- Email: [email protected]
THE NEED FOR ASYLUM FOR THE MENTALLY ILL
546
studies have not control-an atrophic testis from a cause other than in-situ carcinoma. The gold standard is testicular biopsy. In most institutions this procedure is carried out under general anaesthesia, making it unsuitable for routine screening. Bruun et aF3 reviewed their experience of outpatient testicular biopsies under local anaesthesia and found that 28 % of patients thought the procedure was unacceptably uncomfortable and 1-5% had infectious complications. These problems, and the difficulty of excluding malignancy in a testis once it has a biopsy scar, are the major reasons that screening of risk groups has not been undertaken as enthusiastically in the UK or elsewhere as in Denmark. Another factor was the course of action to be taken once the diagnosis is made: until lately orchidectomy was the only therapeutic option. Since this procedure was also the recommended treatment for invasive tumours, with a cure rate exceeding 90%, orchidectomy for in-situ carcinomas hardly seems a major gain. However, attitudes are beginning to change as it is now possible to eliminate in-situ disease without surgery.25 Low-dose radiation (20 cGy in ten fractions) has the disadvantage of inducing infertility, but chemotherapy is equally effective in the short term, although with greater acute toxicity. Since recovery of spermatogenesis after chemotherapy for established metastatic tumours has been well documented,26 this approach might be preferable for patients who wish to remain fertile. However, it is unclear whether a blood-testis barrier will diminish the long-term effectiveness of chemo-
imaging22 are encouraging, incorporated the appropriate
therapy. 27 In this issue (p 528) Dr Daugaard and colleagues take the study of in-situ carcinoma into a new area which was not addressed at last year’s meeting. They provide evidence for in-situ carcinoma in testicular biopsies from 8 of 15 patients thought to have an
extragonadal primary germ-cell tumour, particularly those with predominantly retroperitoneal disease. These findings indicate that such cells may progress directly to demonstrate the fourth property of malignant cells-metastasis without obvious local invasion. Azzopardi and Hoffbrand 211 had previously suggested that spontaneous regression of an established primary tumour might be due to an 22. Thomsen
C, Jensen KE, Giwercman A, et al. Magnetic resonance: in vivo tissue testes in patients with carcinoma-in-situ of the testis and healthy subjects. Int J Androl 1987; 10: 191-98. 23. Bruun E, Frimodt-Moller C, Giwercman A, et al. Testicular biopsy as an outpatient procedure in screening for carinoma-in-situ: complications and the patient’s acceptance. Int J Androl 1987; 10: 199-202. 24. Oliver RTD. Rare cancers and specialist centres. Br Med J 1986; 292: 641-42. 25. Von der Maase H, Giwercman A, Muller J. Management of carcinoma-in-situ of the testis. Int J Androl 1987; 10: 209-20. 26. Oliver RTD. Fertility of patients with germ cell tumours of the testis before and after treatment with platinum and etoposide containing combination chemotherapy regimens. In: Jones WG, Milford Ward A, Anderson CK, eds. Germ cell tumours
immune mechanism whereas seeded metastases continue to grow. Preliminary anecdotal evidence of a possible autoimmune reaction against in-situ carcinoma of the testis29 was an important new development reported in Copenhagen, and provides a new direction for research. Given Klein’s contention30 that if immune surveillance is important in resistance to cancer, then terminal tumours must inevitably have the most efficient systems for evasion of host response, investigation of the immunology of in-situ carcinoma might be a profitable avenue for future research. The high cure rate of in-situ carcinoma of the bladder achieved with intravesical BCG would support that
concept."" Since testicular cancer has such a high cure rate, study of in-situ change might seem largely irrelevant by comparison with the more common drug-resistant adult solid cancers. However, the greater range of biological markers for in-situ carcinoma of the testis provides important insights into cancer biology in general. These findings may aid understanding of the natural history and contribute to better management of all common adult tumours, particularly cervix, lung, and bladder which also have well defined, and more readily detectable, in-situ stages.
