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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.

Introduction

Community care for mentally ill people remains controversial after three decades of mental hospital bed closure.¹ Few systematic data exist on the fate of acutely ill patients since the policy of deinstitutionalisation was adopted in Britain,² especially psychotic people in inner cities, who are most likely to experience abandonment and homelessness.³ While a recent large scale study in an outer London district reported relative optimism,⁴ a study in inner London of schizophrenic patients one year after hospital discharge showed that 55% had psychotic mental states and 22% were functioning socially at very poor or severely maladjusted levels.⁵ Most were in touch with health care services but there was little targeted provision, especially of day care or supported accommodation.

Following this study the mental health service in West Lambeth implemented several improvements in the care of seriously mentally ill people by redeploying existing resources. The total numbers of community psychiatric nurses in the adult services changed very little (20 in 1989 and 19 in 1992), but their allocation and working practices were altered. At the time of the initial study over half of the community psychiatric nurses were either part of the long stay resettlement programme or mainly providing counselling services. Those nurses who were working with chronic "revolving door" patients had large case loads, with no priority being given to the long term mentally ill. Three years later twice as many community psychiatric nurses were working with these patients, each one having a smaller case load. New community teams were in the process of implementing a case management approach^6,7 with assertive follow up of high priority cases held on a case register.⁸ In addition, consultant catchment areas and attendant resources, originally allocated purely on raw population data, were weighted to reflect measures of social deprivation, a better predictor of use of psychiatric services.^9,10 To evaluate the impact of these changes, a further follow up of the original cohort patients from West Lambeth was undertaken four years after the index discharge. Receipt of services, symptoms and social functioning were measured with the original instruments.

Patients and methods

Study area

The service studied provides specialist mental health care to the seventh most underprivileged district health authority in the United Kingdom,⁹ which has unemployment rates above 20%. The 1991 census reported a population of 144000, 18.5% being Afro-Caribbean.

Study group

The original study group consisted of the 90 psychiatric inpatients in West Lambeth aged between 16 and 65 years with a diagnosis of probable or definite schizophrenia (on research diagnostic criteria¹¹ screening of case notes) discharged between 1 November 1987, and 30 April 1988. One year later, four patients had died (three by suicide); 58 patients were interviewed directly and information was obtained from a carer in a further 19. The present study group for interview included the 58 patients who were interviewed face to face in the one year follow up and case notes were traced for the patients whose carers were interviewed. As before, patients were interviewed in their own homes where possible, and if it was appropriate a carer was seen. If patients refused to be interviewed a carer was seen with the patient's permission. Interviews took place between November 1991 and April 1992.

Information collected

As in the first study, the present state examination (a standardised psychiatric examination of patients interviewed directly)¹² was used to assess current mental state. The World Health Organisation's disability assessment schedule¹³ gave a measure of each patient's global social functioning, based on assessments of behaviour, social performance, and any modifying social factors. A questionnaire derived from the treatment outcome study questionnaire developed by the Colorado state treatment outcome programme¹⁴ was also used. This covered demographic details, accommodation, employment, finances, home activities, legal difficulties, use of medication, service receipt, and patients' wishes for services they were not receiving. All assessments were carried out by one of the authors (AC).

Analysis

Data from the present state examination were initially processed with the Catego program,¹² and all data were analysed with the Statistical Package for the Social Sciences PC+.¹⁵ Statistical tests used included the McNemar test for changes in dichotomous variables, Spearman's rank correlation, and paired t tests. Changes at the 5% probability level were considered statistically significant.

Results

Response

Of the 58 patients who were interviewed at the one year follow up, 44 were interviewed in person at four years and a carer was seen for a further seven. Two patients had died (one of these by suicide), four refused to cooperate, and one was untraceable, giving a response rate of 88%. Thirty seven of the 51 respondents were still living in the district, and only three had moved out of London. Recent case notes of 15 of the 19 patients whose carers were interviewed were traced; no deaths were recorded in these.

