Team for the Assessment of Psychiatric Services (TAPS) Project 33: prospective follow-up study of long-stay patients discharged from two psychiatric hospitals

A pilot randomized controlled trial of aquatic-based activities in a group occupational therapy program for adults living with serious mental illness in Spain

Although aquatic-based interventions are increasingly used in the psychiatric rehabilitation services, the effects of this type of community program as an adjuvant therapy for psychosocial problems of people with serious mental illness (SMI) have been under-explored. This research evaluated the feasibility and outcomes of an occupational therapy program consisting of aquatic-based activities (AA-OT program) in the community in Spain. This study is the first randomized controlled trial (RCT) on this topic. This pilot trial was conducted with a sample of 16 adults with SMI who were randomly allocated to the AA-OT program plus treatment as usual or treatment as usual alone (eight in each group). The AA-OT program included activation of daily living skills, warm-up, group activities/tasks, and relaxation. It consisted of two sessions per week over 12 weeks. Outcomes were evaluated at week 0 and 12. A total of 14 participants (87.5%) completed the trial. No adverse events or side-effects were noted. Comparisons between the two groups on change scores showed that participants in the intervention group showed significant improvements in several outcome measures: psychosocial problems (HoNOS), two health-related quality of life scales (SF-36: Physical Functioning and Mental Health), and performance of social activities (Activity and Social Relations scale). Satisfaction with the program was high. In conclusion, the results support the feasibility and potential benefits of this occupational therapy program. 12 weeks of aquatic-based activities in a group intervention may enhance the outcomes of psychiatric rehabilitation improving the severity of psychosocial problems, patient-reported health status, and social relations. This community-based program may be beneficial as a non-pharmacologic method in the illness management and recovery of people with SMI. The findings from this pilot trial need to be confirmed in a large, fully-powered RCT.

Patient needs four years after first psychiatric hospitalization in a Brazilian cohort

Knowledge about the needs of psychiatric patients is essential for mental health care planning. However, research on met and unmet needs is still scarce, particularly in low- and middle-income countries. This study aimed to describe the patients' needs (met and unmet) at least four years after their first psychiatric hospitalization and to verify the role of demographic and clinical features as possible predictors of these needs. Patients who had their first psychiatric admission between January 1, 2006 and December 31, 2007 at an inpatient unit in the city of Ribeirão Preto, Brazil, were eligible to participate in the study. Patients were contacted and face-to-face interviews were conducted by psychologists using the Camberwell Assessment of Need. Data were analyzed using zero-inflated negative binomial regression model. Of 933 eligible patients, 333 were interviewed. The highest level of needs was related to welfare benefits (32.4%, unmet=25.5%), followed by household skills (30.3%, unmet=3.0%), psychotic symptoms (29.4%, unmet=9.0%), psychological distress (27.6%, unmet=8.4%), physical health (24.3%, unmet=5.4%), daytime activities (19.5%, unmet=16.5%), and money (16.8%, unmet=9.0%). Fewer years of schooling, living with relatives, and unemployment at the moment of the first admission were significantly associated with a higher number of both met and unmet needs in the follow-up. Unmet needs were also more often reported by patients living alone. In conclusion, socioeconomic indicators were the best predictors of needs. The unmet needs related to welfare benefits point to the need for specific social and health policies.

Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.

Quality of life and social functioning of former long-stay psychiatric patients transferred into the community: a 10 year follow up study

PURPOSE

Deinstitutionalisation in Ireland began following the impetus of the successful transfer of psychiatric patients into the community in other countries. This study sought to evaluate the quality of life (QoL) and social functioning (SF) of former long-stay institutionalised patients with severe and enduring mental illness who had been relocated into local community settings and followed up 10 years later.

METHOD

One month prior to hospital closure, 87 former long-stay psychiatric patients, the majority of whom had a diagnosis of schizophrenia, were assessed on a range of QoL and SF measures. Patients were followed-up 10 years later in the community, to evaluate baseline predictors of quality of life and social functioning.

RESULTS

Study completers (n = 35) improved significantly on a range of QoL and SF measures over the 10 year period. Specific improvements were noted in domestic skills (t = - 2.8, p < 0.0008), community skills (t = - 4.9, p < 0.001), as well as the activity and social relations measure (t = - 4.1, p < 0.001). Increased social function (t = - 6.3, p < 0.001) and improvement on the social behaviour scale (t = 7.6, p < 0.001) were noted at follow-up. Linear regression analysis found that less social behaviour problems at baseline predicted QoL 10 years later (t = - 2.6, p < 0.02).

CONCLUSION

This study demonstrated that transfer into the community from an institutional environment was associated with long-term improvements in quality of life and social functioning, even in those who spent many years in the institution. Those who demonstrated the greatest improvement in QoL had less social behavioural problems at baseline assessment, providing further evidence of the success of community living for former long-stay patients.

Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes

BACKGROUND

Post-deinstitutionalisation, mental health supported accommodation services have been implemented widely. The available research evidence is heterogeneous in nature and resistant to synthesis attempts, leaving researchers and policy makers with no clear summary what works and for whom. In this context, we undertook a comprehensive systematic review of quantitative studies in order to synthesise the current evidence on mental health and psychosocial outcomes for individuals residing in mental health supported accommodation services.

METHODS

Using a combination of electronic database searches, hand searches, forward-backward snowballing and article recommendations from an expert panel, 115 papers were identified for review. Data extraction and quality assessments were conducted, and 33 articles were excluded due to low quality, leaving 82 papers in the final review. Variation in terminology and service characteristics made the comparison of service models unfeasible. As such, findings were presented according to the following sub-groups: 'Homeless', 'Deinstitutionalisation' and 'General Severe Mental Illness (SMI)'.

