Transcript Models of Community Provision

Models of Community
Provision
Andrew Cole
Consultant Psychiatrist
Why do you need this lecture?

Royal College Curriculum:
– History of Psychiatry
– Epidemiology
– Sociology of Institutions
– Setting up Community Services

Royal College Competencies:
– Contribute to the development and delivery
of services
– Work with others to assess and manage
adults with mental health problems.
My Aims:
Key concepts & people
 Important papers/chapters
 Perspective
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– Anecdotes
“Did Shakespeare know
Schizophrenia? The case of Poor
Mad Tom in King Lear.”
BJP 1985
16th Century essentially no care for the
mentally ill
 1744 Vagrancy Act “Lunatics and
Paupers”
 Private “Madhouses” in 18th Century
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Political and Social Influences
Philippe Pinel 1793 French Revolution
Paris
 William Tuke: The Retreat 1792
 “Moral Treatment”
 John Conolly 1850s
 “Non-Restraint Movement”
 1845 Lunatics Act: Asylum Building
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Scandals and Reforms
Parliamentary Report 1815
 James Norris
 At Bethlem Hospital in an Iron Harness
for 10 years
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Scandals and Reforms
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“The light has been let into Bethlem: it
gives light of the flowers on the wards:
it sets the birds singing in their
aviaries: it brightens up the pictures on
the walls...The star of Bethlem shines
out at last"
Charles Dickens 1850s
But…
Iron replaced by fabric “Straitjackets”
 Asylums became overcrowded
 Moral Treatment replaced by Custodial
Care
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The Effect of Asylums
On public understanding of mental
illness?
 Stigma?
 Recovery?
 1890 Lunacy Act restricted discharge...
Why?

Deinstitutionalisation
CPZ 1952
Was it just Chlorpromazine then?
Scandals
 Institutional Neurosis
 WWII
 NHS
 ECT and Insulin Coma, Leucotomy
 Antipsychiatry
 Cost Cutting?

Erving Goffman
“Asylums” 1960s
 “Total Institution”
 “Institutionalization”
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– "Society is an insane asylum run by the
inmates."
– "Stigma is a process by which the reaction
of others spoils normal identity."
The Antipsychiatry Movement

R.D Laing
 “The divided self”
– Schizophrenia as
intelligible

“The politics of
experience”
– Schizophrenia as
revelation
1986: St Nicholas Hospital Gosforth
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Newcastle Asylum from1860s
Enclosing Wall
Gates had gone by order of Enoch Powell
Farm was defunct
Cricket and Football pitch
Physician Superintendent’s house
Church
...which conveniently burnt down
What Users need outside a total
institution:
Housing with enough support
 Enough Money
 Meaningful Activity
 Support of Carers, friends, services
 Relief from suffering
 Effective Treatments

What Carers need:
Information
 Rapid accessible crisis services
 Practical Support
 Benefit Advice
 Respite Care

