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COMMUNITY TREATMENT ORDERS FOR MENTAL ILLNESS
1457 Recent shifts in the structure of health services in China raise the question, on a vast scale. With the dissolution of rural agricultural communes in 1978-80, collective financial support for the village basic health worker ("barefoot doctor") disappeared in most localities. Government permission and support has been given for private health services. While firm information is hard to find, Dr Li Quing of the department of social and administrative medicine, Beijing Medical University, tells me that 42% of 716 639 village health units are strictly private, and another 11 % are operated under contract, usually between rural doctors and local industrial employers. Thus primary health care is largely under private control. Dr Ma Ming-Gang, epidemiologist at Beijing Medical University, estimates that only about 5% of villages maintain a cooperative-based health service now, and that 60% of all health-care expenditure in China is "self-pay". Out-of-pocket expenses for medical visits are surprisingly high, appearing to represent a substantially greater percentage of disposable income than in western countries, and to limit access for rural families? These changes in Chinese health services seem to have been a purely accidental consequence of the abandonment of the agricultural commune system. Personal costs for care are increasing. At the same time, widening economic gaps develop between winners and losers in the population as free-market innovations work their effect on the economy. Will this leave a large segment of the population critically underserved? I know of only one "before-andafter" study in China that addressed this question.3 Methods for studying the issue exist,4 and this is a good time to begin. same
Department of Family Medicine, University of North Carolina School of Medicine,
WILLIAM L. ALDIS
Chapel Hill, North Carolina 27514, USA
1. Hsiao W. Transformation of health care in china. N Engl J Med 1984; 310: 933. 2. Henderson GE, Cohen MS. Health care in the people’s republic of China: a view from inside the system. Am J Publ Health 1982; 72: 1238.
3.Huang SM. Transforming 1988; 27: 879.
China’s health
care
system:
a
village study. Soc Sci Med
4. Alderman H, Gertler P. The substitutability of public and private health care for the treatment of children in Pakistan. (Wld Bank Pub no 11237). New York: World
Bank, 1989.
second year 9 had been brought back into regular treatment; 1 continued to refuse treatment and contact was lost with the other. In 3 of the 9 cases treatment was started again after imprisonment and subsequent transfer to hospital under Section 37 (with a restriction order under Section 41). They had been convicted of armed robbery, indecent assault, and assault, all the offences being committed when floridly psychotic. 4 of the 9 were brought back into treatment after admissions under Section 3: 1 had assaulted his father and a visiting psychiatric nurse and another had repeatedly threatened his father with violence. Of the remaining 2 patients, 1 was taking treatment from his general practitioner and had refused all contact with psychiatric services and the other displayed mainly negative features of schizophrenia; both agreed to restart depot injections from a community psychiatric nurse after mild relapses. The patient who continued to refuse treatment had, while in an earlier relapse, thrown hot water over a relative and attempted suicide. The findings confirm the increased risk of relapse in patients who fail to receive adequate maintenance therapy’ and the serious adverse consequences that can be associated with relapse. We have identified 11 patients for whom a community treatment order post discharge would have been appropriate. Without this, the only means of ensuring continuity of treatment is through a Home Office restriction order or probation order; neither are intended for this purpose and they can be applied only after an offence has been ctmmittec9_ The London Hospital London E3 4LL
hospital admission. During an audit of the use of depot antipsychotic medication in Tower Hamlets Health District (population 145 000) we identified on one day in 1986 all patients being prescribed depot injections (n=340). We extracted data from case-notes on the process and outcome of their psychiatric care over 2 years. During the first year 61 patients were discharged from hospital. 22 had been subject to compulsory hospital admission orders, 8 having been held under Section 2 (for assessment), 9 under Section 3 (for treatment), and 5 under Section 37 (court order for treatment) of the Mental Health Act 1983. By the end of the first year 10 of the 14 admitted compulsorily under sections 3 or 37 and 1 of the 8 who had been subject to a section 2 admission were persistently refusing further treatment with depot injections. In a further 2 cases (both section 2) injections had been discontinued by a psychiatrist. Males (9/12) were more likely to be refusing treatment than females (2/8). 10 patients refusing injections had schizophrenia or schizoaffective disorder, 4 of whom also abused alcohol or cannabis; 1 had bipolar affective disorder. In all 11 it was a relapse that had led to their index admission and in 9 that had been associated with refusal of depot injections already instituted; in 6 patients, at least two previous admissions followed the refusal of all treatment. The outcome of the group refusing injections was very poor. During the second year of follow-up 10 of them relapsed (compared with 2 of the 9 who continued treatment) and by the end of the
STUART MCLAREN
JOHN COOKSON
1. Johnstone EC, Owens DGC, Gold A, Crow TH, MacMillan JF. Schizophrenic patients discharged from hospital: a follow up study. Br J Psychiatry 1984; 145: 586-90.