RESULTS

Results were mixed, reflecting the heterogeneity of the supported accommodation literature, in terms of research quality, experimental design, population, service types and outcomes assessed. There is some evidence that supported accommodation is effective across a range of psychosocial outcomes. The most robust evidence supports the effectiveness of the permanent supported accommodation model for homeless SMI in generating improvements in housing retention and stability, and appropriate use of clinical services over time, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. The evidence base for general SMI populations is less developed, and requires further research.

CONCLUSIONS

A lack of high-quality experimental studies, definitional inconsistency and poor reporting continue to stymie our ability to identify effective supported accommodation models and practices. The authors recommend improved reporting standards and the prioritisation of experimental studies that compare outcomes across different service models.

Residents' View of Quality in Ordinary Housing with Housing Support for People with Psychiatric Disabilities

The aim of the present study was to investigate the quality of housing support provided in housing services for people with psychiatric disabilities living in ordinary housing with housing support from the residents' perspective, by using the QPC-H instrument. A sample of 174 residents in ordinary housing, receiving housing support from 22 housing support services in nine Swedish municipalities, participated in this study. The results show that the quality of psychiatric care in housing services was mainly rated highly as measured with the QPC-H instrument. The dimensions Encounter and Secluded Environment were the aspects that were rated as the two with the highest quality of housing service. The dimensions Participation and Secure Environment were rated as those with the lowest quality. There were more residents who totally disagreed with the statements in the dimensions Participation and Housing Specific than in the other dimensions. The perceived lower quality in Encounter, Participation, Support and the Housing Specific dimensions was associated with a low frequency of psychiatric outpatient clinic contacts. A conclusion is that the support staff could be more observant regarding the residents' need for support and also talk more with them about what could be done to assist them. It also seems important that the support staff discuss with the residents regarding how they can help them to feel more secure in their accommodation.

Integrating Scale Data and Patient Perspectives for Assessing Functionality in Schizophrenia

There is a growing body of literature devoted to evaluating functionality when planning the psychosocial rehabilitation of patients with schizophrenia. Until recently, psychological scales have been the predominant source of information, whereas patients' perceptions about the most disruptive limitations on their daily life were not considered. The aim of this paper is to illustrate how the integration of the perspectives of patients and patients' relatives improves the evaluation of functionality. A QUAN + QUAL design was implemented collecting quantitative data from Family APGAR and BELS scales, and qualitative information by conducting focus groups. The integration of results made it possible to understand the causes of problems reported by scales, as well as improving the information captured for helping to plan patient therapies. This mixed approach has provided a more comprehensive perspective of functionality, which will be helpful in improving quality of life of patients and their relatives.

Validity and reliability of a Swedish questionnaire for assessing satisfaction with housing and housing support for persons with psychiatric disabilities

The aim of this study was to investigate the reliability and validity of a questionnaire for studying satisfaction with housing and housing support for people with psychiatric disabilities. Most items were gathered from English language questionnaires. These were translated and adapted to a Swedish context and items concerning housing support were added. Two studies were conducted. The first, a test-retest reliability analysis, was performed in a pilot study with 53 participants; in the second study, which had 370 participants, a five factor solution with good internal consistency emerged. Further development of the questionnaire is discussed.

Redevelopment of tertiary psychiatric services in British Columbia: a prospective study of clinical, social, and residential outcomes of former long-stay inpatients

OBJECTIVE

The objective of this study is to assess the clinical and social outcomes for a cohort of patients who were part of the redevelopment of psychiatric services in British Columbia.

METHOD

This study used a naturalistic, quasi-experimental design, to examine the outcomes of a cohort of 189 long-stay patients at Riverview Hospital (RVH), some of whom moved into Tertiary Psychiatric Residential Facilities (TPRFs), some into the community in less structured facilities, and some remained at RVH. Data was collected from clinical files at RVH and at each participating site, semi-structured interviews and self-report measures were completed with patients. In addition, semi-structured interviews were also conducted with staff members.

RESULTS

There was very minimal evidence of transinstitutionalization to prisons or homelessness; one participant resided in a correctional facility, one resided in a forensic facility, and one participant spent some time homeless. In addition, the majority of participants remained in residences that provided 24h care. Eighty percent of our population was diagnosed with a schizophrenia spectrum disorder. Psychiatric symptoms remained fairly stable; some embarrassing social behaviors increased; however, aggressive behaviors showed no increase; neuropsychological deficits did not deteriorate, there were even some improvements. Participants demonstrated increases in several independent living skills including: money management, food preparation and storage, job skills, and transportation skills. In addition, participants experienced a significant increase in their perceived quality of life.

CONCLUSIONS

This study builds on existing research demonstrating that well-planned and appropriately resourced hospital closures can lead to positive psycho-social outcomes for participants and can successfully avoid negative outcomes such as transinstitutionalization to the judiciary system and homelessness.

Factors associated with long-stay status in patients with schizophrenia: an analysis of national databases covering the entire Korean population

BACKGROUND

Admissions lasting over six months (long-stay) occur frequently among patients with schizophrenia in South Korea.

AIMS

To identify some patient-level and institution-level factors associated with long-stay status of patients with schizophrenia.

METHODS

This is a retrospective cross-sectional study. We analysed a nationwide population-based reimbursement claims data set consisting of 496,338 claims for 58,287 patients with schizophrenia between 1 January 2005 and 30 June 2006. A two-level random effects logistic regression model was used to identify those factors.