Demographic details and psychiatric history

Thirty (59%) of the respondents were male. The mean age at the four year follow up was 40.4 (range 20-65) years and 28 (55%) were single compared with 33 (65%) at one year follow up. Table I gives details of ethnic origin and history of illness up to four year follow up. Thirty three patients (65%) had been readmitted at least once during the three years after the original survey and 24 (47%) had been readmitted in the year before the second interview.

Accommodation

Table I also gives details of the type of accommodation at four year follow up. At the first interview no patients were in hospital and 11 (22%) were in specialised housing (a hostel, group home, or residential home). No patients at either time had been homeless or in prison in the three months preceding the interview. Of the 36 who were neither in hospital nor in specialised accommodation at the second interview, 16 (45%) were living alone.

TABLE I - Ethnic origin, history of
illness, and type of accommodation
of schizophrenic patients interviewed
four years after discharge
-------------------------------------
                               No of
                             patients
Characteristic                (n=51)
-------------------------------------
Ethnic origin:
Afro-Caribbean                 20
Asian                           3
White                          27
Other                           1
Duration of illness (years)*:
<5                              5
6-10                           19
11-20                          18
>21                             9
Longest ever stay in mental
hospital:
0-3 months                     17
3-6 months                     15
6-12 months                    11
>1 year                         8
Accommodation:
Hospital                        5
Specialised                    10
Council                        24
Other rented                    7
Owner occupied                  5
-------------------------------------
 *From first psychiatric admission to
interview at four years after index
discharge.

Employment and finances

Forty three people (84%) were unemployed at the four year follow up, 39 (76%) for at least one year and 35 (69%) for at least five years. Seven patients were in paid employment (two full time) and one person was in sheltered employment (at both interviews). The unemployment rate was almost identical at the two interviews; over 60% of patients depended on social security benefits for all their income. Half (24/48) of those receiving benefits at the second interview were receiving the same or lower amounts of benefit income in unadjusted money terms than at the first interview.

Service use

Table II shows receipt of health and social services during the three months preceding each follow up. Five patients (10%) were seeing only their general practitioner. Fifteen patients who did not have contact with a social worker said they would like to have one, particularly for help with managing debts, benefits, and housing.

TABLE II - Numbers of patients (n=51) using services at least once in
three months before interview
-----------------------------------------------------------------------------
                                              Follow up
                               ----------------------------------------------
Service                        One year       Four years         P value*
-----------------------------------------------------------------------------
Health:
Inpatient (psychiatric)           5               13              <0.06
Outpatient (psychiatric)         35               30               0.12
Day hospital                      7                5               0.73
General practitioner             34               26              <0.06
Community psychiatric nurse       8               24              <0.01
Other nurse                      14                6              <0.04
Occupational therapist            4                2               0.63
Any of the above                 50               49               1.00
Social:
Social worker                    17                7              <0.03
Day care(dagger)                 11               13               0.75
-----------------------------------------------------------------------------
 *McNemar test.
 (dagger)Day centre, drop in centre, or industrial therapy.

Thirty eight patients had not been inpatients during the three months before interview. With structured day occupation defined as employment or attendance at any day centre or day hospital for at least one half day in the past three months, 17 (45%) were occupied at one year follow up and 21 (55%) at four year follow up.

Drug treatment

Forty seven people (92%) were being prescribed psychotropic drugs at the four year follow up, compared with 40 (78%) at one year (p<0.01). There was a small increase in the numbers prescribed oral or depot neuroleptic drugs and anticholinergic drugs and a significant increase in the numbers prescribed antidepressants (1 (2%) v 6 (12%)) and mood stabilisers (2 (4%) v 11 (22%)) (p<0.005).

Clinical state

Table III gives details of patients' clinical states at the follow ups; it shows that the proportion of patients with psychotic mental states was approximately halved (McNemar p<0.02). Table IV shows the global social adjustment score at follow ups. Mean global disability score did not differ significantly on paired t testing. There was some regression towards the mean, with those who had been functioning poorly tending to improve and those who had been functioning well tending to worsen. Change in the numbers of symptoms of delusions and hallucinations was not significantly correlated (Spearman r) with change in social functioning.

