- Email: [email protected]
Provision for the long-term discharged patient
Moving out of the asylum
Provision for the long-term discharged patient
What’s new? • The majority of long-stay patients are able to live successfully in community residences
Mohan Isaac
• Living in the community enhances subjective quality of life • Supported housing may represent ‘homes for life’ for many patients
Abstract
• There is a need to incorporate ‘evidence-based’ and ‘recovery-’ oriented practices
Studies from different parts of the developed world have consistently shown that long-term patients discharged from mental hospitals can be successfully resettled into a variety of community-based mental health services. Many of the discharged patients will initially require sheltered accommodation and extensive supervision, but over time this can be gradually reduced to a significant extent. About 40% (many with complex needs) will be readmitted for varying periods and some may become longstay patients again. Readmissions of long-term discharged patients exert pressure on local services and acute beds; very few are able ultimately to move to fully independent living. For many such patients, sheltered accommodation may represent ‘homes for life’. Discharged long-term patients across the world report improved subjective quality of life, satisfaction with services and a marked preference for continued living in the non-hospital settings. There are varied models of supported housing with marked variations in staffing, environmental characteristics and support and supervision arrangements. There is a need to develop taxonomy of supported housing and move forward from mere descriptions of structures and functions to evaluation of processes and outcomes. Stigma and negative community attitudes contribute to social isolation and exclusion of discharged patients. It will be important to match specific components of residential facilities and programmes with specific disabilities and needs of patients. Future provision for long-term discharged patients should incorporate ‘evidence-based’ and ‘recovery-’ oriented practices.
rovided with various alternate forms of services in the comp munity, there is controversy on the nature and quality of clinical, social and administrative outcomes for them and the cost effectiveness of many of the interventions. There is also a lack of consensus on which forms of services are appropriate for which patients. A growing body of research on community mental health services has identified numerous complex issues related to the needs for care and services of this group. A recent report has warned about signs of reinstitutionalization of mentally ill persons, not only in the UK but also elsewhere in Europe.1
Benefits of discharge into the community The TAPS project The benefits of discharge from conventional mental hospitals into the community have been assessed in numerous studies carried out in England, North America, Western Europe, Australia and New Zealand. The best known and largest prospective follow-up studies are those by the Team for the Assessment of Psychiatric Studies (TAPS), carried out into the closure of Friern and Claybury hospitals in North London and reprovision for their patients. The TAPS project, initiated during the mid-1980s, has published extensively on aspects of the 1-year and 5-year follow up and the reprovision for 670 discharged patients.2–4 The discharge and reprovision were well planned and adequately resourced.
Keywords community mental health services; deinstitutionalization; long-term mentally ill; recovery vision; sheltered housing
The past few decades have witnessed a drastic reduction in both the size and number of mental hospitals in the UK and internationally. The number of long-term psychiatric beds in England and Wales declined from 150 000 in the mid-1950s to fewer than 30 000 by 2005. Large numbers of chronic long-stay patients from traditional mental hospitals were discharged into a variety of community-based mental health services. While there is agreement among mental health professionals that a majority of long-stay patients from mental hospitals can successfully be
Long-term outcomes: follow-up of the patients discharged from Friern Barnet and Claybury hospitals showed that community care had enhanced their quality of life. Of the 670 discharged patients, 126 died (all from natural causes) before the 5-year follow-up. This mortality rate of 19% is consistent with the expected higher standard mortality ratios reported for people with schizophrenia. While there was no change in the patients’ clinical state or in their problems of social behaviour, they gained in domestic and social skills and many of them acquired friends and confidants.3 The majority of the patients felt that they were living in much freer conditions and wanted to remain in their community homes. Over the 5-year follow-up period, 61% remained in the homes where they were originally placed. Nine patients could not be traced at the end of 5 years and may have become homeless. Twelve patients were sent to prison, of whom five were later transferred to psychiatric wards. Over the 5-year period, 38% of patients required readmission to a psychiatric ward at least once, with many of them being
Mohan Isaac DPM FRCPsych is Associate Chair of Population Mental Health at the School of Psychiatry and Clinical Neurosciences, The University of Western Australia, and was previously Professor and Head, Department of Psychiatry at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India. His research interests include community psychiatry, particularly in low-resource countries and settings. Conflicts of interest: none declared.
