Are depot antipsychotics more coercive than tablets? The patient's perspective.

Some clinicians consider depot antipsychotics to be stigmatising, coercive and unacceptable to patients. This cross-sectional study investigated patients' perspectives of coercion for depot and oral antipsychotics. In all, 72 participants with chronic mental illness on voluntary maintenance antipsychotic medication were interviewed for their views on oral and depot medication and experiences of coercion. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Mean total coercion levels were higher for those on depot (depot: mean 4.39; oral: 2.80, P = 0.027), as were perceived coercion (2.52 vs 1.73, P = 0.041) and negative pressures subscales (1.17 vs 0.33, P = 0.009). No significant differences were found for the 'voice' subscale and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, P< 0.001). Depots were perceived as more coercive than oral antipsychotics. Greater perceived coercion may explain why some consider depots to be a more stigmatising form of treatment. Although forced medication is sometimes required, the experience of coercion should be minimised by giving patients a fair say in treatment decisions, regardless of formulation.

Media interventions to increase cervical screening uptake in South Africa: an evaluation study of effectiveness.

Successful cervical cancer prevention depends on reaching, screening and treating women with pre-invasive disease. We aimed to evaluate the effectiveness of two media interventions-a photo-comic and a radio-drama-in increasing cervical screening uptake. A randomized controlled trial compared a photo-comic on cervical cancer screening with a placebo comic. One month after the comics were distributed a radio-drama paralleling the photo-comic was broadcast on the community radio station and a retrospective evaluation was carried out. The trial was set in Khayelitsha, a peri-urban squatter community near Cape Town, South Africa. A random sample consisted of 658 women between the ages of 35 and 65 years, from a stratified sample of census areas. The main outcome measure was self-reported cervical screening uptake 6 months after distribution of the comics. Seven percent (18 of 269) of women who received the intervention photo-comic reported cervical screening during the 6 months follow-up, compared with 6% (25 of 389) of controls (P = 0.89). Women who recalled hearing the radio-drama were more likely to report attending screening (nine of 53, 17%) than those who did not (19 of 429, 4%; P < 0.001). We conclude that the photo-comic was ineffective in increasing cervical screening uptake in this population. The radio-drama may have had more impact, but only a minority of women recalled being exposed to it. Future research must concentrate not only on achieving high level of exposure to health messages, but also on investigating the links between exposure and action.

Persuading the persuadable: evaluating compulsory treatment in England using Supervised Discharge Orders.

BACKGROUND: Supervised Discharge Orders (SDOs) were introduced in 1995, as an amendment to the Mental Health Act in England and Wales. They require patients to abide by specific conditions on discharge from hospital, but can not enforce medication compliance. On introduction, SDOs were received with scepticism by the psychiatric profession. The purpose of this study was to describe the use of SDOs in England and the characteristics of patients made subject to these orders, and to evaluate the effectiveness of the order in securing treatment compliance on discharge from hospital. METHOD: A survey was conducted of 170 mental health provider Trusts in England. Interviews with senior managers in 12 Trusts and associated Local Authorities were subjected to qualitative analysis, and a cohort of patients subject to SDOs in 56 randomly sampled Trusts was described. RESULTS: SDOs were being used for 596 patients (1.2 per 100,000 total population) at the survey date in 1999, and use had been increasing steadily since its introduction. The order is not systematically considered for all potential cases. The majority of the 182 patients in the cohort had complied, if sometimes intermittently, with conditions of the order. CONCLUSIONS: For patients compliant with SDOs, the pressures necessary to treat effectively need not involve powers to enforce medication compliance.

Managing severe mental illness in the community using the Mental Health Act 1983: a comparison of Supervised Discharge and Guardianship in England.

BACKGROUND: Two measures in the English Mental Health Act allow requirements to be imposed upon patients living in the community. These are Guardianship (Section 7) and Supervised Discharge (Section 25A). AIMS: The paper aims to compare patients with mental illnesses, made subject to Guardianship or Supervised Discharge. METHOD: Data on patient characteristics, impairment, needs and interventions were collected from keyworkers in a random national sample of Trusts and local authorities. Ratings were obtained on standardised measures of disability, impairment and needs. RESULTS: Patients placed on Supervised Discharge were more likely to have problems of treatment compliance and drug misuse, whilst those on Guardianship were more likely to have problems of social welfare and higher ratings of disability and impairment. Supervised Discharge has a higher proportion of African-Caribbean patients. Interventions delivered are rated as effective for both measures. CONCLUSIONS: Legal changes proposed in England include a single power for supervision in the community. This should not mean a focus on risk management to the neglect of social welfare interventions.

Expenditure on mental health care by English health authorities: a potential cause of inequity.