RESULTS

Age (<20 years (ref), 60-69 (OR 2.000, 95% CI: 1.640-2.438), ≥ 70 (2.068, 1.682-2.543)), male gender (1.192, 1.144-1.242), type of national health insurance plan (national health insurance (ref), Medical Care Aid Type 1 (4.299, 4.024-4.593)), secondary diagnosis (none (ref), psychiatric diagnosis (0.719, 0.666-0.777), non-psychiatric diagnosis (0.918, 0.850-0.991)) and type of institution (clinic (ref), psychiatric hospital (2.769, 1.507-5.087)) were associated with likelihood of long-stay status. Institutional variable associated with long-stay status included a higher number of beds (1.073, 1.013-1.137). The number of professionals (0.752, 0.646-0.876) showed negative association with long-stay status.

CONCLUSIONS

Researchers could improve their assessment of long-stay status of patients with schizophrenia by using a two-level analysis including patient-level and institution-level factors. This study suggests that mental health interventions to reduce the long stay of patients with schizophrenia focus on older male patients, those enrolled in a national medical care aid programme and those admitted to psychiatric hospitals.

The long-term outcomes and unmet needs of a cohort of former long-stay patients in Melbourne, Australia

Former long-stay patients with psychotic disorders have significant unmet needs. This study assessed the long-term outcomes for the original cohort of 18 residents of the Footbridge Community Care Unit (CCU), a residential psychiatric rehabilitation unit at St Vincent's Mental Health Melbourne. A review of case records and interviews were conducted for each member of the cohort 8 years after admission to the CCU. Members of the cohort were living in a variety of settings after discharge from the CCU. Despite significant gains during the period of residential rehabilitation in the CCU after hospital discharge, by the time of follow-up individuals were in general leading restricted lives characterised by a lack of stable residential and social supports. Most reported positively on the support provided in the CCU although later experiences of moving repeatedly from one setting to another were adverse. Five key unmet needs were identified: promotion of independence; stability in accommodation; stability in social networks; consistency of care; and addressing the theme of loss. A longitudinal perspective in management that focuses on stability in residential care is required for long-stay patients.

The economic consequences of deinstitutionalisation of mental health services: lessons from a systematic review of European experience

Many European mental health systems are undergoing change as community-centred care replaces large-scale institutions. We review empirical evidence from three countries (UK, Germany, Italy) that have made good progress with this rebalancing of care. We focus particularly on the economic consequences of deinstitutionalisation. A systematic literature review was conducted using a broad search strategy in accordance with established guidelines. We searched the International Bibliography of the Social Sciences, Health Management Information Consortium, British Nursing Index and PUBMED/Medline to 2008. The on-line search was supplemented by advice and assistance from contacts with government departments, European Commission, professional networks and known local experts. Community-based models of care are not inherently more costly than institutions, once account is taken of individuals' needs and the quality of care. New community-based care arrangements could be more expensive than long-stay hospital care but may still be seen as more cost-effective because, when properly set up and managed, they deliver better outcomes. Understanding the economic consequences of deinstitutionalisation is fundamental to success. Local stakeholders and budget controllers need to be aware of the underlying policy and operational plan. Joint planning and commissioning or devolving certain powers and responsibilities to care managers may aid development of effective and cost-effective care. People's needs, preferences and circumstances vary, and so their service requirements and support costs also vary, opening up the possibility for purposive targeting of services on needs to improve the ability of a care system to improve well-being from constrained resources. As the institutional/community balance shifts, strategic planning should also ensure that the new care arrangements address the specific contexts of different patient groups. Decision-makers have to plan a dynamic community-based system to match the needs of people moving from institutions, and must take the long view.

Better off in the community? A 5-year follow up study of long-term psychiatric patients discharged into the community

BACKGROUND

The quality of life of long-term psychiatric inpatients relocated to the community was investigated in this study. The aim was to investigate what changes, if any occurred, on standardised quality of life related instruments between discharge from hospital and at 1 year after discharge into the community. We were also interested to see if these changes continued 5 years after discharge into the community.

METHOD

87 long-stay psychiatric patients were enrolled in the study. Each patient was assessed on four standardised assessment instruments designed to assess their attitudes towards community living and level of functioning in the community.

RESULTS

Patients reported being satisfied in their new community environment. They showed improvements in their level of self-care and social functioning after 1 year in the community. These improvements were not maintained in their fifth year in the community. In addition, there were no improvements in patient's domestic skills, community skills or activity and social relations levels. Weekly occupation levels increased after 5 years in the community and their level of interests in things increased over the first year but not after 5 years in the community.

CONCLUSIONS

This study adds to the previous work carried out on patients discharged from large psychiatric hospitals into the community. Patients expressed a desire to continue to live in the community and while they showed improvements in self care and social functioning in the first year following discharge, these improvements were not sustained after 5 years in the community. Further training is needed for staff in the community residences so that patients can achieve their maximum potential.

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

BACKGROUND

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings, underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

OBJECTIVES

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management.

SEARCH STRATEGY

We searched The Cochrane Schizophrenia Group Trials Register (March 2006). We manually searched the Journal of Personality Disorders, and contacted colleagues at ENMESH, ISSPD and in forensic psychiatry.

SELECTION CRITERIA

We included all randomised controlled trials of CMHT management versus non-team standard care.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model.

MAIN RESULTS

CMHT management did not reveal any statistically significant difference in death by suicide and in suspicious circumstances (n=587, 3 RCTs, RR 0.49 CI 0.1 to 2.2) although overall, fewer deaths occurred in the CMHT group. We found no significant differences in the number of people leaving the studies early (n=253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). Significantly fewer people in the CMHT group were not satisfied with services compared with those receiving standard care (n=87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11). Also, hospital admission rates were significantly lower in the CMHT group (n=587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to accident and emergency services, contact with primary care, and contact with social services did not reveal any statistical difference between comparison groups.