PSYCHIATRY 6:8
317
© 2007 Elsevier Ltd. All rights reserved.
Moving out of the asylum
admitted more than once and several for periods of more than 6 months. This created a steady demand on local services for acute admissions and strain on the availability of beds. Ten percent became ‘new long-stay’ patients.4
Outcomes of long-stay patients resettled in the community • Enhanced subjective quality of life • Improved satisfaction with services • Marked preference for continuing in the community • Limited improvement in social functioning • Absence of noticeable changes in psychopathology • No increase in mortality rates • Repeated admissions for about one-third of patients • Few patients become ‘new long-stay’ • Very few patients move to independent living • Pressure on local area services and acute beds
Replication in the UK: many findings of the TAPS study were recently replicated by another prospective, non-randomized controlled trial from England at the Cane Hill hospital in South London.5 Sixty predominantly elderly long-term patients who were discharged to community care were compared with matched controls over a period of 1 year after discharge from the hospital. Although no overall differences were detected in the pattern or severity of symptoms between patients who were discharged from the hospital and those who were not, significant improvements in social networks, patients’ preference for community settings and quality of clinical environment were noted. About 40% of the discharged patients required 24-hour staffed accommodation. Only one patient could move to independent accommodation.
Table 1
staffing patterns and support and supervision arrangements for the patients. Availability of non-hospital residential positions for long-term discharged patients grew steadily in England over time, often established in local authority, voluntary and private sectors. Supported accommodation for the discharged mentally ill has been largely a neglected and inadequately researched area. However, a few authors have recently attempted to review comprehensively the issues related to supported housing for this population.10–12 There are diverse models of supported housing and a lack of clarity in the use of terminology to describe them. Supported accommodation with similar characteristics may have different names, such as ‘group home’, ‘care home’, ‘hostel’, ‘staffed housing’ and so on, and facilities with similar names may have very different structure and functions. Patient groups in each facility may be heterogenous with varying deficits and overall levels of needs. The staff support and availability, as well as background, training and staff turnover are also variable. Diversity of the background characteristics and modes of functioning makes meaningful comparison of supported housing facilities difficult.
International findings A comprehensive review of the process of deinstitutionalization worldwide, and Western Europe, North America, Australia and New Zealand in particular, showed that the benefits and disadvantages from closing or downsizing mental hospitals varied widely across countries and depending on numerous factors, including financial resources and social acceptance of the mentally ill by the community.6 However, several evaluations of mental hospital closure from Australia, Italy and Germany have shown that the majority of long-stay patients, both young and old, are able to live successfully in community residences with varying levels of support.7–9 Most patients will initially require 24-hour supervision for several months, while some will require this on a continuous basis. For most patients, the degree of supervision can be reduced gradually over a period of time. Very few patients actually graduate to independent living. The Australian evaluation reported reduction in medication levels over the 6-year period of the study.7 Most studies of long-term discharged patients showed no significant changes in psychopathology or social role functioning. Improved subjective quality of life and marked preference for continued living in the community were consistent findings across various studies from different countries.
‘Homes for life’? There is general agreement that supported housing is a realistic goal for the majority of long-term discharged patients. For many who may never be able to move to fully independent accommodation, supported housing may represent ‘homes for life’. Critics of deinstitutionalization claim that these facilities are just another kind of ‘new asylums in the community’. They argue that the process of discharging long-term patients from mental hospitals and resettling them in the community is better termed as ‘transinstitutionalization’ or ‘dehospitalization’. However, there is robust evidence that patients are more satisfied in supported housing compared with traditional hospitals. Patient satisfaction is now widely accepted as a measure of quality of care in psychiatric services. Most patients prefer the reduced restrictions, greater freedom and privacy in their living arrangements, with access to flexible levels of support when needed.