THE NEED FOR ASYLUM FOR THE MENTALLY
ILL A CONSENSUS statement from a King’s Fund forum1 is the second2 recent declaration that asylum should remain one of the functions of mental illness services. The proposals - merit analysis since this is an area in which good intentions are clearly not sufficient. The statement tends to deal with the darker aspects of asylum by splitting them off into the large institutions of a past era ("symbols of the outdated"), leaving the more benign connotations unsullied for the community services of the future. This approach may increase the risk of repeating past mistakes by denying the institutional era the openminded scrutiny that is still so badly needed before it ends. It certainly confuses what is and what ought to be-a perennial failing of mental illness service ideologies. To state that "Large wards in large institutions cannot and should not be regarded as home for anyone" devalues the experience of the tens of thousands of long-stay patients for whom this has been the reality for decades, and makes it easier to gloss over their present feelings.
characterization of the
II. Pergamon, Oxford: 1986. 467-70. 27. Fowler JE Jr, Whitmore WF Jr. Intratesncular germ cell tumors: observations on the effect of chemotherapy J Urol 1981; 126: 412-14. 28. Azzopardi JG, Hoffbrand AV. Retrogression m testicular seminoma with viable metastases. J Clin Pathol 1965; 18: 135-41.
29. Lehmann D, Muller HJ. Analysis of the autoimmune response in an "in-situ" carcinoma of the testis. Int J Androl 1987; 10: 163-68. 30. Klein G. Immune and non-immune control of neoplastic development: contrasting effects of host and tumour evolution. In: Former JG, Rhoads JE, eds. Accomplishments in Cancer Research 1979. Philadelphia: Lippincott, 1979:
123-46. 31.
Pinsky CM, Camacho FJ, Kerr D, et al. Intravesical administration of Bacillus Calmette-Guerin in patients with recurrent superficial carcinoma of the urinary bladder: report of a prospective, randomized trial. Cancer Treat Rep 1985; 69: 47-53.
1. The need for asylum
in society for the mentally ill or infirm. Consensus statement, the King’s Fund Forum. London: King’s Fund Centre, April, 1987. Community care. Second report from the House of Commons’ Social Services Committee. London: HMSO, 1985; paras 25-26. third
2.
547
The consensus panel might instead have challenged the conventional assumption that unwillingness to opt for an uncertain future on other people’s terms is merely evidence of "institutionalisation", and have taken seriously patients’ actual views. It is clear that, given adequate information, preparation, and choice, long-stay patients are sufficiently realistic and indeed courageous in facing change3for it to be inexcusable that they are still so widely excluded from planning for their own futures. This is important for the mental illness service as a whole. To bring the institutional era to an ugly end by sacrificing the remaining patients’ rights is likely to be the worst possible basis for a new service intended to be founded on respect for the needs and wishes of its consumers. The panel’s approach contrasts with the recommendation of the House of more forthright Commons’ Social Services Committee that "The Department lays an obligation on Authorities to ascertain as far as practicable, and give consideration to, the wishes and feelings of mentally disabled individuals ... in particular where closure of a long-stay facility is contemplated".4 There are several other reasons why the past should not be lightly brushed aside. The overriding image of asylum is of a place of safety for those sheltered within, but the public’s willingness to sanction necessary resources may still hinge on expectation of protection for themselves. Lack of clarity about which interest was being served contributed to some of the malign developments of the institutional era,5 and community care may be similarly distorted. Comprehensive district services-the model supported by the consensus panel-aim to reverse the segregation of the post by dispersing long-term patients in small groups. The ostensible purpose is to normalise their lives, but there is clearly also the hope of defusing public anxieties. Failure to separate assumptions may lead to confusion between unobstructiveness and integration, to denial of the reality of psychiatric disabilities, and even to the view that the very term "special needs" is stigmatising.6 It also leads to acceptance of discriminatory zoning that would lead to an outcry if applied to