Royal College of Psychiatarists. Community treatment orders: a discussion document. London: Royal College of Psychiatrists, 1987. 3. Davis JM. Overview: maintenance therapy in psychiatry: I schizophrenia. Am J Psychiatry 1975; 132: 1237-45. 4. Johnson DAW, Pasterski G, Ludlow JM, Street K, Taylor RDW. The discontinuance of maintenance neuroleptic therapy in chronic schizophrenic patients: drug and social consequences. Acta Psychiat Scand 1983; 67: 339-52. 2.
COMMUNITY TREATMENT ORDERS FOR MENTAL ILLNESS
SiR,—The UK’s policy of care of the mentally ill in the community has led to questions about how long-term patients discharged from hospital should be supervised. The small but significant minority of patients with severe psychoses who repeatedly refuse treatment might better be helped by a community treatment order2 which would permit continued treatment outside hospital and could be applied on discharge after a compulsory
(St Clement’s),
NO MORE HIROSHIMAS
SiR,—Dr Penman’s defence (Nov 18, p 1220) of the use of two bombs in 1945 against the civilian population of Japan should not go unchallenged. It attempts to portray the Japanese soldiers as atom
barbarians and the members of the British Army in Burma and of Southeast Asia as angels. As a citizen of Sri Lanka (an ex-colony of Britain), which was bombed by Japan in early 1940s, I equally deplore the misdeeds and barbaric acts committed by the British for two centuries in Asia, Africa, and Oceania, beginning with the slave and opium trades. Penman should tell us why the "tens of thousands" of British prisoners-of-war were in the area? They were defending a territory far away from their native land—colonial booty inherited from the reign of Queen Victoria. And were the Burmese nationals consulted about their fate in this inglorious transfer? Department of Physiology and Biochemistry, Medical College of Pennsylvania, Philadelphia, Pennsylvania 19129, USA
SACHI SRI KANTHA
CLINICAL RELEVANCE OF SPECIFIC ANTIBODIES TO CARDIOLIPIN
IgG
StR,—Dr Kilpatrick and colleagues’ letter (Oct 21, p 987) Jrompts us to report our experience of specific IgG anti-cardiolipin mtibodies (ACA). We used an ELISA validated by an international xorkshop.1 The positive control contained 90 GPL units/ml 1 GPL unit being the binding activity of 1 tig/mi of an affinity purified IgG ACA from a standard serum) when compared with the workshop standard, and values in specific-binding index (SBI) J11Ìts1 are equivalent to values in GPL units/ml (n=74 r=0-91). 5BI was calculated by subtracting the optical density (OD) for the tegative control from the OD for the unknown sample and expressing the difference as a percentage of OD (positive control) ninus OD (negative control).
Department of Family Medicine, University of North Carolina School of Medicine,
WILLIAM L. ALDIS
Chapel Hill, North Carolina 27514, USA
1. Hsiao W. Transformation of health care in china. N Engl J Med 1984; 310: 933. 2. Henderson GE, Cohen MS. Health care in the people’s republic of China: a view from inside the system. Am J Publ Health 1982; 72: 1238.
3.Huang SM. Transforming 1988; 27: 879.
China’s health
care
system:
a
village study. Soc Sci Med
4. Alderman H, Gertler P. The substitutability of public and private health care for the treatment of children in Pakistan. (Wld Bank Pub no 11237). New York: World
Bank, 1989.