Limitations of mental hospital closure Outcomes of mental hospital closure programmes have in general been satisfactory when they are well planned, coordinated and adequately resourced. However, post-discharge provision in many instances is fragmented and uncoordinated. Several discharged patients frequently require readmissions for a variety of reasons. Besides putting considerable pressure on the limited number of existing beds and provision of acute care by local authorities, this paves the way for the emergence of a new group of ‘long-stay’ patients. Table 1 provides a summary of the outcomes for long-stay patients resettled in the community.
Supported housing
Residents with specific needs Since a large proportion of residents of sheltered accommodation facilities are elderly, age-related physical illnesses pose problems
Diverse models The range of supported housing facilities established to resettle inpatients discharged from mental hospitals had varying sizes,
PSYCHIATRY 6:8
318
© 2007 Elsevier Ltd. All rights reserved.
Moving out of the asylum
needing regular medical attention (it is well documented that the severely mentally ill have higher rates of physical illnesses). They also face greater difficulty in obtaining adequate care for their physical illnesses. In addition, there may be different groups of ‘difficult to manage’ patients with specific needs, such as those who respond poorly to conventional treatment strategies, patients with comorbid substance use and personality disorders, patients with higher risk of violent and aggressive or antisocial behaviour and so on, who would require special provision. Since a substantial proportion of long-term discharged patients would never have worked, helping them to obtain supported employment poses specific challenges. Supported employment can enhance a resident’s self-esteem, reduce dependency and decrease his or her social exclusion. Most residential facilities lack organized active rehabilitation programmes and do not provide adequate recreational facilities for residents. Stigma and negative community attitudes towards the mentally ill hinder development of social networks and their social integration. Long-term discharged patient groups which require special attention are shown in Table 2.
Areas for future research • Studies of specific ‘outcomes’ • Taxonomy of sheltered accommodation • Matching components of services with disability and needs • Use of qualitative research methods • ‘Recovery vision’ Table 3
reside in what sorts of accommodation and for what periods of time are urgently needed. To facilitate research into models of supported housing, consensus on a taxonomy of supported housing with clear operational definitions, patient intake criteria, staffing pattern, optimum training for staff and so on will need to be developed.12 Matching residential facilities with patients’ specific disabilities and needs will ensure better outcomes. Potential areas for future research are shown in Table 3.
International perspectives Studies of non-hospital residential facilities for long-term discharged patients from various countries (focusing on various issues such as the nature of care provided in the facility, staffing and environmental characteristics and residents’ perspectives) show results similar to those obtained in the UK.13–16 Such facilities are referred to by a variety of terms, including ‘hostels’, ‘boarding houses’ (Australia), ‘foster homes’, ‘supported apartments’ (Canada) and ‘long-stay care homes’ (Hong Kong). There is marked variation in the provision across countries and across different regions within countries. However, a consistent finding is that in all countries where provision for long-term discharged are surveyed, most residents are satisfied with their quality of life and do not desire to change their residence. The residential facilities provide them personal autonomy as well as a sense of security and well-being. Perceived freedom is shown to be a good predictor of life satisfaction for people with long-term mental illness.17 Discharge to independent accommodation is still generally rare.