AUTHORS' CONCLUSIONS

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide. The evidence for CMHT based care is insubstantial considering the massive impact the drive toward community care has on patients, carers, clinicians and the community at large.

Long-stay patients in a psychiatric hospital in Southern Brazil

OBJECTIVE: To describe the demographic profile, social functioning, and quality of life of a population of long-stay care patients in a psychiatric hospital. METHODS: A study was carried out in Porto Alegre, Southern Brazil, in 2002. A total of 584 (96%) long-stay patients were assessed by means of the following instruments: the World Health Organization Quality of Life, the Social Behavior Schedule, the Independent Living Skills Survey, the Brief Psychiatric Rating Scale and another instrument for assessing disability (Questionnaire for Assessing Physical Disability). RESULTS: The average hospital stay was 26 years (SD: 15.8) and 46.6% of inpatients had no physical disability. Patients had their social functioning skills and autonomy largely impaired. Few of them (27.7%) answered the instrument for assessing quality of life, and showed significant impairments in all domains. The Brief Psychiatric Rating Scale evidenced a low prevalence of positive symptoms in this population. CONCLUSIONS: The institutionalized population studied presented significantly impaired social functioning, autonomy, and quality of life. These aspects need to be taken into consideration while planning for their deinstitutionalization.

Service use and costs of supporting the most socially disabled patients in a hospital reprovision programme. A two-hospital comparison

BACKGROUND

The UK, in common with other Western countries, has seen a marked reduction in the number of long-stay hospital beds over the past few decades and most asylums have been closed. Whilst hospital closure and discharge programmes differ, a common characteristic is likely to be that those patients who are "difficult-to-place" in the community are amongst the last to be discharged. This paper compares service use and costs of difficult-to-place patients from two UK hospitals (Friern and Warley) and identifies predictors of cost. One of these hospitals (Warley) provided a more intensive programme of rehabilitation.

METHOD

The study included 84 patients (Friern 63, Warley 21). Patient characteristics prior to discharge were recorded. Service use was measured and costs calculated for the year following discharge. Comparisons were made between the Warley and Friern groups and cost predictors were identified using multiple regression analysis.

RESULTS

Post-discharge accommodation, in-patient and outpatient costs were substantially higher for the Friern group, whilst the Warley group had higher day care costs. The total mean costs were pound 13,432 higher for the Friern group. However, non-accommodation costs were substantially higher for the Warley group. Patients with more social skills had higher non-accommodation costs. Higher total costs were associated with more self-care skills, fewer domestic skills and younger age. Longer length of stay prior to discharge was associated with higher non-accommodation and total costs.

CONCLUSIONS

The costs of care following discharge differed substantially between these two groups. This is partly a supply effect given the different strategies for caring for these difficult-to-place patients. In common with other studies, patient characteristics can explain some of the differences in future costs.

Violence and abuse in psychiatric in-patient institutions: a South African perspective

Institutionalisation of psychiatric patients was a prevalent treatment approach in the apartheid era of South Africa. Allegations of violence and abuse towards patients frequently arose during this time. The post-apartheid Department of Health prioritised improvements in mental health care by recommending, inter alia, deinstitutionalisation and reintegration of patients into the community. Ten years later, these interventions have proved difficult to institute and many patients are still hospitalised. The present study investigated whether currently hospitalised patients continued to experienced violence and abuse. This was an exploratory naturalistic study in which both qualitative and quantitative data were collected. Of the 127 who completed the study, more than 50% reported experiences of abuse. The main perpetrators were other patients, although violence by staff was reported. Reasons for the tardiness of implementation of deinstitutionalisation and the prevalence of ongoing violence and abuse in psychiatric hospitals are complex. Factors inherited from the pre-democratic system coupled with increased urban violence and financial constraints appear to be some of the major causes of ongoing dependency upon hospitalisation of mental health care users. The present study highlighted the urgency of implementing mental health care improvements.

Impact of a rehabilitation legislation on the survival in the community of long-term patients discharged from psychiatric hospitals in Israel

BACKGROUND

The aim of the present study was to examine the impact of the Rehabilitation Law 2000 in Israel (which provides a basket of rehabilitation services for every mentally disabled patient) on the survival in the community of a population of long-stay psychiatric patients released from psychiatric hospitals.

METHODS

A naturalistic follow-up study was performed on long-stay patients discharged ("key discharge") from two Israel psychiatric hospitals closed before (in 1997) and after (in 2000) introduction of the Rehabilitation Law 2000. The data source was the National Psychiatric Hospitalization Registry.

RESULTS

The study population consisted of 611 patients. The percentage of patients who, at closure of hospital, were discharged directly into the community was eightfold higher following the Rehabilitation Law 2000 than before. There was also a trend for a lower readmission rate for those patients who were discharged into the community in the post-law period, both for those whose key discharge was directly to the community and for those who were later discharged after being transferred to another hospital at key discharge. Concerning the mean duration of inpatient stay, there was no difference between the two cohorts, whether hospitalizations followed transfer to another hospital from key discharge or rehospitalization from the community. Interestingly, the Rehabilitation Law did not have a significant effect on patients' mortality after key discharge.

CONCLUSION

The Rehabilitation Law 2000 has a beneficial effect on the opportunities of long-stay psychiatric patients to resettle in the community without increasing risk of death.

Suicide among the homeless: a 9-year case-series analysis

BACKGROUND

Among the homeless there are high rates of mortality and a significant number of attempted and completed suicides. In Tel-Aviv, Israel, there is an ongoing municipal outreach program for the homeless.