TABLE III - Mental state of patients interviewed directly one year and
four years after discharge (n=44)
-----------------------------------------------------------------------------------
                                       Mental state at one year*
                             ------------------------------------------------------
Mental state at four years   Psychotic     Neurotic     Other    None    Total
-----------------------------------------------------------------------------------
Psychotic                       14            2           0       0       16
Neurotic                         4            0           1       2        7
Other                            7            3           6       1       17
None                             1            0           2       1        4
-----------------------------------------------------------------------------------
Total                           26            5           9       4       44
-----------------------------------------------------------------------------------
 *Present state examination diagnostic class (by Catego program).

TABLE IV - Global social adjustment scores at one and four years after discharge in 51 schizophrenic patients
------------------------------------------------------------------------------------------------------
                                              Global social adjustment at one year*
                                 ---------------------------------------------------------------------
Global social adjustment at                                              Very poor/severe
four years                            Excellent/good      Fair/poor       maladjustment      Total
------------------------------------------------------------------------------------------------------
Excellent/good                              11               9                 1              21
Fair/poor                                    7              10                 4              21
Very poor/severe maladjustment               0               6                 3               9
------------------------------------------------------------------------------------------------------
Total                                       18              25                 8              51
------------------------------------------------------------------------------------------------------
 *WHO disability assessment schedule global disability rating.

Mean global social disability was significantly associated with psychiatric inpatient admission in the three months and the year before inteview (two tailed t test p<0.005). Provision of other services was not related to current level of disability, and neither the global disability score at one year follow up nor the change in disability score predicted service use at follow up.

Discussion

The long term outcome of schizophrenia is complex, showing varying patterns of fluctuation in symptoms and disability over time as a function of interaction with the social environment.*RF 16-18* The current study has followed up a group consecutively discharged from an inner city catchment area service, measuring symptoms, circumstances, and social disability at one and four years after index discharge. Previous findings of high morbidity but limited community support⁵ and poor service targeting¹⁹ contributed to the local policies giving priority to care of long term seriously mentally ill patients in the community, as well as to resettling long stay patients. These changes resulted in increased contacts with specific psychiatric services, mainly through increases in hospital admission and contact with community psychiatric nurses, but input from other nursing services, general practitioners, and social workers was reduced. The sample in this study is no longer representative of all discharges of people with schizophrenia within the catchment area, as only those individuals who were interviewed in person in the first study were followed up again. Patient characteristics and length of illness did not differ significantly in those followed up and those whose carers were interviewed, but five patients with poor social functioning were lost to follow up. The results set out in this paper are the outcome of a group biased towards better social outcome, suggesting that the picture for the whole cohort may be less optimistic.

Psychotic symptoms

The observed reduction in psychotic symptoms cannot be explained by a "burn out" of symptoms with time as symptom change was not associated with length of illness. However, the reduction may be attributable to increased contact with psychiatric services. Increased admission rates may be partly due to closer supervision and monitoring by community psychiatric nurses, leading to earlier detection and referral to hospital. This agrees with the findings of the previous study,⁵ in which the district with the community oriented service had higher admission rates, implying that such a team can facilitate hospital admission in the absence of other community services to deal with relapse or declining social functioning. This contrasts with the stated goal of many community services, including the one studied - namely, avoiding admission.

Prescribing increased, as presumably did acceptance of all forms of psychotropic drug treatment. In particular, more patients were prescribed antidepressants and mood stabilisers, which may reflect better detection of concurrent depression or change in primary diagnosis. As depression rather than ongoing psychotic symptoms seems to best predict suicide in schizophrenic patients,²⁰ changed prescribing might influence the suicide rate, which has been targeted for reduction in The Health of the Nation.²¹ The apparent reduction in suicide rates compared with the earlier follow up period is encouraging, although it remains unclear whether this is due to improved vigilance and contact rates or reduced psychosis and depression because of a higher prescription rate of psychotropic drugs.

