Integrated services for persons with psychiatric disability

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Integrated services for persons with psychiatric
disability

• Mikael Sandlund, M.D., Ph.D.
• Umeå University

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What is psychiatric disability?

• Impairments in
• Body functions (memory, processing skills)
• Activities (tasks and actions by an individual)
• Participation (involvement in a life situation)
• As consequences of a (any) mental disorder.

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What is psychiatric disability?

• Functioning and disability - a result of complex
  interactions between the health condition/history
  of the individual and the contextual factors of
  the environment.(ICF,WHO 2004)

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Stigmatization

• Contextual factors of the environment
• Fear, Prejudices
• Lack of Knowledge
• Lack of Reasonable Accommodations for People with
  Psychiatric Disability
• Self-stigmatization!

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What are the needs of persons with psychiatric
disabilities?

• Housing, support
• Employment
• Daily activities
• Social network
• Medical care psychiatric needs, somatic needs

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What are the needs of persons with psychiatric
disabilities?

• Housing
• According to a Swedish tradition of taking good
  care of (particularly) basic needs all
  municipalities offers some kind of support
  (supported housing, sheltered homes, home
  visits).
• Support provided suffers from limited
  individualization and flexibility.
• Trans-institutionalism of limited significance

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What are the needs of persons with psychiatric
disabilities?

• Employment
• Less than 10 of persons in the target group are
  employed at the open labor market.
• At least half of the persons in that group wish
  to have a job.

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What are the needs of persons with psychiatric
disabilities?

• Daily activities
• Day centers for persons with psychiatric
  disabilities exist
• Suitable for persons with long term mental
  disorders, the former long stay population of the
  mental hospitals
• Not attractive for young persons, no options to
  have a career.

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What are the needs of persons with psychiatric
disabilities?

• Social network
• Being lonely a major problem.
• Normalization, participation, equal terms
  cornerstones of the official policy on the area
  of disability politics.
• Burden on relatives is a reality.

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What are the needs of persons with psychiatric
disabilities?

• Medical care psychiatric needs, somatic needs
• Medications, as well as psychotherapy develops
  rapidly
• Life expectancy 10 ys shorter!
• Causes of death cardiac, pulmonary diseases,
  diabetes/obesity preventable conditions!
• Co-morbidity (addiction, somatic disease)

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Inpatient services

• Wards are (always.?) overcrowded
• 1967 35,000 inpatient beds
• 2007 5,000 inpatient beds
• A minority of persons in contact with the
  psychiatric services, consume a majority of the
  services revolving door patients

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Good services for persons with psychiatric
disabilities?

• Continuity of care
• Comprehensive services
• Flexibility and around-the-clock accessibility
• Facilitative and positive interpersonal
  relationships with the helper have in-built
  benefits (Hewitt, Coffey, J Adv Nurs. 2005
  Dec52(5)561-70)
• Hope! Recovery orientation.
• User involvement. Relatives involvement.

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Is there evidence for all this?

• NO
• Some important areas not guided by scientific
  results (yet)
• Several important service components have strong
  evidence as to effectiveness

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No evidence

• There is no evidence concerning the effectiveness
  of supported housing models
• Lack of randomized controlled studies
• There is no evidence concerning the effectiveness
  of social day-care interventions
• Lack of randomized controlled studies

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Strong evidence Employment

• Vocational rehabilitation
• Supported employment is more effective than
  pre-vocational training models in finding and
  keeping competitive work
• Pre-vocational training is not more effective
  than treatment as usual in finding and keeping
  competitive work
• No differences in clinical and social outcome

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Supported employment

• Place then train in competitive work situation
• Avoidance of pre-vocational training
• Minimal screening for employability
• Time-unlimited support
• Consideration of client preferences
• Integration with support from the mental health
  care system

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Strong evidence Family interventions

• Family intervention
• Several family intervention models are effective
  in reducing relapse and inpatient treatment, and
  improve compliance with treatment

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Family interventions

• Common features
• Intervention gt 9 months
• Creating a positive alliance with relatives
• Crisis intervention, problem solving modules
• Knowledge about illness and treatment module
• Reducing negative aspects of emotional climate in
  the family (hostility, criticism and over
  involvement)

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Strong evidence Case Management

• Case management
• Intensive case management (Assertive community
  treatment) reduces inpatient treatment and
  homelessness, stabilizes the housing situation
  and keeps clients in contact with care.
• Less intensive case management improves
  compliance with treatment but increases
  admissions to inpatient care and days in hospital

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Assertive Community Treatment

• Multidisciplinary assertive outreach teams
• Each team member responsible for 10 clients
• Time-unlimited support
• Community based training and support
• 24 hour crisis support
• Co-morbidity psychiatric disorder/drug addiction
  in 20 60 of cases. Both areas of needs have to
  be addressed simultaneously.

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Common feature Integration

• Interventions supported by strong evidence
• Often a need of multidisciplinary teams
• Are comprehensive include responsibilities for
  social services as well as psychiatric services
  (in the Swedish context)
• Should preferably be delivered in
  cooperation/integration

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Official policy

• The need for a stronger cooperation between the
  social services and psychiatry (and Social
  Insurance and primary care/GPs and) has been
  recognized by the governmental agencies
• This has resulted in a great number of
  commissions, reports and recommendations. And in
  shortsighted federal funding for projects
• This has not resulted in legislation

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Independent!

• The local authorities (communes, county councils)
  in Sweden are independent. They raise their own
  money (taxes), they have their own parliaments.
• The roles of federal agencies are mainly support
  and surveillance.

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Good hope

• A number of Supported Employment projects are in
  the process of getting started
• (A few) Good examples of ACT-like teams are
  present
• The involvement of users and relatives becomes
  more frequent

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Stigmatization?

• Only a few politicians have the wish to be
  connected to the needs and policies important to
  people with severe mental illness / psychiatric
  disabilities.
• (as long as there are no current scandals in
  today's newspaper I rather keep away from this
  area)

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On the other hand if effective and user
friendly services are developed the area will be
more attractive (also to politicians.)
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