OBJECTIVE

The aim of the present study was to describe the subgroup of homeless persons who had died by suicide.

METHOD

Over a 9-year period the records of each homeless person who had died were assessed by two psychiatrists and a clinical criminologist. The project was undertaken in a large city and was feasible due to close cooperation between the municipal welfare department and mental health consultants.

RESULTS

Of the 1,192 homeless persons located and contacted, 156 persons had died (13.1%). Nine of the deaths were by completed suicide (5.8%). All were male. Mean age for the suicide subgroup was 34 +/- 8.7 years, significantly younger than those who died of other causes (p < .01). The majority had completed high school education. While the majority of deaths were drug or alcohol related, in only 1 of 9 deaths by suicide was there a history of drug abuse. Psychiatric comorbidity was recorded in 4 of the 9 persons. The majority of persons (6/9) had died of suicide by hanging.

CONCLUSION

Suicide is not a negligible cause of death among the homeless population.

Clinical and social changes in severely mentally ill individuals admitted to an outpatient psychosis team: an 18-month follow-up study

AIM

The study investigated clinical and social changes during an 18-month follow-up period in a group (n = 76) of schizophrenic outpatients admitted to a newly implemented outpatient psychosis team. Changes related to level of contact with the psychosis team were also examined as well as aspects of the content of the treatment interventions and work situation from a staff perspective.

METHODS

Structured face-to-face interviews with the patients were performed at baseline and after 18 months. The Camberwell Assessment of Need instrument, the Lancashire Quality of Life Profile and the Interview Schedule for Social Interaction were used on both interview occasions along with Global Assessment of Functioning Scale and Brief Psychiatric Rating Scale. Thematic open-ended questions were used in staff interviews.

RESULTS

Psychiatric symptoms, number of needs and number of met needs decreased, and perceived quality of life improved for the total sample during the follow-up period. Patients only in contact with a psychiatrist in the psychosis team improved more in symptoms and spent fewer days in hospital during follow-up time compared with those who had combined psychiatric and supportive contacts, and were also more satisfied with their medication. Patients with a combined contact deteriorated in psychosocial functioning compared with the group only in contact with a psychiatrist. Some of the elements in treatment interventions and work situation as well as hindrances in providing community-based care adapted to the patients' needs were identified.

CONCLUSIONS

Community-based psychiatric services, to a larger extent, need to embrace evidence-based interventions and to perform regular, structured and comprehensive need assessments in order to ensure the effectiveness of interventions. Attention should be paid to staff motivation and education as well as to providing practical guidelines, supervision and support.

Long-term outcome of long-stay psychiatric in-patients considered unsuitable to live in the community. TAPS Project 44

BACKGROUND

Whereas the majority of long-stay in-patients have been successfully resettled in the community, there is a group of such patients who are too disturbed or disturbing to be managed in standard community homes.

AIMS

To study the long-term outcome of a group of 72 long-stay psychiatric inpatients, regarded as unsuitable for community placement.

METHOD

A prospective cohort study with follow-ups at 1 year and 5 years.

RESULTS

The patients' mental state remained unchanged after 1 year and 5 years. The level of functioning and social behaviour showed minimal change after 1 year, but then improved over the next 4 years. The profile of problematic behaviours changed significantly over 5 years, with a reduction of 50% in their frequency. Physical aggression practically disappeared. The improvements in behaviour enabled 29 patients (40% of the study group) finally to be resettled in various care homes, gaining better access to community amenities and living more independently.

CONCLUSIONS

A high proportion of patients with severe disabilities, designated as 'difficult to place' in the community, could benefit from slow-stream rehabilitation within specialised facilities, enabling them to move into ordinary community homes.

A 'bittersweet pill to swallow': learning from mental health service users' responses to compulsory community care in England

Two forms of compulsory mental healthcare and supervision in the community are provided within the Mental Health Act 1983: Supervised Discharge Orders (SDOs) and guardianship. At a time when the Government are proposing to extend powers of supervision over people with severe mental illness in the community, it is appropriate that service users' experiences of existing legislation are examined and reported. Despite a range of literature that presents mental health service users' views and experiences, it remains unclear how service users respond to compulsory community mental healthcare in England. The present paper presents the findings of a qualitative investigation into service users' perceptions and experiences of living with SDOs. In the interviews, service users communicated their understanding of why mental health professionals placed them on the order and how their lives have been affected. Individual service users are capable of seemingly contradictory responses, simultaneously accepting and resisting the orders. This paper presents a typology of the range of responses. These responses are fatalism and resignation, dependency, ownership, bargaining, cooperation, resistance, and rejection. The study provides a model with which we can begin to understand how service users respond to compulsory community care where their options are legally constrained.

The cost effectiveness of specialised facilities for service users with persistent challenging behaviours

Little systematic research relates specifically to the last people to leave a psychiatric hospital at the end of a closure programme. The long-running evaluation of the reprovision of services from Friern Hospital in North London allowed a special study to be made of such a group (67 people in all), whose range of problem behaviours made placement in community settings most difficult. The patients were relatively young, with a shorter length of stay than the remainder of the former long-stay hospital population. They were assessed three times: before leaving Friern, and one and 5 years after relocation. The social and clinical characteristics of each person were measured, and the full costs of their care calculated. The "difficult-to-place" patients moved to four highly staffed rehabilitation facilities, where the total cost of their care was, on average, 1230 UK pounds per week. There was no overall change in their psychiatric state over the 5 years after they left Friern Hospital although, in the longer-term, they gained skills in several areas of daily functioning. Most importantly, there was a fall of almost 50% in the number of challenging behaviours exhibited by the study group. At the five-year follow-up point, the cost of care had fallen, on average, by 170 UK pounds per week, and 24 people had been able to move to more independent accommodation arrangements. Study participants had gained a new network of community service contacts, and used services provided by a greater variety of agencies. The indicators suggest that high expenditure on alternative care was justified retrospectively by overall long-term outcomes. An important policy lesson from the Friern Hospital reprovision study is that adequate funds should be reserved until the end of the closure programme to allow the investment of resources in provision for patients with the most severe problem behaviours.