BACKGROUND: The York resource allocation formula includes a calculation of the amount needed to purchase mental health services equitably in each health authority in England. However, the amount which is actually spent on services is at the discretion of the authority. AIMS: To compare expenditure on mental health services with allocation, and test the hypothesis that differences between them are to the disadvantage of services in deprived areas. METHOD: A comparison of routine expenditure and allocation data, and linear regression modelling of the ratio of expenditure to allocation. RESULTS: The ratio of expenditure to allocation varies widely. Relative underspending occurs more frequently in deprived areas, although not in the four inner-London health authorities. CONCLUSIONS: The intentions of the York formula are not achieved in practice. The implications of the formula for mental health should be made explicit to health authorities, and shortfalls in mental health expenditure relative to allocation should be justified at a local level.

Psychiatric patients at greatest risk and in greatest need. Impact of the Supervision Register Policy.

BACKGROUND: Mental health provider trusts in England were required in 1994 to establish local Supervision Registers of patients at risk. AIMS: To identify the factors associated with registration, and obtain clinicians' views on its effectiveness. METHOD: At a random sample of 14 trusts data were collected from case notes, key workers and responsible medical officers. RESULTS: A sample of 133 registered patients were more disabled and had more extensive histories of violence and self-harm than 126 comparison patients on the upper tier of the Care Programme Approach (CPA). Those registered were a heterogeneous group. For some there was little evidence of risk. In most cases clinicians did not believe registration had improved care. CONCLUSIONS: The Supervision Register policy has not resulted in the identification of a well-defined group. Its effectiveness is limited by the lack of operationalized measures of risk.

Continuity of care and clinical outcome: a prospective cohort study.

BACKGROUND: Continuity of care is a central objective of community psychiatric services, but there is no consensus about its measurement. AIMS: We developed measures of continuity of care suitable for routine use, and measured continuity and individual patient outcome over a period in which community services were developing. METHOD: One hundred patients with severe mental illness receiving continuing care from two sectorised services were sampled and interviewed. Data were collected concerning their care over 20 months prior to interview. After 20 months prospective follow-up, they were re-interviewed. Continuity was defined as: perceived accessibility of services and knowledge about them, the number of keyworkers in a defined period of time, and the proportion of time out of contact with services. RESULTS: Continuity of care improved significantly on all measures over the period of the study. Individual patient outcome also improved, but in multiple regression models including clinical and demographic variables, measures of continuity were not significant predictors of outcome. Continuity was similar for white and non-white patients. CONCLUSION: Simple measures of continuity are useful in evaluating changes in the process of care, but they are not straightforwardly related to individual outcome.

Routine clinical outcome measures for patients with severe mental illness: CANSAS and HoNOS.

BACKGROUND: Two recently developed measures intended for clinical use are HoNOS (Health of the Nation Outcome Scales), measuring social functioning, and CANSAS (Camberwell Assessment of Need Short Appraisal Schedule), for measuring need. AIMS: We investigated the association between CANSAS and HoNOS. RESULTS: For some domains there were substantial associations, with high HoNOS rating correlated with CANSAS rating of the presence of a need. For other areas the agreement was less than might be expected. Seven factors were identified within the 22 CANSAS domains, and the presence of needs in the Drug/alcohol and Activities of daily living factors was associated with high scores in the related HoNOS domains. CONCLUSIONS: CANSAS and HoNOS assessments differ. HoNOS can track changes in social functioning over time, but may be less useful for treatment planning, and should not be used to infer the level of morbidity in a case-load. CANSAS indicates when treatment should be commenced or continued. It can also be used as a case-load measure, but may be insufficiently sensitive to be used as an outcome measure at the individual level.

Evaluating mental health policy in England. Care Programme Approach and supervision registers.

BACKGROUND: The Care Programme Approach (CPA) and supervision register policies in England are intended to prioritize patients to receive specialist mental health care. AIMS: To describe and evaluate the practical application of the policies. METHOD: A questionnaire survey of key informants in mental health provider trusts and an analysis of aggregated data collected by health authorities using the Mental Illness Needs Index as a measure of population need. RESULTS: On average, 1175 per 100,000 total population are subject to the CPA (95% CI = 1055-1309) and 8.6 per 100,000 (95% CI = 7.5-9.9) are on supervision registers. Wide local variations in the number of people subject to the CPA and supervision registers are not explained by variations in population need. CONCLUSIONS: Prioritization to receive specialist mental health services is carried out inconsistently, and inequitable use of resources may result.

Substance misuse and risk of aggression and offending among the severely mentally ill.