Future directions During the past few years, there has been a greater recognition that services for persons with severe mental illnesses should be guided by ‘evidence-based practice’ and the concept of the ‘recovery vision’.18 There is evidence suggesting a link between the quality of therapeutic alliance (interpersonal processes and relationship between the patient and the primary care provider) and outcomes that are critical to ‘recovery’.19,20 Primary negative symptoms and impaired cognition continue to be major unmet needs in the treatment of people with schizophrenia who constitute the large majority of long-term discharged patients.21 There is an urgent need to incorporate ‘evidence-based’ and ‘recovery-’ oriented practices for this group of patients. ◆
Need for standard terminology Most reports on different models of housing for discharged mentally ill patients have so far been, in general, descriptive mainly of structures and processes. There is a need to move forward and to evaluate specific aspects of outcome systematically, using qualitative methods of research in addition to traditional quantitative methods. Reliable data on numbers of what types of patients
References 1 Priebe S, Badesconyi A, Fioritti A, et al. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. Br Med J 2005; 330: 123–26. 2 Leff J, Treiman N, Knapp M, Hallam A. The TAPS Project. A report of 13 years of research, 1985–1998. Psychiatr Bull 2000; 24: 165–68. 3 Leff J, Treiman N. Long-stay patients discharged from psychiatric hospitals Social and clinical outcomes after five years in the community. TAPS Project 46. Br J Psychiatry 2000; 176: 217–23. 4 Treiman N, Leff J, Glover G. Outcome of long stay psychiatric patients resettled in the community: prospective cohort study. Br Med J 1999; 319: 13–16. 5 Thornicroft G, Bebbington P, Leff J. Outcome for long term patients one year after discharge from a psychiatric hospital. Psychiatr Serv 2005; 56: 1416–22. 6 Fakhoury W, Priebe S. The process of deinstitutionalization: an international review. Curr Opin Psychiatry 2002; 15: 187–92. 7 Hobbs C, Newton L, Tennant C, Rosen A, Tribe K. Deinstitutionalization for long term mental illness: a 6-year evaluation. Aus N Z J Psychiatry 2002; 36: 60–66.
Long-term discharged patients requiring special attention • The elderly with physical illnesses • Patients with a variety of comorbid conditions • Those with past history of deliberate self-harm • Patients who are resistant to conventional treatment • Various ‘difficult to manage’ patients Table 2
PSYCHIATRY 6:8
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© 2007 Elsevier Ltd. All rights reserved.
Moving out of the asylum
8 Barbato A, D’Avanzo B, Rocca G, Amatulli A, Lampugnani D. A study of long-stay patients resettled in the community after closure of a psychiatric hospital in Italy. Psychiatr Serv 2004; 55: 67–70. 9 Priebe S, Hoffmann K, Isermann M, Kaiser W. Do long-term hospital patients benefit from discharge into community? Soc Psychiatry Psychiatr Epidemiol 2002; 37: 387–92. 10 Fakhoury WKH, Murray A, Shepherd S, Priebe S. Research in supported housing. Soc Psychiatry Psychiatr Epidemiol 2002; 37: 301–15. 11 MacPherson R, Shepherd G, Edwards T. Supported accommodation for people with severe mental illness: a review. Adv Psychiatr Treat 2004; 10: 180–88. 12 de Girolamo G, Bassi M. Residential facilities as the new scenario of psychiatric care. Curr Opin Psychiatry 2004; 17: 275–81. 13 Piat M, Ricard N, Lesage A. Evaluating life in foster homes for persons with serious mental illness: resident and care giver perspectives. Journal of Mental Health 2006; 15: 227–42. 14 de Girolamo G, Picardi A, Santone G, et al. The severely mentally ill in residential facilities: a national survey in Italy. Psychol Med 2005; 35: 421–31.
PSYCHIATRY 6:8
15 Horan ME, Muller JJ, Winocur S, Barling N. Quality of life in boarding houses and hostels: a residents’ perspective. Community Mental Health J 2001; 37: 323–34. 16 de Girolamo G, Piccardi A, Micciolo R, et al. Residential care in Italy: national survey of non-hospital facilities. Br J Psychiatry 2002; 181: 220–25. 17 Young KW. Perceived freedom and life satisfaction for people with long-term psychiatric illness. Int J Psychosocial Rehabilitation 2006; 10: 129–37. 18 Anthony W, Roger ES, Farkas M. Research on evidence-based practices: future directions in an era of recovery. Community Mental Health J 2003; 39: 101–14. 19 Howgego IM, Yellowless P, Owen C, Meldrum L, Dark F. The therapeutic alliance: the key to effective patient outcomes? A descriptive review of the evidence in community mental health case management. Aus N Z J Psychiatry 2003; 37: 169–83. 20 Tunner TP, Salzer MS. Consumer perspective on quality of care in treatment of schizophrenia. Adm Policy Ment Health & Ment Health Serv Res 2006; 33: 674–81. 21 Editorial: unmet therapeutic needs. Schizophr Bull 2005; 31: 791–94.