Social functioning

Despite the reductions in psychotic symptoms, mean social functioning did not change, although some regression towards the mean did occur. This dissociation between symptoms and social functioning in the absence of service change*RF 22-24* has been recognised.²⁵ Some studies, however, have suggested some relation between symptom severity and social outcome, at least in specific areas of functioning,⁴ but interventions that benefit mental state have not been causally linked with social functioning. Even when programmes of active social rehabilitation are in place, there may be considerable delays between treatment and improvement in social functioning,²⁶ and a core of very dependent patients will persist.²⁷ The measured pattern serves as a warning that health service targeting alone may well not be sufficient to improve social functioning, which is another major Health of the Nation target for mentally ill people.

The relatively poor social outcome in this group may be partly determined by the high levels of social deprivation in the district.^28,29 Unemployment rates were high compared with those in other studies,³⁰ and most sheltered workshop places were permanently occupied by former long stay patients. Patients tended to be socially isolated and to lack a confiding relationship, and many were financially poorer than three years previously. Only a minority were in supervised or specialised housing.

The greatly reduced contact with social workers is worrying. Fewer patients were allocated a case worker in the community or followed up by hospital based social workers after discharge. This was partly accounted for by social workers' substantially increased responsibilities for child care and partly by the disruption caused by reorganisation. These patients still regarded access to a social worker as particularly important as they were preoccupied with finances and accommodation. The low rate of contact with social workers raises concerns in the context of their new role as case managers, organising and coordinating services for long term mentally ill people.

The reduced contact with general practitioners indicates a need for closer liaison with primary care so that both the psychiatric needs and the considerable physical needs of chronically mentally ill people³¹ can be met. General practitioners tend to perform mental state assessments and adjust drug regimens less often than for long term physically ill patients,³² and some have expressed a wish for sharing care with psychiatric services.³³

In conclusion, this study has shown that deliberately targeting care to long term mentally ill people in a deprived inner city area resulted in increased receipt of services - in particular, hospital admissions, care by community psychiatric nurses, and prescription drugs. The outcome in the patients studied was a reduction in psychotic symptoms but no change in mean social functioning, underlining the independence of clinical and social outcome in schizophrenia. High rates of unemployment and inactivity persisted, and the numbers in specialised accommodation did not change. The Health of the Nation emphasises that improving services can do much to reduce the harm that mental illness can cause and outlines targets for improving both health and social functioning of those suffering from a mental illness.²¹ These targets will not be achieved with patterns of community care such as those found in this study, in which very few patients are receiving coordinated packages of social care to address poor social functioning. There is a need for comprehensive treatment programmes involving long term social activity as well as assertively delivered medical care.

We are grateful to the patients and their relatives who volunteered to be interviewed and to Professor T Craig for his advice.