second year 9 had been brought back into regular treatment; 1 continued to refuse treatment and contact was lost with the other. In 3 of the 9 cases treatment was started again after imprisonment and subsequent transfer to hospital under Section 37 (with a restriction order under Section 41). They had been convicted of armed robbery, indecent assault, and assault, all the offences being committed when floridly psychotic. 4 of the 9 were brought back into treatment after admissions under Section 3: 1 had assaulted his father and a visiting psychiatric nurse and another had repeatedly threatened his father with violence. Of the remaining 2 patients, 1 was taking treatment from his general practitioner and had refused all contact with psychiatric services and the other displayed mainly negative features of schizophrenia; both agreed to restart depot injections from a community psychiatric nurse after mild relapses. The patient who continued to refuse treatment had, while in an earlier relapse, thrown hot water over a relative and attempted suicide. The findings confirm the increased risk of relapse in patients who fail to receive adequate maintenance therapy’ and the serious adverse consequences that can be associated with relapse. We have identified 11 patients for whom a community treatment order post discharge would have been appropriate. Without this, the only means of ensuring continuity of treatment is through a Home Office restriction order or probation order; neither are intended for this purpose and they can be applied only after an offence has been ctmmittec9_ The London Hospital London E3 4LL
hospital admission. During an audit of the use of depot antipsychotic medication in Tower Hamlets Health District (population 145 000) we identified on one day in 1986 all patients being prescribed depot injections (n=340). We extracted data from case-notes on the process and outcome of their psychiatric care over 2 years. During the first year 61 patients were discharged from hospital. 22 had been subject to compulsory hospital admission orders, 8 having been held under Section 2 (for assessment), 9 under Section 3 (for treatment), and 5 under Section 37 (court order for treatment) of the Mental Health Act 1983. By the end of the first year 10 of the 14 admitted compulsorily under sections 3 or 37 and 1 of the 8 who had been subject to a section 2 admission were persistently refusing further treatment with depot injections. In a further 2 cases (both section 2) injections had been discontinued by a psychiatrist. Males (9/12) were more likely to be refusing treatment than females (2/8). 10 patients refusing injections had schizophrenia or schizoaffective disorder, 4 of whom also abused alcohol or cannabis; 1 had bipolar affective disorder. In all 11 it was a relapse that had led to their index admission and in 9 that had been associated with refusal of depot injections already instituted; in 6 patients, at least two previous admissions followed the refusal of all treatment. The outcome of the group refusing injections was very poor. During the second year of follow-up 10 of them relapsed (compared with 2 of the 9 who continued treatment) and by the end of the
STUART MCLAREN
JOHN COOKSON
1. Johnstone EC, Owens DGC, Gold A, Crow TH, MacMillan JF. Schizophrenic patients discharged from hospital: a follow up study. Br J Psychiatry 1984; 145: 586-90.
Royal College of Psychiatarists. Community treatment orders: a discussion document. London: Royal College of Psychiatrists, 1987. 3. Davis JM. Overview: maintenance therapy in psychiatry: I schizophrenia. Am J Psychiatry 1975; 132: 1237-45. 4. Johnson DAW, Pasterski G, Ludlow JM, Street K, Taylor RDW. The discontinuance of maintenance neuroleptic therapy in chronic schizophrenic patients: drug and social consequences. Acta Psychiat Scand 1983; 67: 339-52. 2.
COMMUNITY TREATMENT ORDERS FOR MENTAL ILLNESS
SiR,—The UK’s policy of care of the mentally ill in the community has led to questions about how long-term patients discharged from hospital should be supervised. The small but significant minority of patients with severe psychoses who repeatedly refuse treatment might better be helped by a community treatment order2 which would permit continued treatment outside hospital and could be applied on discharge after a compulsory
(St Clement’s),
NO MORE HIROSHIMAS
SiR,—Dr Penman’s defence (Nov 18, p 1220) of the use of two bombs in 1945 against the civilian population of Japan should not go unchallenged. It attempts to portray the Japanese soldiers as atom
barbarians and the members of the British Army in Burma and of Southeast Asia as angels. As a citizen of Sri Lanka (an ex-colony of Britain), which was bombed by Japan in early 1940s, I equally deplore the misdeeds and barbaric acts committed by the British for two centuries in Asia, Africa, and Oceania, beginning with the slave and opium trades. Penman should tell us why the "tens of thousands" of British prisoners-of-war were in the area? They were defending a territory far away from their native land—colonial booty inherited from the reign of Queen Victoria. And were the Burmese nationals consulted about their fate in this inglorious transfer? Department of Physiology and Biochemistry, Medical College of Pennsylvania, Philadelphia, Pennsylvania 19129, USA
SACHI SRI KANTHA
CLINICAL RELEVANCE OF SPECIFIC ANTIBODIES TO CARDIOLIPIN
IgG
StR,—Dr Kilpatrick and colleagues’ letter (Oct 21, p 987) Jrompts us to report our experience of specific IgG anti-cardiolipin mtibodies (ACA). We used an ELISA validated by an international xorkshop.1 The positive control contained 90 GPL units/ml 1 GPL unit being the binding activity of 1 tig/mi of an affinity purified IgG ACA from a standard serum) when compared with the workshop standard, and values in specific-binding index (SBI) J11Ìts1 are equivalent to values in GPL units/ml (n=74 r=0-91). 5BI was calculated by subtracting the optical density (OD) for the tegative control from the OD for the unknown sample and expressing the difference as a percentage of OD (positive control) ninus OD (negative control).