Mental health services I

Case history 1

John is a 23-year-old unemployed, single man who lives with his parents. He has chronic schizophrenia. When he is acutely unwell he becomes distressed because he hears threatening voices, and is suspicious and frightened of his parents. He has threatened his mother in the past, and she is frightened of him, although he has never hurt her physically. Medication is effective in controlling these episodes, but he does not like taking it and often ‘forgets’. Between these episodes he is withdrawn, spending most of his time lying on his bed, with little contact with his family and no friends. His father is angry that he is ‘lazy’ and would like him to move out, but John shows no signs of going.

a Which members of the psychiatric multidisciplinary team should be involved in John’s care, and what are their roles?

b Which team member would be the most appropriate care co-ordinator, and why?

Most mental illnesses are caused by a combination of biological, psychological and social factors. Some patients have complex needs that cannot be met by a single mental health professional. When ill, patients are often unable to fulfil their usual role at home, work and elsewhere, and may neglect or harm themselves. Their behaviour may be odd, impulsive, disinhibited or violent, and this may damage relationships or lead to others being harmed. Social factors such as homelessness and unemployment may act as precipitating or maintaining factors in the illness, and clearly cannot be ignored in treatment. It is essential, therefore, that a mental health service should include psychiatric services, social services, housing agencies, voluntary agencies and others working closely together (Fig. 1). This style of inter-agency working is characteristic of psychiatry and distinguishes it from many other branches of medicine. Psychiatrists usually work in multidisciplinary teams, in a variety of settings, including hospitals and the community.

Fig. 1 Agencies involved in mental health services.

The changing face of psychiatry

The majority of old psychiatric hospitals were built as a result of the Lunatics Act of 1845. They were generally large, imposing buildings in isolated rural locations, cut off from the outside world. The hospitals were rapidly filled, and bed numbers over the following 100 years rose at an alarming rate. In the absence of adequate systems for assessment and diagnosis, many patients were admitted inappropriately and lack of effective treatments meant that management was largely custodial. Patients were generally held against their will and for long periods. Wards were locked, with patients allowed outside only under supervision from staff.

In the late 1930s, electroconvulsive therapy (ECT) was introduced, and there was a slow move towards unlocking wards, voluntary treatment and provision of outpatient services. The number of psychiatric beds began to reduce and this process was accelerated by the discovery of the first effective drug treatment for schizophrenia, chlorpromazine, in 1952. Patients who had previously been very disturbed and difficult to manage improved on this drug, allowing more wards to be unlocked and patients to be discharged. Rehabilitation techniques accelerated the discharge process by tackling the effects of institutional living that in itself left many patients disabled and unable to live independently.

Since then there has been a steady move towards providing psychiatric treatment in the community. Psychiatric inpatient beds have been closed in large numbers (Fig. 2), and long stay residents of the old institutions have been rehoused, some to independent living and others to wards in the community, staffed hostels or supported lodgings. Where possible, patients are now treated in their own homes, outpatient clinics or day hospitals. Inpatient treatment will always be necessary for some and, ideally, should be provided in purpose-built units close to the community that the patient comes from, allowing regular contact with family and friends and a smooth transition from hospital to home when well.