models of community provision andrew cole consultant psychiatrist
TRANSCRIPT
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
– 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
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
Scandals and Reforms
Parliamentary Report 1815 James Norris At Bethlem Hospital in an Iron Harness
for 10 years
Scandals and Reforms
“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
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”
– "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
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
What was the answer? 1970s-90s
DGH Units Community Psychiatry Sector Psychiatry CPA
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?
Community Psychiatry
Principles & practices needed to provide mental health services for a local population by:1. Establishing population-based needs2. Providing a service system: wide
range, adequate capacity, accessible locations.
3. Delivering evidence-based treatments
Level 1: The CommunityAll 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
Goldberg & Huxley 1992
Sector Psychiatry 1992
“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
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
Care Programme Approach
1991 Virginia Bottomley Minister for Health - response to “failures”
Key Worker Assessment Care Plan Initially for people with SMI
What’s in a Name?
CPA Care Coordination Case Management Care management Brokerage Model Key Worker Model
Infamous Cases:
Christopher Clunis 1992 Ben Silcock 1993 Georgina Robinson 1993
CPA for all patients Supervision Register Supervised Discharge
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.
Community Psychiatry and a Bad Press Violence? Prison? Homelessness?
End of Part One!
1999 National Service Framework
Standard 1 Mental health promotionStandards 2,3 Primary care/access to
servicesStandards 4,5 Effective services for
SMIStandard 6 Caring about carersStandard 7 Preventing suicide
NSF Teams
CAT AOT EIP
Crisis Teams: Essential Elements? Single Point of Access 24hr 7 days MDT Trained (esp. in Risk Assessment) Able to provide Home Based Treatment
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.
Cochrane Review (Joy CB et al 2004)
No Change• Deaths; Mental state
ed• Hospital admission (NNT = 11 using 3 RCTs)• Family burden (NNT = 3 using 1 RCT)• Cost
ed• Contact with services and Satisfaction
CATS among the Pigeons….
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%
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….
0
20
40
60
80
100
120
140
1 - 7 days 8 - 30 days 31 - 90 days 91 + days
lenght of admission
2000 2001 2002 2003 2004
What do you think?
For: 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
Key Paper:
Stein & Test 1980 “Alternative to Mental Hospital Treatment”
Stein & Test Key Features
Assertive Engagement
Treatment in Community
Low caseloads 12-15
Continuity of care across time and place
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
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
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!
What do you think?
For: Against:
EIP Teams: Key Elements?
Key Paper:Early Intervention in SchizophreniaBirchwood et al 1997 BJP Early Detection of at risk mental states Early Treatment of first psychotic
episode Target interventions at “Critical Period”
Illness Duration
Pre-morbidAt-Risk Phase Psychosis Remission
DUP
Start RxOnset Positive SymptomsFunctional
Decline
First Rx
Illness Onset Episode Onset
(Prodrome)
DUI (Illness)
Pre Psychotic Phase:“At Risk period” 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
Explanations of DUP effect?
Psychosis is “toxic”– Developmental– Social– Relationships (EE)– Psychiatric
But causality not proven
Early Detection
Training for Primary Care– 75% of cases contacted GP in critical
period Public Education Responsive Service
– 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!!
Early Treatment
“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
Dosage in 1st 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
Traditional Intervention
Multiple health agencies contacted before person finally engaged
80% are hospitalised– 50-60% admitted under MHA– Long lengths of stay in hospital
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
EPPIC– ~2 fold in detection rates
– < 50% of people admitted– Suicide rate from 4% 0.4%
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?
For: 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
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.
New Ways of Working
Functional Teams More specialist consultant roles Distributed responsibility
An end to “Spectrum Psychiatry”
PROs CONs
Leadership Mutual support Defined
responsibility Focus CPD Focus on quality
More sustainable? Recruitment?
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
Can we get away from Asylum thinking all together? Stigma Early intervention Recovery Employment
The End
Thank You