320
© 2007 Elsevier Ltd. All rights reserved.
Provision for the long-term discharged patient
What’s new? • The majority of long-stay patients are able to live successfully in community residences
Mohan Isaac
• Living in the community enhances subjective quality of life • Supported housing may represent ‘homes for life’ for many patients
Abstract
• There is a need to incorporate ‘evidence-based’ and ‘recovery-’ oriented practices
Studies from different parts of the developed world have consistently shown that long-term patients discharged from mental hospitals can be successfully resettled into a variety of community-based mental health services. Many of the discharged patients will initially require sheltered accommodation and extensive supervision, but over time this can be gradually reduced to a significant extent. About 40% (many with complex needs) will be readmitted for varying periods and some may become longstay patients again. Readmissions of long-term discharged patients exert pressure on local services and acute beds; very few are able ultimately to move to fully independent living. For many such patients, sheltered accommodation may represent ‘homes for life’. Discharged long-term patients across the world report improved subjective quality of life, satisfaction with services and a marked preference for continued living in the non-hospital settings. There are varied models of supported housing with marked variations in staffing, environmental characteristics and support and supervision arrangements. There is a need to develop taxonomy of supported housing and move forward from mere descriptions of structures and functions to evaluation of processes and outcomes. Stigma and negative community attitudes contribute to social isolation and exclusion of discharged patients. It will be important to match specific components of residential facilities and programmes with specific disabilities and needs of patients. Future provision for long-term discharged patients should incorporate ‘evidence-based’ and ‘recovery-’ oriented practices.
rovided with various alternate forms of services in the comp munity, there is controversy on the nature and quality of clinical, social and administrative outcomes for them and the cost effectiveness of many of the interventions. There is also a lack of consensus on which forms of services are appropriate for which patients. A growing body of research on community mental health services has identified numerous complex issues related to the needs for care and services of this group. A recent report has warned about signs of reinstitutionalization of mentally ill persons, not only in the UK but also elsewhere in Europe.1
Benefits of discharge into the community The TAPS project The benefits of discharge from conventional mental hospitals into the community have been assessed in numerous studies carried out in England, North America, Western Europe, Australia and New Zealand. The best known and largest prospective follow-up studies are those by the Team for the Assessment of Psychiatric Studies (TAPS), carried out into the closure of Friern and Claybury hospitals in North London and reprovision for their patients. The TAPS project, initiated during the mid-1980s, has published extensively on aspects of the 1-year and 5-year follow up and the reprovision for 670 discharged patients.2–4 The discharge and reprovision were well planned and adequately resourced.
Keywords community mental health services; deinstitutionalization; long-term mentally ill; recovery vision; sheltered housing
The past few decades have witnessed a drastic reduction in both the size and number of mental hospitals in the UK and internationally. The number of long-term psychiatric beds in England and Wales declined from 150 000 in the mid-1950s to fewer than 30 000 by 2005. Large numbers of chronic long-stay patients from traditional mental hospitals were discharged into a variety of community-based mental health services. While there is agreement among mental health professionals that a majority of long-stay patients from mental hospitals can successfully be
Long-term outcomes: follow-up of the patients discharged from Friern Barnet and Claybury hospitals showed that community care had enhanced their quality of life. Of the 670 discharged patients, 126 died (all from natural causes) before the 5-year follow-up. This mortality rate of 19% is consistent with the expected higher standard mortality ratios reported for people with schizophrenia. While there was no change in the patients’ clinical state or in their problems of social behaviour, they gained in domestic and social skills and many of them acquired friends and confidants.3 The majority of the patients felt that they were living in much freer conditions and wanted to remain in their community homes. Over the 5-year follow-up period, 61% remained in the homes where they were originally placed. Nine patients could not be traced at the end of 5 years and may have become homeless. Twelve patients were sent to prison, of whom five were later transferred to psychiatric wards. Over the 5-year period, 38% of patients required readmission to a psychiatric ward at least once, with many of them being
Mohan Isaac DPM FRCPsych is Associate Chair of Population Mental Health at the School of Psychiatry and Clinical Neurosciences, The University of Western Australia, and was previously Professor and Head, Department of Psychiatry at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India. His research interests include community psychiatry, particularly in low-resource countries and settings. Conflicts of interest: none declared.