1. Lamb HR. Lessons learned from deinstitutionalisation in the US. Br J Psychiatry 1993;162:587-92. [Abstract/Free Full Text]
2. Shanks J. Mental illness services in Britain: counting the costs, weighing the benefits. Hosp Community Psychiatry 1989;40:878-9. [Abstract/Free Full Text]
3. Craig T, Timms PW. Out of the wards and on to the streets? Deinstitutionalisation and the homeless in Britain. J Ment Health 1992;1:265 -75.
4. Johnstone EC. Disabilities and circumstances of schizophrenic patients - a follow-up study. Br J Psychiatry 1991;159:(suppl 13):13-20.
5. Melzer D, Hale AS, Malik SJ, Hogman GA, Wood S. Community care for patients with schizophrenia one year after hospital discharge. BMJ 1991;303:1023-6.
6. Intagliata J. Improving the quality of community care for the chronically mentally disturbed: the role of case management. Schizophr Bull 1982;8:655-74.
7. Shepherd G. Case management. Health Trends 1990;2:59-61.
8. Olfson M. Assertive community treatment: an evaluation of the experimental evidence. Hosp Community Psychiatry 1990;41:634-41. [Abstract/Free Full Text]
9. Hirsch S. Psychiatric beds and resources: factors influencing bed use and service planning. London: Gaskell/Royal College of Psychiatrists, 1988.
10. Thornicroft G. Social deprivation and rates of treated mental disorder. Developing statistical models to predict psychiatric service utilisation. Br J Psychiatry 1991;158:475-84. [Abstract/Free Full Text]
11. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria instrument No 58. New York: New York State Psychiatric Institute, 1975.
12. Wing JK, Cooper J, Sartorius N. The measurement and classification of psychiatric symptoms. Cambridge: Cambridge University Press, 1974.
13. World Health Organisation. WHO psychiatric disability assessment schedule. Geneva: WHO, 1988.
14. Ellis RE, Wilson NZ, Foster MF. Statewide treatment outcome assessment in Colorado: the Colorado client assessment record. Community Ment Health J 1984;20:72-89. [Medline]
15. Norusis MJ. Statistical package for the social sciences PC+. Chicago: SPSS, 1986.
16. Ciompi L. Is there really a schizophrenia? The long-term course of psychotic phenomena. Br J Psychiatry 1984;145:636-40. [Abstract/Free Full Text]
17. Harding CM, McCormick RV, Strauss JS, Ashikaga T, Brooks GW. Computerised life chart methods to map domains of function and illustrate patterns of interactions in the long-term course trajectories of patients who once met the criteria for DSM-III schizophrenia. Br J Psychiatry 1989;155(Suppl 5):100-6
18. Watt DC, Katz K, Shepherd M. The natural history of schizophrenia: a five year prospective follow up of a representative sample of schizophrenics by means of a standardized clinical and social assessment. Psychol Med 1983;13:663-70. [Medline]
19. Johnstone EC, Owens DGC, Gold A, Crow TJ, MacMillan JF. Schizophrenic patients discharged from hospital - a follow-up study. Br J Psychiatry 1984;145:586-90. [Abstract/Free Full Text]
20. Addington DE, Addington JM. Attempted suicide and depression in schizophrenia. Acta Psychiatr Scand 1992;85:288-91. [Medline]
21. Department of Health. The health of the nation: a strategy for health in England. London: HMSO, 1992.
22. Lee PWH, Lieh-Mak F, Yu KK, Spinks JA. Patterns of outcome of schizophrenia in Hong Kong. Acta Psychiatr Scand 1991;84:346-52. [Medline]
23. Breier A, Schreiber JL, Dyer J, Pickar D. National Institute of Mental Health longitudinal study of chronic schizophrenia. Prognosis and predictors of outcome. Arch Gen Psychiatry 1991;48:239-46. [Abstract/Free Full Text]
24. Carone BJ, Harrow M, Westermeyer JF. Posthospital course and outcome in schizophrenia. Arch Gen Psychiatry 1991;48:247-53. [Abstract/Free Full Text]
25. Shepherd G. The management of schizophrenia in the community: what services do we need? In: Jenkins R, Field V, Young R, eds. The primary care of schizophrenia. London: HMSO, 1992.
26. Thornicroft G, Breakey WR. The COSTAR programme. 1: Improving social networks of the long-term mentally ill. Br J Psychiatry 1991;159:245-9. [Abstract/Free Full Text]
27. Lawrence RE. The impact of community care on the course of schizophrenia in Kidderminster. In: Hall P, Brockington IF, eds. The closure of mental hospitals. London: Gaskell/Royal College of Psychiatrists, 1991.
28. Rice P, Irving D, Davies G. Information about district health authorities in England from the 1981 census. London: King's Fund, 1984.
29. Wing JK. Meeting the needs of people with psychiatric disorders. Soc Psychiatry Psychiatr Epidemiol 1990;25:2-8. [Medline]
30. Scottish Schizophrenia Research Group. The Scottish first episode schizophrenia study. VII. Two-year follow-up. Acta Psychiatr Scand 1989;80:597-602. [Medline]
31. Bhugra TS, Wing JK, Smith BL. Physical health of the long term mentally ill in the community. Is there unmet need? Br J Psychiatry 1988;155:777-81.
32. King MB. Management of patients with schizophrenia in general practice. Br J Gen Pract 1992;42:310-1. [Medline]
33. Kendrick T, Sibbald B, Burns T, Freeling P. Role of general practitioners in care of long term mentally ill patients. BMJ 1991;302:508-10.

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