BACKGROUND: The aim of this study was to investigate whether 'dual diagnosis' (substance misuse and severe mental illness) is associated with aggression and offending. METHOD: Twenty-seven people meeting the criteria for both psychotic illness and a substance use disorder and 65 people with psychosis only were interviewed. Case notes were also examined and keyworkers asked to rate substance misuse and aggression. RESULTS: The severity of aggression and offending among this community treatment sample was low. Individuals with a dual diagnosis were significantly more likely than those with psychosis only to report any history of committing an offence (P = 0.001), or recent hostile behaviour (P = 0.001). Keyworkers were more likely to report recent aggression among the dually diagnosed (P = 0.01). Significant differences persisted when we used logistic regression to control for potentially confounding demographic and clinical variables. CONCLUSIONS: Dual diagnosis may be an important factor in aggression and offending among severely mentally ill individuals in inner-city areas. Accurate risk assessment requires examination of substance use.

Can deinstitutionalised care be provided for those at risk of violent offending?

OBJECTIVE: The aim of this article is to explain the current status of deinstitutionalisation and of community care development in the UK. DESIGN: Literature review of articles and reports on deinstitutionalisation. SETTING: Articles included in the review related either to the whole of the UK, to England and Wales, or to a specific area such as London. MAIN OUTCOME MEASURES: The review was carried out pertaining to the question of the extent to which community care can or should take over the functions of the asylum, with particular reference to those at risk of behaving violently. These functions include those that are manifest, or explicit, and those that are latent, or unintended but implicit (Bachrach, 1976). RESULTS: The example of patients at risk of violent behaviour is-one that highlights the continuing relevance of both these sets of functions, which are argued to be exerting a powerful influence on the processes of asylum closure and community care development. This influence is seen in delayed asylum closure, transinstitutionalisation (the shift of some patients from asylums to other institutions), and the institutionalisation of aspects of community care. CONCLUSIONS: Both the manifest and the latent functions of asylums must be acknowledged by those involved in planning community care; where it is felt desirable that community care does not take over certain functions, the consequences of this must be anticipated so that they can be prevented or dealt with in other ways.

Integration between primary and secondary services in the care of the severely mentally ill: patients' and general practitioners' views.

BACKGROUND: Communication between secondary and primary care is an important aspect of continuity of care. We investigated communication between general practitioners (GPs) and psychiatric teams about a representative group of patients with severe mental illness (SMI). We also sought views on GP involvement in care from the patients and their GPs. METHODS: One hundred patients with SMI were randomly selected from those under the care of two psychiatric sector teams in inner London. The patients and their GPs were interviewed. RESULTS: GPs' knowledge about the care their patients received was limited. Most GPs perceived their role as providing physical care and prescribing. Few patients consulted GPs for mental health care. GPs perceived themselves as less involved in the care of Black Caribbean or Black African patients. CONCLUSIONS: Considerable discontinuities of care between secondary and primary care were identified. GP involvement in the care of patients with SMI appears limited. Better communication is necessary if care is to be shared.

Continuity of care for the severely mentally ill: concepts and measures.

Very few useful measures of service functioning are as yet available for the evaluation of mental health services. Continuity of care has been identified as "the strategic first choice" for the development of such process measures. The term "continuity" has been used to refer to a variety of important aspects of service functioning, including whether services maintain contact with patients, whether patients consistently see the same staff, success of transfer between services, degree to which plans for services are followed through, integration between service providers, and comprehensiveness in meeting patient's individual needs. In this paper, we reviewed the main theoretical definitions of continuity of care for the severely mentally ill, and discussed the work that has attempted to operationalise these definitions and to apply them in the study of mental health services. We concluded that whilst continuity of care has had a central place in theoretical discussions of community service planning, progress in developing and applying practical measures has so far been sporadic and limited. Obstacles to such research have included great diversity in definitions of continuity and the confounding influence of individual patient characteristics on the relationship between service process and outcome. Despite these limitations, research in this field has indicated that developing and applying measures of continuity of care may be feasible and produce useful results with findings of some of the studies suggesting a relationship between continuity of care and individual outcome.

Combination treatment with noradrenalin and serotonin reuptake inhibitors in resistant depression.

Eight cases of resistant recurrent depression were treated with a combination of nortriptyline and a new serotonin reuptake inhibitor, with or without concurrent lithium therapy. Significant improvement was seen in all patients where other drug regimes and ECT had been ineffective. No adverse reactions occurred in any of our patients, seven of whom were elderly. The combination treatment was more effective than individual therapies alone.

Oxidized low density lipoprotein induces ceroid accumulation by murine peritoneal macrophages in vitro.

The presence of ceroid pigment inclusions within macrophage foam cells is a well-recognized phenomenon in human atherosclerosis but its significance is unclear. Murine peritoneal macrophages, maintained in a medium containing 10% lipoprotein-deficient fetal calf serum to which oxidized low density lipoprotein (LDL) has been added, rapidly accumulate similar ceroid inclusions. However, cells exposed to LDL, acetyl--LDL or dextran sulphate--LDL complexes fail to develop ceroid under the same culture conditions. Oxidation of LDL results in considerable physico-chemical changes to both protein and lipid moieties, and these may be important in the uptake of the particles by macrophages and, subsequently, the accumulation of intracellular ceroid.