PSYCHIATRY 6:8
317
© 2007 Elsevier Ltd. All rights reserved.
Moving out of the asylum
admitted more than once and several for periods of more than 6 months. This created a steady demand on local services for acute admissions and strain on the availability of beds. Ten percent became ‘new long-stay’ patients.4
Outcomes of long-stay patients resettled in the community • Enhanced subjective quality of life • Improved satisfaction with services • Marked preference for continuing in the community • Limited improvement in social functioning • Absence of noticeable changes in psychopathology • No increase in mortality rates • Repeated admissions for about one-third of patients • Few patients become ‘new long-stay’ • Very few patients move to independent living • Pressure on local area services and acute beds
Replication in the UK: many findings of the TAPS study were recently replicated by another prospective, non-randomized controlled trial from England at the Cane Hill hospital in South London.5 Sixty predominantly elderly long-term patients who were discharged to community care were compared with matched controls over a period of 1 year after discharge from the hospital. Although no overall differences were detected in the pattern or severity of symptoms between patients who were discharged from the hospital and those who were not, significant improvements in social networks, patients’ preference for community settings and quality of clinical environment were noted. About 40% of the discharged patients required 24-hour staffed accommodation. Only one patient could move to independent accommodation.
Table 1
staffing patterns and support and supervision arrangements for the patients. Availability of non-hospital residential positions for long-term discharged patients grew steadily in England over time, often established in local authority, voluntary and private sectors. Supported accommodation for the discharged mentally ill has been largely a neglected and inadequately researched area. However, a few authors have recently attempted to review comprehensively the issues related to supported housing for this population.10–12 There are diverse models of supported housing and a lack of clarity in the use of terminology to describe them. Supported accommodation with similar characteristics may have different names, such as ‘group home’, ‘care home’, ‘hostel’, ‘staffed housing’ and so on, and facilities with similar names may have very different structure and functions. Patient groups in each facility may be heterogenous with varying deficits and overall levels of needs. The staff support and availability, as well as background, training and staff turnover are also variable. Diversity of the background characteristics and modes of functioning makes meaningful comparison of supported housing facilities difficult.
International findings A comprehensive review of the process of deinstitutionalization worldwide, and Western Europe, North America, Australia and New Zealand in particular, showed that the benefits and disadvantages from closing or downsizing mental hospitals varied widely across countries and depending on numerous factors, including financial resources and social acceptance of the mentally ill by the community.6 However, several evaluations of mental hospital closure from Australia, Italy and Germany have shown that the majority of long-stay patients, both young and old, are able to live successfully in community residences with varying levels of support.7–9 Most patients will initially require 24-hour supervision for several months, while some will require this on a continuous basis. For most patients, the degree of supervision can be reduced gradually over a period of time. Very few patients actually graduate to independent living. The Australian evaluation reported reduction in medication levels over the 6-year period of the study.7 Most studies of long-term discharged patients showed no significant changes in psychopathology or social role functioning. Improved subjective quality of life and marked preference for continued living in the community were consistent findings across various studies from different countries.
‘Homes for life’? There is general agreement that supported housing is a realistic goal for the majority of long-term discharged patients. For many who may never be able to move to fully independent accommodation, supported housing may represent ‘homes for life’. Critics of deinstitutionalization claim that these facilities are just another kind of ‘new asylums in the community’. They argue that the process of discharging long-term patients from mental hospitals and resettling them in the community is better termed as ‘transinstitutionalization’ or ‘dehospitalization’. However, there is robust evidence that patients are more satisfied in supported housing compared with traditional hospitals. Patient satisfaction is now widely accepted as a measure of quality of care in psychiatric services. Most patients prefer the reduced restrictions, greater freedom and privacy in their living arrangements, with access to flexible levels of support when needed.
