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The outcome of targeting community mental health services: evidence from the West Lambeth schizophrenia cohort

United Medical and Dental Schools of Guy's and St Thomas's Hospital, St Thomas's Hospital, London SE1 7EH. Cambridge Health Authority, Cambridge CB1 5EF Correspondence to: Dr David Melzer, Cambridge Health Authority, Fulbourn Hospital, Cambridge CB1 5EF.

Abstract

Objectives : To report outcome of targeting community mental health services to people with schizophrenia in an inner London district who had been shown, one year after discharge, to have high levels of psychotic symptomatology and social disability but very low levels of supported housing and structured day activity.
Design : Repeat interview survey of symptoms, disability, and receipt of care four years after index discharge. Setting - Inner London health district with considerable social deprivation and a mental hospital in the process of closure.
Subjects : 51 patients originally aged 20-65 years who satisfied the research diagnostic criteria for schizophrenia.
Main outcome measures : Contact with services during the three months before interview, levels of symptoms (from present state examination),global social disability rating.
Results : 65% (33/51) of the study group had been readmitted at least once in the three years between surveys. Recent contacts with community psychiatric nurses and rates of hospital admission increased (8 at one year v 24 at four years, p<0.01; 5 v 13, p<0.06). Conversely, fewer patients were in contact with social workers (17 v 7, p<0.03). Proportions in supported housing, day care, or sheltered work did not change. Unemployment rates remained very high. A considerable reduction (almost a halving) in psychiatric symptoms was observed, but there was no significant change in mean levels of20social disability.
Conclusions : The policy of targeting the long term mentally ill resulted in significant increases in professional psychiatric input ot the cohort but failed to improve access to social workers or suitable accommodation. Improvements in social functioning did not follow from reductions in the proportions of patients with psychotic mental states. Social interventions are likely to be crucial to achieving the Health of the Nation target of improving social functioning for the seriously mentally ill, as improving mental state seems in itself to be insufficient.

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