Prevalence of mental illness in homeless men in Munich, Germany: results from a representative sample

OBJECTIVE

The aim of the study was a reliable assessment of the prevalence of DSM-IV mental disorders in a representative sample of homeless men in the city of Munich.

METHOD

A preliminary survey yielded an estimate of 1,022 single homeless men in Munich divided among three sectors (shelter users, service users and street dwellers). A random sample of 265 single homeless men was surveyed from these three sectors. An age-matched comparison group of 178 men was selected randomly from a community register. The Structured Clinical Interview for DSM-IV (SCID-IV) was used for diagnostic classification.

RESULTS

The lifetime prevalence rates of mental disorders were as follows: 72.7% vs. 15.2% for alcohol dependence, 32.8% vs. 7.3% for mood disorders, 15.9% vs. 6.2% for anxiety disorders and 9.8% vs. 0.6% for psychotic disorders. Of the homeless males in Munich, 93.2% had at least one lifetime DSM-IV axis I diagnosis, while this was the case for only 38.2% of the community controls. One-month prevalence for all SCID DSM-IV axis I disorders in homeless males was 73.4%.

CONCLUSION

Lifetime DSM-IV axis I mental disorders were 2.4 times more frequent among homeless individuals compared to community control. Implications for health care planning are discussed.

Home treatment

BACKGROUND

Deinstitutionalisation has stressed where care is no longer taking place. Home treatment in rehabilitation reflects the steady increase in emphasis on support and treatment for individuals with long-term disorders where it matters for them--in their own homes.

MATERIALS AND DISCUSSION

Whether dealing with individuals discharged after long periods in hospital or with the increasing number who have experienced repeated short-term admissions, most modern day rehabilitation takes place in the patients' homes and neighbourhoods. We are increasingly convinced that this decentralisation is a positive strength, not a problem. Its advantages include improving social inclusion and the ability to conduct more accurate, personalised assessments of disabilities and strengths. Skills training is more focused and we discuss the components of home treatment and assertive community treatment as they are relevant to rehabilitation. This involves both medication and practical help, brokerage and involvement with the voluntary sector.

CONCLUSIONS

Rehabilitation remains, at its core, a set of relationships between whole individuals (not just skills and needs). A home-based approach is proposed as the norm, not the exception. It is based on a rounded understanding of the patient as a unique person and emphasises the importance of a strong working alliance.

Long-stay patients discharged from psychiatric hospitals. Social and clinical outcomes after five years in the community. The TAPS Project 46

BACKGROUND

There have been no large-scale prospective studies evaluating the transfer of care from psychiatric hospitals to district-based services.

AIMS

We aimed to compare the quality of life of patients in two north London hospitals scheduled for closure with that in the community homes to which they were discharged.

METHOD

The total long-stay population of Friern Hospital and several hundred long-stay patients in Claybury Hospital were assessed with a batch of eight schedules while in hospital. They were followed up after one year in the community and then at five years.

RESULTS

Of the 670 discharged patients, 126 died before the five-year follow-up. Data were obtained on 523 (97%) of the survivors. There was no change in the patients' clinical state or in their problems of social behaviour. However, they gained domestic and community living skills. They also acquired friends and confidants. They were living in much freer conditions and the great majority wanted to remain in their current homes.

CONCLUSIONS

Community care has enhanced the quality of life of this group of patients, involved in a well-planned and adequately resourced reprovision programme.

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

BACKGROUND

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

OBJECTIVES

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), the Cochrane Library (1998, Issue 2), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. The Journal of Personality Disorders was hand searched, and contact was made with colleagues at ENMESH, ISSPD and in forensic psychiatry.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of CMHT management versus non-team standard care.

DATA COLLECTION AND ANALYSIS

The selection of trials, assessment of quality and data extraction was undertaken independently and in parallel by two reviewers. Where possible the data were entered into RevMan and an intention-to-treat analysis undertaken. Tests of heterogeneity were undertaken.

MAIN RESULTS

CMHT management may be associated with fewer deaths by suicide and in suspicious circumstances (OR 0.32 CI 0.09-1.12). It causes less people to be dissatisfied with their care (OR 0.34 CI 0.2-0.59) and to leave the studies early (OR 0.61 CI 0.45-0.83). No clear difference was found in admission rates, overall clinical outcomes and duration of in-patient hospital treatment, although this was partly a consequence of poorly presented data.

REVIEWER'S CONCLUSIONS

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide.

The changing hopes, worries, and community supports of individuals moving from a closing long-term care facility

This study examines client's hopes, worries, and social networks before, one year, and two years following release from a long-term care facility. More clients expressed hopes than worries before closure but, over time, hopes decreased and worries increased significantly. Before closing, independence was cited most often as a hope, followed by work and finances. Criminal opportunities headed up concerns, followed by mental health treatment, finances, living arrangements and independence. Over time, respondents were less excited about independence and living arrangements but more hopeful about social opportunities and everyday practicalities. Worries relating to family increased while concerns about deviance decreased. Respondents reported an average increase in network ties but the proportion of family members decreased while professional supports and ties with former CSH patients increased. The trends highlight particular vulnerability at the one-year point, the necessity of viewing movement into the community as a nonlinear process, and the importance of marking outcomes periodically.