other groups. The evidence is that the social networks of long-term mentally ill persons are mainly composed of other patients, ex-patients and staff, and their own families.7 This seems to be the case not only for those discharged after long stays in hospital, but also for many who have spent most of their lives in "the community". There is thus a danger of progressive social isolation if such ties are broken by too widespread dispersal, and wider relationships remain a pious hope. Under such circumstances emotional tensions within small groups in daily close contact, to which schizophrenic patients are particularly vulnerable, are likely to be inimical to genuine asylum. Patients have a right to relationships both with other patients and with "normal" people: these are not reciprocal,8 as sometimes assumed, and may fulfil different functions.9 Community care’ should not merely
reverse the one-sidedness of institutional life—especially not for those who will experience both. One approach to achieving a balance is to bring the community to the patients, as well as the reverse. "New community"1° or "haven"" projects propose using the major resources of space, public acceptance, and in some cases buildings, of mental hospital sites to develop a range of resources for the long-term mentally ill. Their economic potential is such that a variety of supported accommodation and occupational and leisure facilities could be fundedmixed and to some extent combined with public provision including up-market housing, shops, and parks. The utopian ring of some descriptions should not deflect attention from the practicality of the concept: schemes could be developed on varying scales appropriate to local circumstances, as one component of comprehensive services. At the most modest level they would add to the range of choices open to long-stay patients and mitigate the Poor Law flavour produced by dispersal to district of origin irrespective of present loyalties. It is difficult to understand why this aproach was ignored by the consensus panelagain in contrast to the Social Services Committee’s recommendations that no mental-handicap or mental illness hospital site should be disposed of without it being considered. 12 Urgent action is needed as wards deteriorate, whilst dispersed schemes meet planning obstructions that restrict both their number and their ability to cater for the more disturbed patients. These schemes are also needed to increase resources for future generations of long-term patients, who may otherwise lack opportunities for asylum even in its most primitive sense of shelter. More intangibly, these patients will benefit from the signal that their special needs are to be taken seriously in the new service. Developments in understanding13 and treatrnent14 make it no longer tolerable for interest in long-term schizophrenic illnesses to be regarded as evidence of nostalgia for the mental hospital, unfitting for the would-be community psychiatrist. IS
STEROIDS IN HAEMORRHAGIC STROKE CLINICAL trials of stroke treatment have tended to infarction rather than haemorrhage-where the two have been adequately distinguished and if we leave aside primary subarachnoid haemorrhage. This is not to say that we are now much better at treating infarction. The probable reason is that rationales have been more easily conceived for drug therapy of cerebral infarction-even if wrong. A prominent target for drug activity has been oedema formation, and dexamethasone has been one of the concentrate on
Jones K. Mental hospital closures-the way forward? York: University of York Institute of Advanced Architectural Studies, 1987. 11. Wing JK, Furlong R. A haven for the severely disabled within the context of a comprehensive psychiatric community service. Br J Psychiatry 1986; 149: 449-57. 10.
3.Abrahamson D, Brenner D. Do 4 5
6 7 8
long-stay psychiatric patients want to leave hospital? Health Trends 1982, 14: 95-97. Community care. Second report from the House of Commons’ Social Services Committee. London: HMSO, 1985: para 149. Scull AT Museums of madness. London: Penguin, 1982. Heginbotham C. Good practices in housing for people with long-term mental illnesses. In Good practices in mental health. London: 1985. Abrahamson D, Ezekiel A. Social networks of psychiatric patients. Paper to symposium, King’s Fund Centre, London, June, 1985. Segal SP, Aviram U.The mentally ill in community based sheltered care.New York:
Wiley, 1978 9 Estroff SE.Making it crazy.London:
University of California Press,
1981.
