passionate about our services social and rehabilitation psychiatry richard laugharne peninsula...
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Passionate about our servicesPassionate about our services
Social and Rehabilitation Psychiatry
Richard LaugharnePeninsula MRCPsych Course 2013
Passionate about our services
Truth about dangerous mental patients let out to
kill•http://www.telegraph.co.uk/news/uknews/crime/10358251/Truth-about-dangerous-mental-patients-let-out-to-kill.html by Andrew Gilligan 9:00PM BST 05 Oct 2013
Passionate about our services
Passionate about our services
Tyrer 2013“society alternates between embracing community psychiatry as an inclusive and positive way of treating the mentally ill, and an exclusive psychiatry at other times, when those with mental illness are perceived as dangerous….and detained in institutions”
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History of psychiatric services Moral treatment Asylums: the invention of the psychiatrist Outpatients and voluntary care Day hospitals, deinstitutionalisation and resettlement Community care and ‘recovery’ Specialist teams: Assertive Outreach, EIT, HTT Reinstitutionalisation Community treatment orders DISCUSS ASYLUMS
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The asylum eraWhat happened to the mentally ill before the
asylum era?Moral treatment: Pinel, TukeTwo eras of asylum building in 1830s and 1880sPositive aspectsNegative aspects recognised early
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Problems with asylumsOvercrowdingLoss of individuality: GoffmanNeglectStigmatisationOutpatients 1890sVoluntary patients 1930s
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New developments in 20th century
Adolf Meyer: knowledge of patient as an individual, more to assessment than diagnosis
Therapeutic communities in WW2Day hospitalsCommunity mental health teams
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The Three Hospitals StudyThree large asylums with different care regimesClinical and social functioning differed and
closely associated with these regimesIn schizophrenia, the course of the disorder is
affected by the social environment(Wing and Brown 1961)
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DeinstitutionalisationPsychiatric inpatients one third in 1990
compared to 1950International phenomenon‘Unholy alliance between therapeutic liberals
and fiscal conservatives’Less ill patients first
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TAPS Study
Leff 1997Patients in two large London asylumsBaseline clinical and social functioning‘Stayers’ and ‘leavers’5 years follow up
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TAPS outcomesFew patients admitted permanentlyMany had repeated short acute admissionsNearly all preferred being out in the
communityAlmost none vagrant or lost to FUSmall number need institutional care
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StigmaAsylums – out of sight, out of mindPoor understanding – fantasies and mythsMedia distortionFears of violence: increased risk, little change
since 1950Taylor and Gunn 1999
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Combating StigmaUnderstand illnessesUnderstand treatmentsSeeing individualsGiving a voice to mentally illSocial inclusion
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Definitions of severe mental illnessSeparation between ‘severe mental illness’ and
‘common mental disorders’Reflects previous divisions between ‘psychosis’ and
‘neurosis’ etc.Not well defined and a cause of controversy e.g.
severe OCD, severe depression, severe BPDReflects commitment (Burns 2004)
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The three DsDiagnosis: psychotic illness, major affective
disorderDuration: at least two yearsDisability: inability to work or fulfil a major
role e.g. parent• Bachrach 1988
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Service Delivery
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Recent history 1954-1990s: deinstitutionalisation and the birth of community
teams (antipsychiatry) 1959 MHA to protect the public from psychiatrists 1990s: the service user movement and evidence based
medicine 2000s: specialist community teams 2000s: recovery movement 2008: community treatment orders 2013: beds down, detentions up, forensic beds up
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Evaluating servicesEFFECTIVENESSEFFICIENCYEQUITYACCEPTABILITYACCESSIBILITYAPPROPRIATENESS
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Service delivery in the 21st century Recovery Community mental health teams Assertive outreach teams Early intervention teams Home treatment teams/ crisis intervention Community Treatment Orders Employment
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RecoveryA philosophy rather than a treatment
programmeHow to live well with persistent illnessKindness, compassion, respect and hope of
recoveryNot that different to TukeUser led and doctor led
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RecoveryNarrative and evidence basedInternational Study of Schizophrenia (Harrison
2001)More than half have favourable outcomes at
15 and 25 yearsLate recovery effectDeveloping vs developed world
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Recovery The expert patientHope and optimismSelf help, collaboration with sufferers, self
relianceRoberts and Wolfson 2004, Advances in
Psychiatric Treatment, 10,37-49
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Assertive OutreachSmall caseloads – about 10 patientsVisit at least twice weeklyAssertive follow upTreat at homeEmphasis on engagementEmphasis on medicationDeliver on health and social care needsSupport carers
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Key papers in Assertive Outreach Stein and Test 1980
More effective than standard care in US UK700 1999
See paper by Tom Burns, Lancet, 1999 Killaspy 2008
WHY?
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Other teams
Early intervention teams– Discuss the ‘for and against’
Home treatment teams/ crisis teamsCommunity mental health teamsDebate: what makes a service last?
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Employment SMI: 18% in employment in 2000 90% would like to work Barriers: – High rate of unemployment– Benefits trap– Stigma– Low expectations of professionals– Lack of evidence base– Illness vs. disability model
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Employment Work schemes – very differentSupported employmentPrevocational trainingLook at paper on IPS 2009Look at paper on why IPS not implemented
2013
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Issues today and tomorrow Specialists vs. generalists Functionalisation vs. integration Physical health of patients with a psychosis Employment How do we measure outcomes and quality? BRAINSTORM Stepped care, equitable services and rationing Self management and using technology Therapeutic relationships and ‘effective interventions’: industrialised
health care Treatment and care: the difference
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Developing world
Why do patients with psychosis do better?Urbanisation