Closing of a state hospital: an overview and framework for a case study

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

The closing of Central State Hospital: long-term outcomes for persons with severe mental illness

This study examined the clinical/community functioning of long-stay patients following closing of a large state psychiatric hospital. Two overlapping samples were followed: (1) the tracking project collected information on patient location, treatment provision, legal contacts, and level of functioning (LOF) and followed all discharged patients and (2) the research study subsample, drawn from the final group of discharged patients, gathered information on quality of life (QOL), LOF, and general physical and mental health. At follow-up, patients were functioning equal to or better than prior to discharge. There were consistent improvements in QOL (especially safety and occupational satisfaction) and LOF (especially housing and income/benefits). Fewer than 27% of patients discharged into the community were rehospitalized, and fewer than 4% were either in jail or homeless after 24 months. The study demonstrates that even persons who have been hospitalized for extremely long periods can do well in the community.

Outcome of long stay psychiatric patients resettled in the community: prospective cohort study

OBJECTIVE

To examine the outcome of a population of long stay psychiatric patients resettled in the community.

DESIGN

Prospective study with 5 year follow up.

SETTING

Over 140 residential settings in north London.

SUBJECTS

670 long stay patients from two London hospitals (Friern and Claybury) discharged to the community from 1985 to 1993.

MAIN OUTCOME MEASURES

Continuity and quality of residential care, readmission to hospital, mortality, crime, and vagrancy.

RESULTS

Of the 523 patients who survived the 5 year follow up period, 469 (89.6%) were living in the community by the end of follow up, 310 (59.2%) in their original community placement. A third (210) of all patients were readmitted at least once. Crime and homelessness presented few problems. Standardised mortality ratios for the group were comparable with those reported for similar populations.

CONCLUSIONS

When carefully planned and adequately resourced, community care for long stay psychiatric patients is beneficial to most individuals and has minimal detrimental effects on society.

The Qualyop Project. 1: Monitoring the dismantlement of Italian public psychiatric hospitals. Characteristics of patients scheduled for discharge

OBJECTIVES

Monitoring and evaluating the Italian psychiatric hospitals closure process, stated by the law to be concluded by 31 December 1996, and then postponed to 31 March 1998, identifying characteristics related to the possibility of discharge in 4493 patients living in twenty-two public psychiatric hospitals.

METHOD

Sociodemographic and clinical data, information on impairment and functioning and plans for discharge in the subsequent twelve months of all patients were collected at baseline using a standard questionnaire.

RESULTS

Discharge was planned within twelve months for 11% of the patients: 4% to other psychiatric or non-psychiatric institutions and 7% to community settings. Severely disabled patients and patients with some behavioural problems were more frequently scheduled to go to institutional settings. For both types of discharge, an adequate network of social relationships was an important determinant. Patients were more frequently planned for discharge if they resided in hospitals with a higher care providers/patients ratio, and in Emilia Romagna and Rome, than in Lombardy and Liguria.

CONCLUSION

Frequency of planned discharge depended partly on the patients' personal characteristics related to independence and functioning, but the effect of these factors on frequency of planned discharge was influenced by characteristics of the hospitals where the patients lived.

The TAPS Project 42: the last to leave hospital--a profile of residual long-stay populations and plans for their resettlement. Team for the Assessment of Psychiatric Services

This study aims to assess the service needs of residual hospital populations and the adequacy of the alternative facilities provided for them following the closure of psychiatric hospitals. The remaining 368 long-stay patients in four representative English hospitals scheduled for closure within 1 year were assessed by means of a standardized schedule devised to rate problem behaviours. The residual populations consisted predominantly of elderly, male and very long-stay patients. The most frequent problem behaviours were hostility, physical aggression and incontinence. The one hospital which allowed new admissions to continue indefinitely had the highest proportion of problematic patients. Alternative care facilities were provided by a diverse range of agencies. Large residential homes were the predominant type of provision for most patients, and private nursing homes often accommodated mixed groups of elderly people. NHS trusts catered for most of the 'difficult to place' patients within specialized facilities, based in the community. There were some indications that compromises led to insufficient and understaffed specialist facilities. In view of the increasing demand for long-term intensively staffed facilities, this policy might put an extra burden on the local health services.

Subjective quality of life and standard of living: a 10-year follow-up of out-patients with schizophrenia

In 1984, a study in Goteborg, Sweden, reported the quality of life of 61 out-patients with schizophrenia (DSM-III) to be low, despite their high standard of living. The respondents used an instrument (QLS-100) developed by the author to indicate which of 100 items they considered to be unsatisfactory. Interviews captured objective conditions of the patients' lives and their quality-of-life goals for each unsatisfactory item. The results of the study led during the late 1980s to deliberately individualized services, aimed at helping patients to attain their own quality-of-life goals. In total, 40 of the subjects took part in a 10-year follow-up. The 1994 study showed that the incidence of living alone in one's own home increased. Overall quality of life remained unchanged. Although still low, quality of life increased significantly in three of 14 domains, namely contacts, inner experiences, and knowledge and education. The reasons for these improvements and the maintained overall quality of life could be that patients increased their ability to interact with the environment, that they increased and/or modified their aspirations in the light of available resources and/or deficits, and that housekeeping assistance and service were provided conditional on the patients' own quality-of-life goals and needs.

[Economic perspectives in the care and treatment of patients diagnosed with schizophrenia]

OBJECTIVE

To consider the main problems associated with care and treatment of patients with diagnosis of schizophrenia in the light of the more recent literature of the economic aspects of this pathology.