12. Community care—Second report of the House of Commons’ Social Services Committee. London: HMSO, 1985: para 208. 13. Bleuler M. The schizophrenic disorders: long-term patient and family studies. New Haven: Yale University Press, 1978. 14. Steinglass P. Psychoeducational family therapy for schizophrenia: a review essay. Psychiatry 1987; 50: 14-23. 15. Sturt J, Waters H. Role of the psychiatrist in community-based mental health care. Lancet 1985; i: 507-08. 1. Ng LKY, Nimmannitya J. Massive cerebral infarction with severe brain swelling: a clinicopathological study. Stroke 1970; 1: 158-63.
studies have not control-an atrophic testis from a cause other than in-situ carcinoma. The gold standard is testicular biopsy. In most institutions this procedure is carried out under general anaesthesia, making it unsuitable for routine screening. Bruun et aF3 reviewed their experience of outpatient testicular biopsies under local anaesthesia and found that 28 % of patients thought the procedure was unacceptably uncomfortable and 1-5% had infectious complications. These problems, and the difficulty of excluding malignancy in a testis once it has a biopsy scar, are the major reasons that screening of risk groups has not been undertaken as enthusiastically in the UK or elsewhere as in Denmark. Another factor was the course of action to be taken once the diagnosis is made: until lately orchidectomy was the only therapeutic option. Since this procedure was also the recommended treatment for invasive tumours, with a cure rate exceeding 90%, orchidectomy for in-situ carcinomas hardly seems a major gain. However, attitudes are beginning to change as it is now possible to eliminate in-situ disease without surgery.25 Low-dose radiation (20 cGy in ten fractions) has the disadvantage of inducing infertility, but chemotherapy is equally effective in the short term, although with greater acute toxicity. Since recovery of spermatogenesis after chemotherapy for established metastatic tumours has been well documented,26 this approach might be preferable for patients who wish to remain fertile. However, it is unclear whether a blood-testis barrier will diminish the long-term effectiveness of chemo-
imaging22 are encouraging, incorporated the appropriate
therapy. 27 In this issue (p 528) Dr Daugaard and colleagues take the study of in-situ carcinoma into a new area which was not addressed at last year’s meeting. They provide evidence for in-situ carcinoma in testicular biopsies from 8 of 15 patients thought to have an
extragonadal primary germ-cell tumour, particularly those with predominantly retroperitoneal disease. These findings indicate that such cells may progress directly to demonstrate the fourth property of malignant cells-metastasis without obvious local invasion. Azzopardi and Hoffbrand 211 had previously suggested that spontaneous regression of an established primary tumour might be due to an 22. Thomsen
C, Jensen KE, Giwercman A, et al. Magnetic resonance: in vivo tissue testes in patients with carcinoma-in-situ of the testis and healthy subjects. Int J Androl 1987; 10: 191-98. 23. Bruun E, Frimodt-Moller C, Giwercman A, et al. Testicular biopsy as an outpatient procedure in screening for carinoma-in-situ: complications and the patient’s acceptance. Int J Androl 1987; 10: 199-202. 24. Oliver RTD. Rare cancers and specialist centres. Br Med J 1986; 292: 641-42. 25. Von der Maase H, Giwercman A, Muller J. Management of carcinoma-in-situ of the testis. Int J Androl 1987; 10: 209-20. 26. Oliver RTD. Fertility of patients with germ cell tumours of the testis before and after treatment with platinum and etoposide containing combination chemotherapy regimens. In: Jones WG, Milford Ward A, Anderson CK, eds. Germ cell tumours
immune mechanism whereas seeded metastases continue to grow. Preliminary anecdotal evidence of a possible autoimmune reaction against in-situ carcinoma of the testis29 was an important new development reported in Copenhagen, and provides a new direction for research. Given Klein’s contention30 that if immune surveillance is important in resistance to cancer, then terminal tumours must inevitably have the most efficient systems for evasion of host response, investigation of the immunology of in-situ carcinoma might be a profitable avenue for future research. The high cure rate of in-situ carcinoma of the bladder achieved with intravesical BCG would support that
concept."" Since testicular cancer has such a high cure rate, study of in-situ change might seem largely irrelevant by comparison with the more common drug-resistant adult solid cancers. However, the greater range of biological markers for in-situ carcinoma of the testis provides important insights into cancer biology in general. These findings may aid understanding of the natural history and contribute to better management of all common adult tumours, particularly cervix, lung, and bladder which also have well defined, and more readily detectable, in-situ stages.
