Models of Community Provision

1. Models of Community Provision Andrew Cole Consultant Psychiatrist

2. 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.

3. My Aims: • Key concepts & people • Important papers/chapters • Perspective • Anecdotes

4. “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

5. 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

6. Scandals and Reforms • Parliamentary Report 1815 • James Norris • At Bethlem Hospital in an Iron Harness for 10 years

7. 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

8. But… • Iron replaced by fabric “Straitjackets” • Asylums became overcrowded • Moral Treatment replaced by Custodial Care

9. The Effect of Asylums • On public understanding of mental illness? • Stigma? • Recovery? • 1890 Lunacy Act restricted discharge... Why?

10. CPZ 1952 Deinstitutionalisation

11. Was it just Chlorpromazine then? • Scandals • Institutional Neurosis • WWII • NHS • ECT and Insulin Coma, Leucotomy • Antipsychiatry • Cost Cutting?

12. 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."

13. The Antipsychiatry Movement • R.D Laing • “The divided self” • Schizophrenia as intelligible • “The politics of experience” • Schizophrenia as revelation

14. 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

15. 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

16. What Carers need: • Information • Rapid accessible crisis services • Practical Support • Benefit Advice • Respite Care

17. But… • Services outside St Nick’s in 1970-80s • Consultant OP clinics • DVs • CPNs

18. What was the answer? 1970s-90s • DGH Units • Community Psychiatry • Sector Psychiatry • CPA

19. 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?

20. Community Psychiatry Principles & practices needed to provide mental health services for a local population by: • Establishing population-based needs • Providing a service system: wide range, adequate capacity, accessible locations. • Delivering evidence-based treatments

21. Goldberg & Huxley 1992

22. Sector Psychiatry 1992 • “Spectrum Psychiatry” • Crisis Response • Assertive Outreach • Community Care for SMI • Inpatients • Partial Hospitalisation • Primary Care Liaison

23. Problems for Sector Psychiatry • CMHTs and the “worried well” • New Long Stay • Political influences - CPA

24. 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

25. Care Programme Approach • 1991 Virginia Bottomley Minister for Health - response to “failures” • Key Worker • Assessment • Care Plan • Initially for people with SMI

26. What’s in a Name? • CPA • Care Coordination • Case Management • Care management • Brokerage Model • Key Worker Model

27. Infamous Cases: • Christopher Clunis 1992 • Ben Silcock 1993 • Georgina Robinson 1993 • CPA for all patients • Supervision Register • Supervised Discharge

28. 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.

29. Community Psychiatry and a Bad Press • Violence? • Prison? • Homelessness?

30. End of Part One!

31. 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

32. NSF Teams • CAT • AOT • EIP

33. Crisis Teams: Essential Elements? • Single Point of Access • 24hr 7 days • MDT • Trained (esp. in Risk Assessment) • Able to provide Home Based Treatment

34. 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.

35. 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

36. 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

37. CATS among the Pigeons….

38. For: Against: What do you think?

39. 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

40. Key Paper: • Stein & Test 1980 “Alternative to Mental Hospital Treatment”

41. 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 Stein & Test Key Features

42. Patient Selection for AOT (Burns) • Psychotic Illness • Fluctuating • Poor Adherence/Engagement • Relapse would have serious consequences • 0.3-2 /1000/ year

43. 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

44. 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!

45. For: Against: What do you think?

46. EIP Teams: Key Elements?

47. 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”

48. Illness Duration Illness Onset Episode Onset Start Rx Onset Positive Symptoms Functional Decline Pre-morbid At-Risk Phase Psychosis First Rx Remission (Prodrome) DUP DUI (Illness)

49. 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

50. DUP