METHOD

An analysis of the literature related to the social costs of schizophrenia, the economic analysis of different health-care models, and the evaluation of the costs of antipsychotic treatments has been carried out.

RESULTS

Schizophrenia is a pathology creating huge social costs. The health costs associated with the care of schizophrenia take up a significant amount of the resources of healthcare systems in the principal industrialised countries. Indirect costs, due mainly to the patients' exclusion from work, exceed the direct costs of treatment. In those countries where community care has been supported by a real organisational effort to create community and residential services, it has proved to be a cost-effective solution compared with psychiatric hospital-based care and provides patients and family members with better results. The introduction of new antipsychotic drugs and the development of psychosocial support could represent the means of encouraging new healthcare strategies.

CONCLUSIONS

From an economic perspective, the organisation, technological means, and strategies which would allow the available resources to be invested in a rational way must be considered. Consideration of these issues appears to be unavoidable today, not only for the administrators and the policy makers but also for mental health service professionals.

The TAPS Project 41: homes for life? Residential stability five years after hospital discharge. Team for the Assessment of Psychiatric Services

This paper describes pathways followed by 567 long-stay patients who were resettled into the community, as part of a program to close two psychiatric hospitals in London and replace them with community-based services. Sixty-one percent of the former patients remained in their original placement--mostly group homes--over the five-year follow-up. Transition from one house to another mostly took a direct course, with only 27 patients changing houses by way of long intermediate hospitalisation. Change of residence was at the same level of support, with only a slight trend towards less supervised facilities. Ten patients could not be traced and have possibly become homeless. Only 3 patients were in prison during the five-year follow-up. More than a third of the sample were readmitted at least once during that period. It is concluded that community residences established under the resettlement program served as relatively stable homes for the majority of patients.

The Taps Project 40: quality of care provisions for the elderly mentally ill--traditional vs alternative facilities

The study evaluates some aspects of care reprovision for psychogeriatric patients. Seven hospital wards are compared with four community settings, established as part of the reprovision programme for Friern Hospital in London. Each facility was assessed for policy and programme, social climate and physical characteristics; staff attitudes in regard to their tasks, training needs and job satisfaction were also explored. Community settings were superior to hospital wards in providing more privacy for the residents and were better equipped with physical amenities and safety features. There were relatively small differences between the way staff perceived the social climate in community homes and in hospital. The former were regarded as encouraging greater independence. Care staff in the hospital were more likely to express dissatisfaction with pay, working conditions and social status, while community staff were more dissatisfied with the quality of cooperation between staff members. Clients transferred to Social Services facilities had a higher level of functioning and needed less on-site medical care. This was further reflected by the lower frequency of nursing care tasks being performed by staff in community facilities. Overall, the shift towards a less medical model of care in community-based homes appears to be beneficial to psychogeriatric patients, provided that current and prospective physical needs of the residents are adequately addressed.

Costs of schizophrenia

BACKGROUND

Schizophrenia is a common and burdensome illness, with implications not only for the health service but for a host of other care agencies--public and private--as well as for patients, families and the wider society.

METHOD

The paper reviews available UK evidence on the cost of schizophrenia (broadly defined) and on the cost-effectiveness of treatment options and alternative care arrangements. New evidence potentially alters our view of the costs of this illness.

RESULTS

Aggregating the identifiable direct and indirect costs of schizophrenia for England suggests an annual cost of 2.6 billion pounds, but even this sum omits some indirect impacts which cannot currently be costed. Just over half the identified total is accounted for by the direct costs falling to the NHS, local authorities, charities and the criminal justice system. In helping to tackle this cost burden, there is now a body of evidence on cost-effective community care arrangements, antipsychotic drugs and psychological interventions.

CONCLUSIONS

Although the costs of schizophrenia are considerable, there are treatments and care arrangements which can reduce this aggregate burden while maintaining or improving effectiveness.

Cognitive impairment in geriatric chronic schizophrenic patients: a cross-national study in New York and London

Severe cognitive impairment has been reported in large numbers of geriatric chronic schizophrenic patients in the US, with this impairment also being related to severe negative symptoms and adaptive deficits. It is not clear if this impairment is related to the particular environment of the American state hospitals and would not generalize to other countries. In this study, a sample composed of geriatric (age > 70) chronic schizophrenic patients in London, who were assessed by the Team for Assessment of Psychiatric Services (TAPS) (N = 137), and a group of geriatric chronic schizophrenic patients in a New York psychiatric center (N = 86) were compared for the severity of cognitive impairment and on measures of adaptive functioning. Patients received essentially identical Mini-Mental State Examination (MMSE) scores, but differed on 3/4 measures of adaptive functioning. The correlations among all four aspects of adaptive deficit and MMSE scores were very similar in the two samples, suggesting that cognitive deficits and their relationship with adaptive impairments are relatively invariant across different psychiatric systems of care, while adaptive functioning deficits are more variable and possibly more influenced by environmental factors. These data add to previous results suggesting that cognitive impairment is a common feature in poor outcome geriatric patients with schizophrenia.

The TAPS project 38: level of training and its availability to carers within group homes in a London district. Team for the Assessment of Psychiatric Services

This study investigates the professional characteristics of care staff working in group homes for the mentally ill in a north London region. Opportunities for training and staff attitudes with respect to training and career prospects are examined. The majority of care staff are unqualified and in many cases the training needs of staff are not being met. Staff viewed their career prospects as limited. Training that is on offer to staff in principle is often not accessed, possibly owing to budget restrictions. The need for more stringent guidelines on staff training to maintain standards across agencies is highlighted.