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health services

These are shocking figures

25 Sep, 09 | by Steven Reid, Evidence-Based Mental Health

This was the response of a spokesman for the charity Rethink to the results of the national survey of mental health inpatient services published today by the Care Quality Commission (the regulator of health and social care for England). You can see both the national results and those for individual trusts here. Of course, his comments were not a reaction to the three quarters of patients who rated their care as good, very good or excellent. Or the 85% who felt they were made welcome on admission. No, the headline findings are that the majority of respondents felt unsafe at times during their stay on a psychiatric ward, information about their care was lacking, and that only a minority were offered any sort of talking treatment.

I tend to view these surveys with scepticism. The questions are often worded ambiguously and how representative can you be with a response rate of 28%? Yet, the results here surely come as no surprise. It was only last year that the president of the Royal College of Psychiatrists, Dinesh Bhugra, lambasted inpatient units, calling them unsafe, overcrowded and uninhabitable: ‘I would not use them, and neither would I let any of my relatives do so.’

So why are mental health wards so unsatisfactory? Inpatient psychiatry has been neglected as a consequence of the emphasis on community care, a development not limited to the UK (see a previous post ‘A Place of Greater Safety’). Resources were diverted from comparatively expensive inpatient units, with a reduction in bed numbers leaving room only for the most severely ill: in the inner cities detention under the Mental Health Act is almost a requirement for admission. This has led to overcrowded, high-turnover wards filled with patients at their most unwell – is it any surprise that people feel unsafe at times? And faced with this pressure cooker environment the most talented and motivated staff soon joint the flight to fashionable, well-resourced, specialist teams in the community.

The Care Services minister Phil Hope is, um, hopeful: “We will make sure that the experiences people have shared in this report feed into New Horizons, our new vision for mental health.” Of which more later…

Welcome to the asylum!

30 Apr, 09 | by Steven Reid, Evidence-Based Mental Health

If they are not mad when they go into these cursed Houses, they are soon made so by the barbarous Usage they there suffer.
Daniel Defoe, Augusta Triumphans (1728)

“Civil lunatics are people that the society doesn’t want to be roaming around causing problems, unfortunately they are dumped in our prisons”, comments the controller of Enugu Prison in Nigeria. In this article from the BBC Andrew Walker visits a prison where people with mental illness may be detained indeterminately by court order, often on spurious grounds. Given the level of overcrowding in Nigerian jails, the prison service itself is keen for ‘civil lunatics’ to be diverted elsewhere – sounds familiar?

Prison Rehabilitation and Welfare Action
(PRAWA) is a human rights organisation lobbying for the discharge of the mentally ill from prisons. Since 2007 they have managed to get 54 people released from Enugu Prison, clearly an arduous task. And what happens in the community? You can read more about mental health care in Nigeria here.

Interesting fact: there are more Nigerians working as psychiatrists in the UK alone than in the whole of Nigeria.

You’ve Never Had it so Good

27 Nov, 08 | by Steven Reid, Evidence-Based Mental Health

That’s not exactly what he said but Andrew Lansley, the Conservative Party’s shadow health secretary, has been slapped down by the party leadership for suggesting that the economic recession may bring health benefits. This is what he did actually say on his blog:
I’ve been reading up on the impact of previous economic downturns on our health. Interestingly on many counts, recession can be good for us. People tend to smoke less, drink less alcohol, eat less rich food and spend more time at home with their families.

You can’t read this now as the post was swiftly removed from the Conservative Party website but to be fair he prefaced his statement by emphasising that for many the everyday reality of recession does mean human misery. Furthermore it certainly is the case, as he reports, that some economists have identified a variety of health indicators that improve during a depression, a notable exception being that of mental health. His comments have caused the inevitable political spat with calls for his head and Mr Lansley has apologised (presumably through gritted teeth).

What does this rumpus have to do with mental health? Well, Lansley was actually trying to highlight the impact of a recession on mental health. He suggests that the recession may lead to a 26% rise in the number of people suffering with mental health disorders by 2010. I’m not sure where those figures come from – they sound rather speculative to me – but what is clear is that debt and mental health are inextricably linked. Seemingly self-evident, it is a point reinforced by good epidemiological data. A study by Rachel Jenkins and colleagues using data from a national cross-sectional survey demonstrated this association, showing that one quarter of people with mental health problems are living with debt or arrears (compared to one tenth of the general population) and 10% have had a domestic utility disconnected. A timely joint initiative has just been launched by the Royal College of Psychiatrists and the First Step Trust. The aim is to provide guidance on supporting patients with debt and mental health problems, an area of ignorance for many health care professionals. The leaflet ‘Final demand – Debt and Mental Health’ can be accessed here and is informative whether you have mental health problems or not. So Mr Lansley’s comments, deemed nonsensical by many, are actually noteworthy. It’s a pity that they will be lost amidst the shrill cacophony emanating from the Westminster village.

