COMPULSORY PSYCHIATRIC ADMISSIONS

IN ENGLAND: 1984–1996

		0.14																							30,000
Proportion of all admissions	that were compulsory	0.12																							25,000	Total compulsory admissions
		0.10																							20,000
		0.08
																									15,000
		0.06
		0.04																							10,000
		0.02																							5000
		0																							0
		1984	1985	1986		8		9			90		1		2		3		4		5		6		7
					–		–					–		–		–		–		–		–		–
					1987		1988			–		1990		1991		1992		1993		1994		1995		1996
									1989

Year of admission

Figure 5.6 Despite the policy of care in the community there was a rise in total admissions between 1984 and 1996, and a rise in the proportion of compulsory admissions. A combination of increased prevalence of comorbid drug misuse, reductions in available bed numbers (a reduction of 43 000 in the UK between 1982 and 1992), and changes in the thresholds for admission and discharge, has meant that patients are more severely ill before admission, and services are under greater pressure, leading to a paradoxical increase in the use of compulsory detention. (Bars represent the total number of compulsory psychiatric admissions to NHS facilities and the line represents the proportion of all admissions that were compulsory in England, 1984–96. Data on compulsory admissions not available for 1987–89). Figure reproduced with permission from Wall S, Hotopf M, Wessely S, Churchill R. Trends in the use of the Mental Health Act, England 1984–1996. Br Med J 1999;318:1520–1

schizophrenia which act as disincentives to early referral and treatment.

Managing schizophrenia in the community

The move toward treating people with schizophrenia in the community (Figures 1.15 and 5.6) was made possible (both clinically and politically), from the 1950s onwards, by the introduction of effective antipsychotic drugs. The purpose of this was to give patients with psychosis a better quality of life, and there is no doubt that patients generally prefer to be treated in their own home rather than in hospital (Figure 5.7). However, since drug treatment was so crucial to the move towards community care, the delivery and monitoring of

medication became a major preoccupation of the organizational systems that developed to support it. A second priority, intermittently reinforced by clinical scandal and catastrophe, has been the assessment and management of the risks, both perceived and real, associated with the shift of care away from the relatively secure and contained environment of the hospital ward. Thirdly, the new community mental health teams needed to lubricate the interactions between their ill and sometimes institutionalized patients and the complex bureaucracies – housing, social security, the judicial system, employers – of the outside world. However, none of this should distract us from the objective of delivering better care, and the awareness that good care involves more than simply drug treatment.

©2002 CRC Press LLC

ASSESSMENT OF CARE IN THE COMMUNITY

Switzerland

Sweden

Denmark

Netherlands

Spain

Italy

Germany

France

UK

0%		20%		40%				60%		80%		100%
				Percentage of doctors
		adequate				poor

Figure 5.7 Prior to the 1950s and the introduction of effective antipsychotic treatment, most patients with schizophrenia would have been institutionalized in largescale psychiatric hospitals. This painting from 1843 shows one such hospital in Gartnavel, Glasgow, UK

Figure 5.8 An international study of pyschiatrists’ attitudes to community care. Note that the countries in which psychiatrists have the most positive attitudes, Switzerland, Denmark, The Netherlands and Germany, have the highest per capita spending on mental health services

©2002 CRC Press LLC