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PAPERS: Noam Trieman, Julian Leff, and Gyles Glover Outcome of long stay psychiatric patients resettled in the community: prospective cohort study BMJ 1999; 319: 13-16 [Abstract] [Full text]

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Dangerous Inference

Phillip Brewer   (5 July 1999)

Care in the community

Sudip Sikdar   (8 July 1999)

Re: Care in the community

D B Double   (30 May 2000)

Dangerous Inference 5 July 1999
Phillip Brewer, Assistant Professor/Attending Physician Yale University Send response to journal: Re: Dangerous Inference	While encouraging in its outcome, there is a major pitfall which must be avoided in generalizing the favorable results of long-term community placement of this cohort of psychiatric patients. There is a growing problem of patients with psychiatric disorders who also abuse drugs and /or alcohol, the so-called dually diagnosed (DD). It would be a mistake to assume that the DD population would do as well in a setting where access to alcohol and drugs of abuse is facilitated. given the rising preponderance of this group in the psychiatric population, attempts to provide community treatment settings must be matched by effective means to limit access to and use of alcohol and other drugs of abuse.
Care in the community 8 July 1999
Sudip Sikdar Send response to journal: Re: Care in the community	Editor I read with great interest Triemans' paper1 on efficacy of their model of care in the community, but I wonder whether their 'robust evidence' can be generalized to the real world of community care outside the the largely government funded TAPS project. The problem in community care in the real world is predominantly with younger male schizophrenics with comorbid substance abuse and noncompliance with psychotropics and a lack of appropriate community residential settings.The combination of these factors invariably lead to recurrent readmissions but with the dwindling number of inpatient beds (because of the Government initiative on community care), this causes a great deal of commotion and tremendous stress both on patients and on the inpatient facilities. Successfully placing patients in their mid fifties (average age of study population is 54 years), 60% of whom have spent more than 20 years in institutional settings is of course no mean achievement but is in no way reflective of the true reasons of failure in community care for reasons mentioned above. For community care to work, we need more money, stopping of closure of inpatient units and a new mental health act so that smaller number of patient groups can be cared for by assertive outreach work, be it compulsorily. Dr Sudip Sikdar MD, MRCPsych. Specialist Registrar in Psychiatry Park Lodge Orphan Drive Liverpool L6 7UN 1 Trieman N, Leff J, Glover G. Outcome of long stay psychiatric patients resettled in the community: prospective cohort study. BMJ1999;319:13-16. (3 July).
Re: Care in the community 30 May 2000
D B Double, Consultant Psychiatrist 80 St Stephen's Rd, Norwich NR1 3RE Send response to journal: Re: Re: Care in the community	EDITOR- I take Dr Sikdar's point that the situation on acute wards may be different from that on long-stay wards, as studied by the TAPS project. We did find differences when we looked at this issue in Sheffield.1,2 The argument about the failure of community care has been fuelled by the number of homeless mentally ill, but this problem seems to be more related to housing policy that psychiatric dehospitalisation.3 There is little argument that the failures of community have been caused by underfunding, inadequate care and poor management, but the policy has brought many benefits.4 It is important to recognise the reactionary influences which have brought the government to its current position, not least many psychiatrists themselves, who are opposed to community care, because of their loss of power in the traditional psychiatric hospital.5 Psychiatrists' attitudes to community care need to change before it can be said to have been properly implemented. The review of the Mental Health Act should provide further safeguards against the potential abuse of medical power, reinforcing the motivation for the 1983 reforms 6       1. Double DB & Wong TI. What's happened to patients from longstay psychiatric wards? Psychiatric Bulletin 1991; 15: 735-6 http://www.uea.ac.uk/~wp276/outcome2.htm 2. Double DB, Macpherson R & Wong TI. Tracing patients from acute psychiatric wards. Journal of the Royal Society of Medicine 1993; 86: 533-4 http://www.uea.ac.uk/~wp276/outcome3.htm 3. Double DB. Homelessness and mental illness. The Mental Health Policy Website. http://www.uea.ac.uk/~wp276/homeless.htm 4. Double DB. In what sense has community care failed? eBMJ http://www.bmj.com/cgi/eletters/318/7175/3#EL11 5. Double DB. Have psychiatrists failed community care? eBMJ http://www.bmj.com/cgi/eletters/318/7175/3#EL8 6. Critical Psychiatry Network. Response to the consultation document Reform of the Mental Health Act. http://www.critpsynet.freeuk.com/ResponseReform.htm