THE NEED FOR ASYLUM FOR THE MENTALLY
ILL A CONSENSUS statement from a King’s Fund forum1 is the second2 recent declaration that asylum should remain one of the functions of mental illness services. The proposals - merit analysis since this is an area in which good intentions are clearly not sufficient. The statement tends to deal with the darker aspects of asylum by splitting them off into the large institutions of a past era ("symbols of the outdated"), leaving the more benign connotations unsullied for the community services of the future. This approach may increase the risk of repeating past mistakes by denying the institutional era the openminded scrutiny that is still so badly needed before it ends. It certainly confuses what is and what ought to be-a perennial failing of mental illness service ideologies. To state that "Large wards in large institutions cannot and should not be regarded as home for anyone" devalues the experience of the tens of thousands of long-stay patients for whom this has been the reality for decades, and makes it easier to gloss over their present feelings.
characterization of the
II. Pergamon, Oxford: 1986. 467-70. 27. Fowler JE Jr, Whitmore WF Jr. Intratesncular germ cell tumors: observations on the effect of chemotherapy J Urol 1981; 126: 412-14. 28. Azzopardi JG, Hoffbrand AV. Retrogression m testicular seminoma with viable metastases. J Clin Pathol 1965; 18: 135-41.
29. Lehmann D, Muller HJ. Analysis of the autoimmune response in an "in-situ" carcinoma of the testis. Int J Androl 1987; 10: 163-68. 30. Klein G. Immune and non-immune control of neoplastic development: contrasting effects of host and tumour evolution. In: Former JG, Rhoads JE, eds. Accomplishments in Cancer Research 1979. Philadelphia: Lippincott, 1979:
123-46. 31.
Pinsky CM, Camacho FJ, Kerr D, et al. Intravesical administration of Bacillus Calmette-Guerin in patients with recurrent superficial carcinoma of the urinary bladder: report of a prospective, randomized trial. Cancer Treat Rep 1985; 69: 47-53.
1. The need for asylum
in society for the mentally ill or infirm. Consensus statement, the King’s Fund Forum. London: King’s Fund Centre, April, 1987. Community care. Second report from the House of Commons’ Social Services Committee. London: HMSO, 1985; paras 25-26. third
2.
547
The consensus panel might instead have challenged the conventional assumption that unwillingness to opt for an uncertain future on other people’s terms is merely evidence of "institutionalisation", and have taken seriously patients’ actual views. It is clear that, given adequate information, preparation, and choice, long-stay patients are sufficiently realistic and indeed courageous in facing change3for it to be inexcusable that they are still so widely excluded from planning for their own futures. This is important for the mental illness service as a whole. To bring the institutional era to an ugly end by sacrificing the remaining patients’ rights is likely to be the worst possible basis for a new service intended to be founded on respect for the needs and wishes of its consumers. The panel’s approach contrasts with the recommendation of the House of more forthright Commons’ Social Services Committee that "The Department lays an obligation on Authorities to ascertain as far as practicable, and give consideration to, the wishes and feelings of mentally disabled individuals ... in particular where closure of a long-stay facility is contemplated".4 There are several other reasons why the past should not be lightly brushed aside. The overriding image of asylum is of a place of safety for those sheltered within, but the public’s willingness to sanction necessary resources may still hinge on expectation of protection for themselves. Lack of clarity about which interest was being served contributed to some of the malign developments of the institutional era,5 and community care may be similarly distorted. Comprehensive district services-the model supported by the consensus panel-aim to reverse the segregation of the post by dispersing long-term patients in small groups. The ostensible purpose is to normalise their lives, but there is clearly also the hope of defusing public anxieties. Failure to separate assumptions may lead to confusion between unobstructiveness and integration, to denial of the reality of psychiatric disabilities, and even to the view that the very term "special needs" is stigmatising.6 It also leads to acceptance of discriminatory zoning that would lead to an outcry if applied to other groups. The evidence is that the social networks of long-term mentally ill persons are mainly composed of other patients, ex-patients and staff, and their own families.7 This seems to be the case not only for those discharged after long stays in hospital, but also for many who have spent most of their lives in "the community". There is thus a danger of progressive social isolation if such ties are broken by too widespread dispersal, and wider relationships remain a pious hope. Under such circumstances emotional tensions within small groups in daily close contact, to which schizophrenic patients are particularly vulnerable, are likely to be inimical to genuine asylum. Patients have a right to relationships both with other patients and with "normal" people: these are not reciprocal,8 as sometimes assumed, and may fulfil different functions.9 Community care’ should not merely
