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Guest Maram

Assertive out reach & Early intervention teams

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This was a question given in the course(what else ! SuperEgo.)

Discuss how the implications of introducing specialist teams for the delivery of mental health care,with references to Assertive Outreach Teams & Early Intervention Services.

INTRODUCTION :-

Britain,along with most developed nations has now less than a third of the Psychiatric inpatient beds than it had in the 1950’s, from the previous 150,000 in the past to the present 30,000 beds(approximately). The discovery of Chlorpromazine by Delay &amp:lol:eniker in 1952 & Sociologist Erving Goffman’s Asylums published in 1961 which recognised “Institutionalisation” & its negative consequences on patients, both played a part in the reduction of bed provision.

All the above reasons led to the eventual “Care in the Community”. Care in the Community was a policy of the Thatcher Government in the 1980’s. Its professed aim was a more liberal way of helping people with mental health problems, by removing them from impersonal, often Victorian institutions, and caring for them in their own homes. Also, better psychotropic Medication became available and this meant that patients could be treated at home. It was also meant to reduce the cost of institutionalizing so many mentally ill people.

The policy has been beset by problems, not the least of which has been a number of killings by mentally ill people being cared for in their own homes. One of the most high profile failures well publicized by the news media is the case of Jonathan Zito, who was stabbed to death by schizophrenic Christopher Clunis in 1992 in the London Underground .

Care in the Community highlighted the importance of reorganizing mental healh services to prevent loss to follow up of patients & to serve our patients better to improve their quality of life. The Community Mental Health teams initially set up mushroomed into Assertive Outreach teams,Early Intervention teams,Criminal Justice Liason Teams, Crisis Resolution & Home Treatment Teams etc…….

IMPLICATIONS OF THESE TEAMS :-

New research began to emerge with Stein &Test(USA) in the 1980’s with their Seminal paper in the Archives of General Psychiatry highlighted the importance of Assertive outreach services in the management of complex patients preventing hospitalization & preventing loss to follow up. This has subsequently been propogated in the UK by Tom Burns & others…..

Early intervention service for First Episode Psychosis also started in the early 90’s & spread across the western world with the Department of Health has announced its intention to set up 50 Early Intervention Teams to provide care to all young people with a first episode of psychosis in England . Prof Max Birchwood from the Birmingham Service advocated its use in the UK.

There were obvious advantages from both these teams being set up. The assertive outreach team prevented loss to follow up, ensure better engagement between staff & clients, helped clients reintegrate in the community by focusing on the problem solving approach & drug & alcohol awareness work etc…..The Early Intervention Service ensured the duration of untreated psychosis was shortened(any more than 2 years is the single most predictor of poor prognosis in Schizophrenia, Coryell & Gitlin), there by preventing atleast some of the long term effects of Negative & Cognitive symptoms in Schizophrenia. The new services also were working in the communities and so were able to bring the families closer to the clients, help them with accommodation,benefits and employment(in some cases) etc…

Marshall & Lockwood in their Cochrane Review about Early intervention service in the UK could not identify sufficient trials to make any definitive conclusions. The PACE study in Australia showed that it is possible to delay & potentially avert the progression to full diagnostic threshold for psychotic disorder. In high risk individuals using low dose neuroleptics &CBT.

The REACT study Published in the BMJ in 2006 concluded “Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams, but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services.”. Systematic reviews of Assertive Outreach have concluded that when targeted at high users of inpatient services, assertive community treatment reduces the costs of care by decreasing frequency and length of admissions. The Cochrane review concluded that there was a case for a further randomised trial of assertive community treatment in the United Kingdom. The equivocal evidence has not prevented the Department of Health encouraging the implementation of assertive community treatment as a tertiary model of care. (continued in next post)

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By 2004, 263 such teams existed in England

It has been difficult to appraise the efficacy of assertive community treatment in England and other European countries with similar service systems. This was because the models of intensive forms of community care investigated were not based closely on such treatment and did not focus on participants who were difficult to engage. Also, comparison groups in these UK studies were more community based than those in US trials.

The weight of evidene forAssertive Outreach & Early Intervention for Psychosis are encouraging, but unfortunately far from conclusive.

Add to this the other difficulties in staffing(these services potentially deplete staff from existing services, there is some evidence to support this), Problems with classification atleast for early intervention services(as prodrome is not in the ICD-10 or DSM-4) & hence use of mental health legislation can be tricky(how to detain somebody who does not clearly fulfil the category or potentially does not have immediate risks, when he refuses CBT or Neuroleptic medication). Some issues around equality and diversity ( Psychotherapy services for Black and Minority Ethnic clients who cannot speak English, for example) remain, atleast in some services.

CONCLUSIONS:-

The reorganization of Mental Health Services have certainly, atleast partly achieved their objective in preventing hospitalization & preventing loss to follow up resulting tragic incidents. The evidence as highlighted in Cochrane Reviews is encouraging but far from conclusive. Cochrane Collaboration advocates further research . The Government is aiding these services by proposing changes in mental health legislation namely (community treatment orders) & increasing spending in setting up these teams. Clients are less stigmatized because of prevention of hospitalization. These services tend draw staff from existing services & those services suffer as a result. Some pragmatic solutions & innovation are the need of the hour.

Hope it saves some time for folks.........!

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I purposefully did not mention the UK 700study & the PRISM study,as they are quite a bit old & the cochrane review is quite recent.

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Thanks Maram,

thats really helpful!I guess we also need to mention something about crises resolution/home treatment team as well.

best of luck!

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thanks maram. that was very usefull. did the course mention any other hot topics which might come in autum

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thank you mariam. you covered the recent mental service changes since late 70's including principal personnel which i think examiners love it.

Gret work. thanks

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Haven't got the link, but there is a brill AOT essay on trickcyclists. It has all the important refs. Defo read the services section in Oxford textbook - gives a great outline on how to plan a service.

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I am taking my part-2 in spring 2007. These are some of the essays I thought would be important.

1) Stigma (college ran anti stigma campaign but hasnt asked a question on it so far when they finished defeat depression campaign they gave an essay)

2) Caring for carers(Prev President Mike Shooter is a real promotor of this issue, so worth a shout)

3)Bipolar Affective Disorder(recent NICE guidance might sway the the examiners in this direction), something on evidence of psychotherapy in Biploar or something like that.

4) Something about Cannabis and Psychosis( as they are probably going to upgrade cannabis to 'B' class from 'C') may be a general visit of this area.

5)essay on service provision probably eating disorder service or perinatal psychiatry service etc........(Cox & Holden; Kumar etal from the Maudsley are big names in perinatal psychiatry)

6)some focus on children in care(There is an APT article)

I sincerely request people to post their essay plans if they have any(like I did)

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another essay plan would be:-

7)prison suicide & ways to manage them?(Luke Birmingham has an excellent article in the APT a while back)

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Amazing work, well done Maram.

May i point put, however, that essay style means that one must discuss critically - therefore I would summarize that excellent history a little bit and leave some space for a critical discussion in the main body. That's where ypu make your marks..

Citing refs is always good but don;t get too tide up with it - you can pass with none or just one or two.

For ex. - advantages of providing AOT service against costs and potential pitfalls would be desirable.

Good Luck

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It really is an excellent essay!

the problem is...it is too good! Is it really realistic that we are able to write such a well referenced essay in exam situations?

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