Models of Community Provision

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Models of Community Provision

• Andrew Cole
• Consultant Psychiatrist

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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.

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My Aims

• Key concepts people
• Important papers/chapters
• Perspective
• Anecdotes

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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

• 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

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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?

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Deinstitutionalisation
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Was it just Chlorpromazine then?

• Scandals
• Institutional Neurosis
• WWII
• NHS
• ECT and Insulin Coma, Leucotomy
• Antipsychiatry
• Cost Cutting?

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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."

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The Antipsychiatry Movement

• R.D Laing
• The divided self
• Schizophrenia as intelligible
• The politics of experience
• Schizophrenia as revelation

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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 Superintendents house
• Church
• ...which conveniently burnt down

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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

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What Carers need

• Information
• Rapid accessible crisis services
• Practical Support
• Benefit Advice
• Respite Care

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But

• Services outside St Nicks 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 Guys 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
• Establishing population-based needs
• Providing a service system wide range, adequate
  capacity, accessible locations.
• Delivering evidence-based treatments

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Goldberg Huxley 1992
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Sector Psychiatry 1992

• Spectrum Psychiatry
• Crisis Response
• Assertive Outreach
• Community Care for SMI
• Inpatients
• Partial Hospitalisation
• Primary Care Liaison

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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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Whats 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
• 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!
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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

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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)

• 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

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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

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CATS among the Pigeons.
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What do you think?

• For

• Against

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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

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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

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Patient Selection for AOT (Burns)

• Psychotic Illness
• Fluctuating
• Poor Adherence/Engagement
• Relapse would have serious consequences
• 0.3-2 /1000/ year

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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 doesnt 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?

• For

• Against

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EIP Teams Key Elements?
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Key PaperEarly 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

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Start Rx
Onset Positive Symptoms

• Illness
  Duration

Functional Decline
Pre-morbid
At-Risk Phase
Psychosis
Remission
First Rx
(Prodrome)
DUP
DUI (Illness)
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Pre Psychotic PhaseAt 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

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DUP
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Why Worry about DUP?

• Johnstone et al 1986
• DUP gt 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?

• Psychosis is toxic
• Developmental
• Social
• Relationships (EE)
• Psychiatric
• But causality not proven

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Early Detection

• Training for Primary Care
• 75 of cases contacted GP in critical period
• Public Education
• Responsive Service
• Old style services didnt treat Critical Period

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Drug Induced Psychosis?

• Hallucinogen Intoxication- 24hrs
• Cannabis intoxication alone doesnt cause
  psychosis
• late prodromal stage brief psychotic episodes
• I have made this mistake several times!!

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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

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Dosage in 1st Episode Psychosis

• 50 of 36 responded to 2 mg Haloperidol
• Lieberman et al 2000
• Only 4 of 136 required gt 6 mg of Haloperidol
• Zipursky et al 1999
• 2 mg Haloperidol gives 80 D2 occupancy
• Kapur et al 1998

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Targeted Interventions

• NOT just medication
• CBT
• Family education
• Employment/Education
• Substance Misuse
• Prevent Social Decline

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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

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Outcomes with Specific EIP Strategies

• EPPIC
• 2 fold ? in detection rates
• lt 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

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What do you think?

• For

• Against

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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
• An end to Spectrum Psychiatry

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PROs CONs

• Leadership
• Mutual support
• Defined responsibility
• Focus CPD
• Focus on quality
• More sustainable?
• Recruitment?

• Interfaces
• Lack of continuity?
• Overspecialisation?
• Less professional?

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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