But…
Services outside St Nick’s in 1970-80s
 Consultant OP clinics
 DVs
 CPNs
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What was the answer? 1970s-90s
DGH Units
 Community Psychiatry
 Sector Psychiatry
 CPA
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DGH Psychiatric Units
Lunatic Ward at Guy’s Hospital London
1728
 1930 Mental Treatment Act allowed
informal patients
 1959 MHA
 1961 Water Tower Speech Enoch
Powell
 Pros and Cons?
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Community Psychiatry
Principles & practices needed to provide
mental health services for a local
population by:
1. Establishing population-based needs
2. Providing a service system: wide
range, adequate capacity, accessible
locations.
3. Delivering evidence-based
treatments
Goldberg & Huxley 1992
 Level 1: The Community
All adults with an episode of mental disorder in last 1 year = 260-315/1000/year
----------------------------First Filter: Illness Behaviour-------------------------------------------------
 Level 2: Primary Care Attenders (Total)
All adults with an episode of mental disorder in last 1 year and seek help from a
primary care physician = 230/1000/year
----------------------------Second Filter: Ability to detect disorder------------------------------------
 Level 3: Primary Care Attenders (Detected Conspicuous Psychiatric
Morbidity)
All adults considered mental disordered by primary care physician in last 1 year =
101.5/1000/year
----------------------------Third Filter: Referral to MH services----------------------------------------
 Level 4: Mental Illness Services (Total)
All adults treated by mental illness services in last 1 year = 23.5/1000/year
----------------------------Fourth Filter: Admission to psychiatric beds------------------------------
 Level 5: Mental Illness Services (Hospitalised)
= 5.71/1000/year
Goldberg & Huxley 1992
Sector Psychiatry 1992
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“Spectrum Psychiatry”
– Crisis Response
– Assertive Outreach
– Community Care for SMI
– Inpatients
– Partial Hospitalisation
– Primary Care Liaison
Problems for Sector Psychiatry
CMHTs and the “worried well”
 New Long Stay
 Political influences - CPA
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New Long Stay
Lelliott & Wing 1994 BJP
 6 month – 3 year admissions
 18-64 yr old
 1.3 per lakh per year
 Young men with schizophrenia
 Older women with affective and physical
illness
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Care Programme Approach
1991 Virginia Bottomley Minister for
Health - response to “failures”
 Key Worker
 Assessment
 Care Plan
 Initially for people with SMI
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What’s in a Name?
CPA
 Care Coordination
 Case Management
 Care management
 Brokerage Model
 Key Worker Model
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Infamous Cases:
Christopher Clunis 1992
 Ben Silcock 1993
 Georgina Robinson 1993
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CPA for all patients
 Supervision Register
 Supervised Discharge
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Newspaper quotes:
 Why aren't people such as Ben Silcock
in hospital?
 To some extent it hinges on the clout of
individual doctors, haggling with fellow
health or social services professionals
on a patient's behalf.
 Probably under 7 per cent of
schizophrenics are cared for
permanently in hospital.
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Community Psychiatry and a Bad
Press
Violence?
 Prison?
 Homelessness?
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End of Part One!
1999 National Service
Framework
Standard 1
Mental health promotion
Standards 2,3 Primary care/access to
services
Standards 4,5 Effective services for SMI
Standard 6
Caring about carers
Standard 7
Preventing suicide
NSF Teams
CAT
 AOT
 EIP
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Crisis Teams: Essential
Elements?
Single Point of Access
 24hr 7 days
 MDT
 Trained (esp. in Risk Assessment)
 Able to provide Home Based Treatment
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Key Paper:
Hoult J, Reynolds I, et al (1983).
Psychiatric hospitalisation vs community
treatment; the results of a randomised
controlled trial. Aust NZ J Psychiatry 17:
160-167
 Melbourne, Australia.
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Cochrane Review (Joy CB et al
2004)
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No Change
• Deaths; Mental state
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ed
• Hospital admission (NNT = 11 using 3 RCTs)
• Family burden (NNT = 3 using 1 RCT)
• Cost
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ed
• Contact with services and Satisfaction
CATS among the Pigeons….
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Introduction of CATS
– ed admission rate by 45%
• esp. in younger adults and non psychotic
disorders
– Length of stay ed (36-61%)
– Bed occupancy was ed by ~20%
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No change in mortality from suicide and injury
 Number of detentions under S. 2 & 3 ed,
whilst detentions under S. 5(2) & 5(4) ed
CATS among the Pigeons….
What do you think?
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For:
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Against:
Assertive Outreach Teams:
Essential elements?
Difficult to engage clients
 So work on clients turf and on their
priorities
 “In Vivo” approach
 Team approach
 Extended hours
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Key Paper:

Stein & Test 1980 “Alternative to Mental
Hospital Treatment”
Stein & Test Key Features
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Assertive
Engagement
 Treatment in
Community
 Low caseloads 1215
 Continuity of care
across time and
place
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Key Worker
 Care Plan
 One team
responsible for
health & Social care
 Primary goal is
improved function
Patient Selection for AOT
(Burns)
Psychotic Illness
 Fluctuating
 Poor Adherence/Engagement
 Relapse would have serious
consequences
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0.3-2 /1000/ year
The REACT study: randomised evaluation of
assertive community treatment in north London
Helen Killaspy, Paul Bebbington, et al BMJ APR 2006
No  in bed use
 No  in cost or  in cost effectiveness
 No  in outcome
 BUT  engagement
 AND  satisfaction
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Why doesn’t Does AOT work in
the UK? (Burns)
Fidelity to the model?
 The control condition?
 Its not that AOTs are unfaithful to the
Stein model, but that CMHTs are
already too faithful!
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What do you think?
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For:
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Against:
EIP Teams: Key Elements?
Key Paper:Early Intervention in
Schizophrenia
Birchwood et al 1997 BJP
Early Detection of at risk mental states
 Early Treatment of first psychotic
episode
 Target interventions at “Critical Period”
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Onset Positive
Functional
Symptoms
Decline
Pre-morbid
At-Risk Phase
Start Rx
Psychosis
(Prodrome)
DUP
Illness Onset
Episode Onset
Illness Duration
DUI (Illness)
First Rx
Remission
Pre Psychotic Phase:
“At Risk period”
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High prevalence of depression
Subjective and objective cognitive deficits
High prevalence of substance misuse
Onset of social stagnation and decline
So, early interventions are justified
DUP
Why Worry about DUP?
Johnstone et al 1986
 DUP > 1yr
 Relapse rate x3 over next 2 years
 Loebel et al 1992
 DUP predicts  time to remission
 DUP predicts  extent of remission
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Explanations of DUP effect?
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Psychosis is “toxic”
– Developmental
– Social
– Relationships (EE)
– Psychiatric
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But causality not proven
Early Detection
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Training for Primary Care
– 75% of cases contacted GP in critical
period
Public Education
 Responsive Service
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– Old style services didn’t treat Critical
Period
“Drug Induced Psychosis”?
Hallucinogen Intoxication- 24hrs
 Cannabis intoxication alone doesn’t
cause psychosis
 “late prodromal stage” brief psychotic
episodes
 I have made this mistake several times!!
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Early Treatment
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“Start Low Go Slow”
– 0.5-1 mg of Risperidone, increasing by 1
mg/week according to response
To minimise adverse effect
 Aim for antipsychotic but not sedative
effect
 Use Benzos if need sedation
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Dosage in
st
1
Episode Psychosis
 50% of 36 responded to 2 mg Haloperidol
 Lieberman et al 2000
 Only 4% of 136 required > 6 mg of Haloperidol
 Zipursky et al 1999
 2 mg Haloperidol gives 80% D2 occupancy
Kapur et al 1998
Targeted Interventions
NOT just medication:
 CBT
 Family education
 Employment/Education
 Substance Misuse
 Prevent Social Decline
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Traditional Intervention
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Multiple health agencies contacted before
person finally engaged
 80% are hospitalised
– 50-60% admitted under MHA
– Long lengths of stay in hospital
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High drop-out with community follow-up
Concentration on treating positive symptoms
Neglect of psychological and functional
recovery
Co-morbidity (e.g. depression, drug use)
overlooked
Limited attention to needs of Carers
Outcomes with Specific EIP Strategies
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EPPIC
– ~2 fold  in detection rates
– < 50% of people admitted
– Suicide rate  from 4%  0.4%
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Birmingham
– 100% contact with all clients
– ~80% in education, training or employment
–  Relapse rate 8-20% (normally 50% in 2
years)
– No suicides
What do you think?
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For:
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Against:
Other Developments
Supervised Community Treatment
 New ways of working
 Physical Health Monitoring
 New mental health strategy and NHS
reform
 New patient groups: ADHD, ASD, LD,
PD
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Supervised Community Treatment
Section 17A of MHA amended 2007
 Power of recall
 If “there would be a risk of harm to their
health or safety or to other people..”
 Conditions are not directly enforceable
but non compliance “taken into account”
when deciding need to recall.
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New Ways of Working
Functional Teams
 More specialist consultant roles
 Distributed responsibility
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An end to “Spectrum Psychiatry”
PROs
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Leadership
Mutual support
Defined
responsibility
Focus CPD
Focus on quality
More sustainable?
 Recruitment?
CONs
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Interfaces
 Lack of continuity?
 Overspecialisation?
 Less professional?
Conclusion: We may have replaced
all the functions of the Asylum in the
Community?
Supported housing
 NSF teams and treatments
 CPA
 SCT
 Physical Health Monitoring
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Can we get away from Asylum
thinking all together?
Stigma
 Early intervention
 Recovery
 Employment
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The End
Thank You