Limitations of mental hospital closure Outcomes of mental hospital closure programmes have in general been satisfactory when they are well planned, coordinated and adequately resourced. However, post-discharge provision in many instances is fragmented and uncoordinated. Several discharged patients frequently require readmissions for a variety of reasons. Besides putting considerable pressure on the limited number of existing beds and provision of acute care by local authorities, this paves the way for the emergence of a new group of ‘long-stay’ patients. Table 1 provides a summary of the outcomes for long-stay patients resettled in the community.
Supported housing
Residents with specific needs Since a large proportion of residents of sheltered accommodation facilities are elderly, age-related physical illnesses pose problems
Diverse models The range of supported housing facilities established to resettle inpatients discharged from mental hospitals had varying sizes,
PSYCHIATRY 6:8
318
© 2007 Elsevier Ltd. All rights reserved.
Moving out of the asylum
needing regular medical attention (it is well documented that the severely mentally ill have higher rates of physical illnesses). They also face greater difficulty in obtaining adequate care for their physical illnesses. In addition, there may be different groups of ‘difficult to manage’ patients with specific needs, such as those who respond poorly to conventional treatment strategies, patients with comorbid substance use and personality disorders, patients with higher risk of violent and aggressive or antisocial behaviour and so on, who would require special provision. Since a substantial proportion of long-term discharged patients would never have worked, helping them to obtain supported employment poses specific challenges. Supported employment can enhance a resident’s self-esteem, reduce dependency and decrease his or her social exclusion. Most residential facilities lack organized active rehabilitation programmes and do not provide adequate recreational facilities for residents. Stigma and negative community attitudes towards the mentally ill hinder development of social networks and their social integration. Long-term discharged patient groups which require special attention are shown in Table 2.
Areas for future research • Studies of specific ‘outcomes’ • Taxonomy of sheltered accommodation • Matching components of services with disability and needs • Use of qualitative research methods • ‘Recovery vision’ Table 3
reside in what sorts of accommodation and for what periods of time are urgently needed. To facilitate research into models of supported housing, consensus on a taxonomy of supported housing with clear operational definitions, patient intake criteria, staffing pattern, optimum training for staff and so on will need to be developed.12 Matching residential facilities with patients’ specific disabilities and needs will ensure better outcomes. Potential areas for future research are shown in Table 3.
International perspectives Studies of non-hospital residential facilities for long-term discharged patients from various countries (focusing on various issues such as the nature of care provided in the facility, staffing and environmental characteristics and residents’ perspectives) show results similar to those obtained in the UK.13–16 Such facilities are referred to by a variety of terms, including ‘hostels’, ‘boarding houses’ (Australia), ‘foster homes’, ‘supported apartments’ (Canada) and ‘long-stay care homes’ (Hong Kong). There is marked variation in the provision across countries and across different regions within countries. However, a consistent finding is that in all countries where provision for long-term discharged are surveyed, most residents are satisfied with their quality of life and do not desire to change their residence. The residential facilities provide them personal autonomy as well as a sense of security and well-being. Perceived freedom is shown to be a good predictor of life satisfaction for people with long-term mental illness.17 Discharge to independent accommodation is still generally rare.