reverse the one-sidedness of institutional life—especially not for those who will experience both. One approach to achieving a balance is to bring the community to the patients, as well as the reverse. "New community"1° or "haven"" projects propose using the major resources of space, public acceptance, and in some cases buildings, of mental hospital sites to develop a range of resources for the long-term mentally ill. Their economic potential is such that a variety of supported accommodation and occupational and leisure facilities could be fundedmixed and to some extent combined with public provision including up-market housing, shops, and parks. The utopian ring of some descriptions should not deflect attention from the practicality of the concept: schemes could be developed on varying scales appropriate to local circumstances, as one component of comprehensive services. At the most modest level they would add to the range of choices open to long-stay patients and mitigate the Poor Law flavour produced by dispersal to district of origin irrespective of present loyalties. It is difficult to understand why this aproach was ignored by the consensus panelagain in contrast to the Social Services Committee’s recommendations that no mental-handicap or mental illness hospital site should be disposed of without it being considered. 12 Urgent action is needed as wards deteriorate, whilst dispersed schemes meet planning obstructions that restrict both their number and their ability to cater for the more disturbed patients. These schemes are also needed to increase resources for future generations of long-term patients, who may otherwise lack opportunities for asylum even in its most primitive sense of shelter. More intangibly, these patients will benefit from the signal that their special needs are to be taken seriously in the new service. Developments in understanding13 and treatrnent14 make it no longer tolerable for interest in long-term schizophrenic illnesses to be regarded as evidence of nostalgia for the mental hospital, unfitting for the would-be community psychiatrist. IS
STEROIDS IN HAEMORRHAGIC STROKE CLINICAL trials of stroke treatment have tended to infarction rather than haemorrhage-where the two have been adequately distinguished and if we leave aside primary subarachnoid haemorrhage. This is not to say that we are now much better at treating infarction. The probable reason is that rationales have been more easily conceived for drug therapy of cerebral infarction-even if wrong. A prominent target for drug activity has been oedema formation, and dexamethasone has been one of the concentrate on
Jones K. Mental hospital closures-the way forward? York: University of York Institute of Advanced Architectural Studies, 1987. 11. Wing JK, Furlong R. A haven for the severely disabled within the context of a comprehensive psychiatric community service. Br J Psychiatry 1986; 149: 449-57. 10.
3.Abrahamson D, Brenner D. Do 4 5
6 7 8
long-stay psychiatric patients want to leave hospital? Health Trends 1982, 14: 95-97. Community care. Second report from the House of Commons’ Social Services Committee. London: HMSO, 1985: para 149. Scull AT Museums of madness. London: Penguin, 1982. Heginbotham C. Good practices in housing for people with long-term mental illnesses. In Good practices in mental health. London: 1985. Abrahamson D, Ezekiel A. Social networks of psychiatric patients. Paper to symposium, King’s Fund Centre, London, June, 1985. Segal SP, Aviram U.The mentally ill in community based sheltered care.New York:
Wiley, 1978 9 Estroff SE.Making it crazy.London:
University of California Press,
1981.
12. Community care—Second report of the House of Commons’ Social Services Committee. London: HMSO, 1985: para 208. 13. Bleuler M. The schizophrenic disorders: long-term patient and family studies. New Haven: Yale University Press, 1978. 14. Steinglass P. Psychoeducational family therapy for schizophrenia: a review essay. Psychiatry 1987; 50: 14-23. 15. Sturt J, Waters H. Role of the psychiatrist in community-based mental health care. Lancet 1985; i: 507-08. 1. Ng LKY, Nimmannitya J. Massive cerebral infarction with severe brain swelling: a clinicopathological study. Stroke 1970; 1: 158-63.