1. Passionate about our services Social and Rehabilitation Psychiatry Richard Laugharne Peninsula MRCPsych Course 2013

2. 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

3. Passionate about our services

4. 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”

5. Passionate about our services 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

6. Passionate about our services The asylum era  What happened to the mentally ill before the asylum era?  Moral treatment: Pinel, Tuke  Two eras of asylum building in 1830s and 1880s  Positive aspects  Negative aspects recognised early

7. Passionate about our services Problems with asylums  Overcrowding  Loss of individuality: Goffman  Neglect  Stigmatisation  Outpatients 1890s  Voluntary patients 1930s

8. Passionate about our services New developments in 20 th century  Adolf Meyer: knowledge of patient as an individual, more to assessment than diagnosis  Therapeutic communities in WW2  Day hospitals  Community mental health teams

9. Passionate about our services The Three Hospitals Study  Three large asylums with different care regimes  Clinical and social functioning differed and closely associated with these regimes  In schizophrenia, the course of the disorder is affected by the social environment  (Wing and Brown 1961)

10. Passionate about our services Deinstitutionalisation  Psychiatric inpatients one third in 1990 compared to 1950  International phenomenon  ‘Unholy alliance between therapeutic liberals and fiscal conservatives’  Less ill patients first

11. Passionate about our services TAPS Study  Leff 1997  Patients in two large London asylums  Baseline clinical and social functioning  ‘Stayers’ and ‘leavers’  5 years follow up

12. Passionate about our services TAPS outcomes  Few patients admitted permanently  Many had repeated short acute admissions  Nearly all preferred being out in the community  Almost none vagrant or lost to FU  Small number need institutional care

13. Passionate about our services Stigma  Asylums – out of sight, out of mind  Poor understanding – fantasies and myths  Media distortion  Fears of violence: increased risk, little change since 1950  Taylor and Gunn 1999

14. Passionate about our services Combating Stigma  Understand illnesses  Understand treatments  Seeing individuals  Giving a voice to mentally ill  Social inclusion

15. Passionate about our services Definitions of severe mental illness  Separation 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 BPD  Reflects commitment (Burns 2004)

16. Passionate about our services The three Ds  Diagnosis: psychotic illness, major affective disorder  Duration: at least two years  Disability: inability to work or fulfil a major role e.g. parent Bachrach 1988

17. Passionate about our services Service Delivery

18. Passionate about our services 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

19. Passionate about our services Evaluating services EFFECTIVENESS EFFICIENCY EQUITY ACCEPTABILITY ACCESSIBILITY APPROPRIATENESS

20. Passionate about our services Service delivery in the 21 st century  Recovery  Community mental health teams  Assertive outreach teams  Early intervention teams  Home treatment teams/ crisis intervention  Community Treatment Orders  Employment

21. Passionate about our services Recovery  A philosophy rather than a treatment programme  How to live well with persistent illness  Kindness, compassion, respect and hope of recovery  Not that different to Tuke  User led and doctor led

22. Passionate about our services Recovery  Narrative and evidence based  International Study of Schizophrenia (Harrison 2001)  More than half have favourable outcomes at 15 and 25 years  Late recovery effect  Developing vs developed world

23. Passionate about our services Recovery  The expert patient  Hope and optimism  Self help, collaboration with sufferers, self reliance  Roberts and Wolfson 2004, Advances in Psychiatric Treatment, 10,37-49

24. Passionate about our services Assertive Outreach  Small caseloads – about 10 patients  Visit at least twice weekly  Assertive follow up  Treat at home  Emphasis on engagement  Emphasis on medication  Deliver on health and social care needs  Support carers

25. Passionate about our services 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?

26. Passionate about our services Other teams  Early intervention teams – Discuss the ‘for and against’  Home treatment teams/ crisis teams  Community mental health teams  Debate: what makes a service last?

27. Passionate about our services 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

28. Passionate about our services Employment  Work schemes – very different  Supported employment  Prevocational training  Look at paper on IPS 2009  Look at paper on why IPS not implemented 2013

29. Passionate about our services 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

30. Passionate about our services Developing world Why do patients with psychosis do better? Urbanisation