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rajeevkrishnadas

Deinstitutionalising and Reinstitutionalising

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Thot we could discuss deinstitutionalisng and reinstitutionalising issues.. Issues we can write in an essay...

I have summarised, the findings of a  landmark study which evaluated closure of 2 asylums...

Evaluating asylum closure programs:

TAPS study : Team for assessment of Psychiatric services

( All references to Leff and Treiman B J Psych 2000 – 2002)

Undertaken at 2 north London Hospital Friern and Claybury which closed in 1990s

473 from Friern

200 from Claybury

In addition – 64 difficult to place Friern patients

5 year follow up outcomes of 670 patients discharged to community.

1. No change in symptoms and behavioural problem

2. Significant gains in social and domestic outcome

3. Enrichment of social network

4. Objective improvement in living conditions

5. Patients preferred being out of hospital

6. 19% had died of natural causes (consistent with SMR of Schizophrenia)

7. Re admission rates were 38% over 5 years

8. 1/3 of readmissions became long stay once again.

64 difficult to place from Friern:

Placed in nurse based services

1. No evidence of improvement in mental state

2. Significant improvement in functional abilities

3. Marked reduction in severe behavioural problems

4. 40% were able to move into less supported accommodation

Least satisfactory aspect of closure was its impact on these patients using acute wards in busy general hospitals, which experienced significant pressure.

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Try to think not just about numbers and quotes, but what they mean in real life.

Don't forget R Barton's Institutional Neurosis (1976) or Wing and Brown's 'three hospitals study' in the 1960s. Also the antipsychiatry movement in the 1960s and 1970s and E. Goffman's concept of 'Total Institutions'...

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True... numbers are not important... but the jist of the study...

Starting with history... ( Borrowed from Psychiatry journal)

From early 19th centrury till mid 1950s, dominant resource for treatment of mentally ill remained the lunatic asylum.

Asylums act 1845 - all county autorities had to build asylums and number of inmates rose until mid 50s..

Asylums were institutions, disposal sanctuaries and museums of madness. Treatment was largely moral management.

New mental health act (1959) ; open door movement;  therapeutic community; community care; asylum closure

Intention - mental illness could be treated in acute units like other medical illness, with continuing care in society...

Why deinstitutionalisation:

Factors which led to move towards community based service:

1. Crumbling state of victorian asylums

2. Perception that cheaper non hospital care was available

3. Seminal study published in Lancet 1961 by Tooth et al forecasted a reduced need for beds... later quoted by the then Minister of Health ' ENoch Powell' as one of the rationale behind asylum closure..

4. Criticism of psychiatry - Antipsychiatry movements : Laing, Szaz, Goffman... Media - including films like One flew... stigmatisation of mental illness

Hospital inquiries through 1969 to 1980 - outlined neglect, abuse and 'scandalous practices'

Law 180 in Italy - abolished all mental hospitals in one swoop and banned re admission.

5. Advances in psychopharmacology - CPZ, Imipramine; depot medicaions. Rising number of CMHT, outreach clinics were all part of the advance in psychopharmacology.

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Evidence for failure of Community care?

1. There is evidence to say that patients discharged from psychiatric hospitals were settled appropriately

(Findings of the TAPS study support this finding)

Costs of placing more difficult patients in units are significant.

Potential abuse of ageing, difficult to manage, ex asylum psychotics were exposed in the 'Beech house enquiry'

2. Evidence that Assertive outreach can maintain stability (Marshall and Lockwoods cochrane review)

3. In conclusion, community care, properly provided can improve QOL in serious mental illness. But most disabled patients continue to require 'asylum' in some form.

Problems with chronic patients

1. Dehumanisation and pauperisation of chronically mental ill was a striking feature of deinstitutionalisation.

The Times journalist, Marjorie Wallace, outlined the isolation and neglect of C/c Schizophrenia patients - led to founding of SANE - partial reversal of hospital closure.

Particular problem - non compliant, non engaging, non responder - revolving door, cycling in and out.

2. Homicides commited by mentally ill - Spokes report into Sharon Campbell, who murdered her social worker; Christopher Clunis who murdered Christopher Zito...the failures in the care were numerous and well document... Also adding the recent cases of murder commited by a patient released on leave...

This led to Patients in the Community act (1995) - demanding a supervision register for all risk patients.

CPA, risk management, and mandatory inquiries into any further such incidents

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