Obama vs. McCain on Mental Health

30 Sep, 08 | by Steven Reid, Evidence-Based Mental Health

No, it didn’t crop up in the first presidential debate – arguably there were more pressing issues to deal with. But the National Alliance on Mental Illness, a US advocacy group, has posted the replies to a questionnaire on mental health care sent to both Barack Obama and John McCain. Unsurprisingly, health care reform features prominently in the campaign platforms of both candidates. The problems are well known: the US has the most expensive health care system in the world, but 47 million Americans remain uninsured with both life expectancy and infant mortality falling well short compared to other developed nations. Dissatisfaction with the status quo is widespread but there is little agreement about how to change it. Mental health care always struggles to get attention until, of course, cases of gross neglect such as that of Esmin Green come to light. So that NAMI were able to get detailed responses from the two presidential candidates is noteworthy, whatever you think of the responses themselves.

Unlike McCain, Obama did answer all 24 questions that were submitted. In fact he responded by “strongly supporting” every point raised by NAMI: he’s all for guaranteeing comprehensive coverage, improving access to services, increasing funding for all, and awarding all of those living with mental illness a $1 million dollar tax-free lump sum (that last part is fiction, but you get the idea). In other words, an adroit political response: overwhelmingly supportive, but promising nothing too specific.

Although John McCain responded with his own statement (his campaign doesn’t do questionnaires), his comments are certainly more revealing than those made by Obama. Firstly, a positive: he recognises the importance of co-existing psychological disorder in chronic medical illness, stating that untreated depression raises dramatically the costs of treating the physical ailments such as diabetes. Let’s integrate psychological care into general medical practice: not much to argue with there. I’m not so sure about his emphasis on “the central role of personal responsibility” which sounds like a rerun of the ‘mental illness equals lack of moral fibre’ argument.  What comes across most clearly, however, is his enthusiasm for cutting costs, mentioned four times here. At least that’s consistent with his overall approach to health care reform: “Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation.” Oh dear.

A Place of Greater Safety

11 Sep, 08 | by Steven Reid, Evidence-Based Mental Health

In the current issue of EBMH John Markowitz makes an impassioned plea for the revival of inpatient psychiatry – which if trends in the US continue may soon become a thing of the past. He pours scorn on the idea that bed days and numbers have been cut because of increased clinical effectiveness and is convinced that the primary motivating factor is reduced costs. This is a view that will be shared, I’m sure, by many mental health professionals in the UK.

Psychiatric beds in England have been cut to about one fifth of the number available in the 1960s. Social and political pressures originally drove the reduction, with perhaps some help from the introduction of chlorpromazine. A principal aim of course was to close the asylums. As a junior doctor I worked in one of these forbidding institutions on the outskirts of London, shortly before its closure. I have to say my abiding memory of working there is one of plentiful space, greenery, and a fairly easy workload. A singular perspective though and anyone looking for a less nostalgic view should take a look at the recently published “Bedlam: London and It’s Mad” by Catherine Arnold. This richly anecdotal social history chronicles the development of the asylum to the Victorian institutions: with as many as 3000 beds these were warehouses where brutality and neglect were commonplace.

Care in the community, to use that rather trite label, is now widely regarded as the ideal model but what remains of inpatient psychiatry? With the development of community services and more stringent criteria for admission, only the most unwell and often most difficult patients get into hospital, an environment that you might struggle to call therapeutic. Unsafe, understaffed, and unsanitary: not surprisingly, newly trained nursing staff are keen to abandon ship as soon as possible and join the specialist community teams. Is ‘the patient experience’ on an inpatient ward really any better than what was provided 40 years ago? Cost, as Markowitz argues, is important and it remains the case that mental health struggles to attract funding, but we also have to ask what we want of inpatient services? Are psychiatric wards simply holding cells for the topping up of antipsychotics, or do we have more to offer?

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