Models of Community Provision Andrew Cole Consultant Psychiatrist.

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