Future directions During the past few years, there has been a greater recognition that services for persons with severe mental illnesses should be guided by ‘evidence-based practice’ and the concept of the ‘recovery vision’.18 There is evidence suggesting a link between the quality of therapeutic alliance (interpersonal processes and relationship between the patient and the primary care provider) and outcomes that are critical to ‘recovery’.19,20 Primary negative symptoms and impaired cognition continue to be major unmet needs in the treatment of people with schizophrenia who constitute the large majority of long-term discharged patients.21 There is an urgent need to incorporate ‘evidence-based’ and ‘recovery-’ oriented practices for this group of patients. ◆
Need for standard terminology Most reports on different models of housing for discharged mentally ill patients have so far been, in general, descriptive mainly of structures and processes. There is a need to move forward and to evaluate specific aspects of outcome systematically, using qualitative methods of research in addition to traditional quantitative methods. Reliable data on numbers of what types of patients
References 1 Priebe S, Badesconyi A, Fioritti A, et al. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. Br Med J 2005; 330: 123–26. 2 Leff J, Treiman N, Knapp M, Hallam A. The TAPS Project. A report of 13 years of research, 1985–1998. Psychiatr Bull 2000; 24: 165–68. 3 Leff J, Treiman N. Long-stay patients discharged from psychiatric hospitals Social and clinical outcomes after five years in the community. TAPS Project 46. Br J Psychiatry 2000; 176: 217–23. 4 Treiman N, Leff J, Glover G. Outcome of long stay psychiatric patients resettled in the community: prospective cohort study. Br Med J 1999; 319: 13–16. 5 Thornicroft G, Bebbington P, Leff J. Outcome for long term patients one year after discharge from a psychiatric hospital. Psychiatr Serv 2005; 56: 1416–22. 6 Fakhoury W, Priebe S. The process of deinstitutionalization: an international review. Curr Opin Psychiatry 2002; 15: 187–92. 7 Hobbs C, Newton L, Tennant C, Rosen A, Tribe K. Deinstitutionalization for long term mental illness: a 6-year evaluation. Aus N Z J Psychiatry 2002; 36: 60–66.
Long-term discharged patients requiring special attention • The elderly with physical illnesses • Patients with a variety of comorbid conditions • Those with past history of deliberate self-harm • Patients who are resistant to conventional treatment • Various ‘difficult to manage’ patients Table 2
PSYCHIATRY 6:8
319
© 2007 Elsevier Ltd. All rights reserved.
Moving out of the asylum
8 Barbato A, D’Avanzo B, Rocca G, Amatulli A, Lampugnani D. A study of long-stay patients resettled in the community after closure of a psychiatric hospital in Italy. Psychiatr Serv 2004; 55: 67–70. 9 Priebe S, Hoffmann K, Isermann M, Kaiser W. Do long-term hospital patients benefit from discharge into community? Soc Psychiatry Psychiatr Epidemiol 2002; 37: 387–92. 10 Fakhoury WKH, Murray A, Shepherd S, Priebe S. Research in supported housing. Soc Psychiatry Psychiatr Epidemiol 2002; 37: 301–15. 11 MacPherson R, Shepherd G, Edwards T. Supported accommodation for people with severe mental illness: a review. Adv Psychiatr Treat 2004; 10: 180–88. 12 de Girolamo G, Bassi M. Residential facilities as the new scenario of psychiatric care. Curr Opin Psychiatry 2004; 17: 275–81. 13 Piat M, Ricard N, Lesage A. Evaluating life in foster homes for persons with serious mental illness: resident and care giver perspectives. Journal of Mental Health 2006; 15: 227–42. 14 de Girolamo G, Picardi A, Santone G, et al. The severely mentally ill in residential facilities: a national survey in Italy. Psychol Med 2005; 35: 421–31.
PSYCHIATRY 6:8
15 Horan ME, Muller JJ, Winocur S, Barling N. Quality of life in boarding houses and hostels: a residents’ perspective. Community Mental Health J 2001; 37: 323–34. 16 de Girolamo G, Piccardi A, Micciolo R, et al. Residential care in Italy: national survey of non-hospital facilities. Br J Psychiatry 2002; 181: 220–25. 17 Young KW. Perceived freedom and life satisfaction for people with long-term psychiatric illness. Int J Psychosocial Rehabilitation 2006; 10: 129–37. 18 Anthony W, Roger ES, Farkas M. Research on evidence-based practices: future directions in an era of recovery. Community Mental Health J 2003; 39: 101–14. 19 Howgego IM, Yellowless P, Owen C, Meldrum L, Dark F. The therapeutic alliance: the key to effective patient outcomes? A descriptive review of the evidence in community mental health case management. Aus N Z J Psychiatry 2003; 37: 169–83. 20 Tunner TP, Salzer MS. Consumer perspective on quality of care in treatment of schizophrenia. Adm Policy Ment Health & Ment Health Serv Res 2006; 33: 674–81. 21 Editorial: unmet therapeutic needs. Schizophr Bull 2005; 31: 791–94.
320
© 2007 Elsevier Ltd. All rights reserved.