnderstand treatmentsSeeing individualsGiving a voice to mentally illSocial inclusion

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Definitions of severe mental illnessSeparation between ‘severe mental illness’ and

‘common mental disorders’Reflects previous divisions between ‘psychosis’ and

‘neurosis’ etc.Not well defined and a cause of controversy e.g.

severe OCD, severe depression, severe BPDReflects commitment (Burns 2004)

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The three DsDiagnosis: psychotic illness, major affective

disorderDuration: at least two yearsDisability: inability to work or fulfil a major

role e.g. parent• Bachrach 1988

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Service Delivery

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Recent history 1954-1990s: deinstitutionalisation and the birth of community

teams (antipsychiatry) 1959 MHA to protect the public from psychiatrists 1990s: the service user movement and evidence based

medicine 2000s: specialist community teams 2000s: recovery movement 2008: community treatment orders 2013: beds down, detentions up, forensic beds up

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Evaluating servicesEFFECTIVENESSEFFICIENCYEQUITYACCEPTABILITYACCESSIBILITYAPPROPRIATENESS

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Service delivery in the 21st century Recovery Community mental health teams Assertive outreach teams Early intervention teams Home treatment teams/ crisis intervention Community Treatment Orders Employment

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RecoveryA philosophy rather than a treatment

programmeHow to live well with persistent illnessKindness, compassion, respect and hope of

recoveryNot that different to TukeUser led and doctor led

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RecoveryNarrative and evidence basedInternational Study of Schizophrenia (Harrison

2001)More than half have favourable outcomes at

15 and 25 yearsLate recovery effectDeveloping vs developed world

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Recovery The expert patientHope and optimismSelf help, collaboration with sufferers, self

relianceRoberts and Wolfson 2004, Advances in

Psychiatric Treatment, 10,37-49

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Assertive OutreachSmall caseloads – about 10 patientsVisit at least twice weeklyAssertive follow upTreat at homeEmphasis on engagementEmphasis on medicationDeliver on health and social care needsSupport carers

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Key papers in Assertive Outreach Stein and Test 1980

More effective than standard care in US UK700 1999

See paper by Tom Burns, Lancet, 1999 Killaspy 2008

WHY?

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Other teams

Early intervention teams– Discuss the ‘for and against’

Home treatment teams/ crisis teamsCommunity mental health teamsDebate: what makes a service last?

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Employment SMI: 18% in employment in 2000 90% would like to work Barriers: – High rate of unemployment– Benefits trap– Stigma– Low expectations of professionals– Lack of evidence base– Illness vs. disability model

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Employment Work schemes – very differentSupported employmentPrevocational trainingLook at paper on IPS 2009Look at paper on why IPS not implemented

2013

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Issues today and tomorrow Specialists vs. generalists Functionalisation vs. integration Physical health of patients with a psychosis Employment How do we measure outcomes and quality? BRAINSTORM Stepped care, equitable services and rationing Self management and using technology Therapeutic relationships and ‘effective interventions’: industrialised

health care Treatment and care: the difference

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Developing world

Why do patients with psychosis do better?Urbanisation