S-63-01
Trust and choice in mental health - some postmodern implications for the future
R. Laugharne. University of Exeter, Exeter, United Kingdom
Objective: Postmodern critics of scientific modernism have questioned the knowledge and power of medical scientists. The issues of trust and patient choice are two areas of interest stimulated by this criticism. We sought to review the research evidence on trust and choice in mental health.
Methods: We completed a literature review of trust and patient choice in mental health, and completed a survey of mental health patients.
Results: Trust in dodtors remains high. Higher levels of trust are associated with older age, continuity of care and choosing your doctor. Patients want choice in their treatment but in partnership with their doctor. Giving patients choice in their treatment improves engagement with services but the effect on treatment outcome is variable.
Conclusion: Issues raised by postmodern cultural change have practical implications for mental health. Trust remains high in doctors, but this finding needs to be investigated for psychiatrists. Patients want choice, not as a pure consumer but using advice from their doctor.
S-63-02
Re-institutionalisation in different European countries
S. Priebe, A. Badesconyi, A. Fioritti, L. Hansson, R. Kilian, F. Torres Gonzalez, T. Turner, D. Wiersma. Queen Mary, Univ. of London Newham Centre for Mental Healt, London, United Kingdom
Objective: De-institutionalisation has been the dominant process of mental health care reforms in Western Europe since the 1970s. It has been argued that this process may now have been superseded by the new era of re-institutionalisation. Major characteristics of the new process are an increase of forensic beds, involuntary admissions, and places in supported housing. Yet, there has been little systematic research on the subject, and this study assessed data from different countries.
Methods: Changes of forensic beds, involuntary admissions, places in supported housing, conventional psychiatric hospital beds and the general prison population between 1990/1 and 2002/3 were identified in England, Germany, Italy, Netherlands, Spain and Sweden.
Results: The number of forensic beds and places in supported housing increased in all countries, whilst changes in involuntary admissions were inconsistent. Conventional psychiatric beds showed further decrease in five of the six countries, but the degree varied. The general prison population has risen markedly in all countries.
Conclusion: Whether the new process is seen as re-institutionalisation or trans-institutionalisation depends on the interpretation and the balance between new places in different institutions, further reduction of hospital beds and the capacity of services in the community. Re-institutionalisation appears to occur in countries with different traditions and health care systems. Explanations and implications for future directions of mental health care are discussed.
S-63-03
Changing legal frameworks for mental health care in Europe
A. Fioritti. Direttore Sanitario Azienda USL Rimini, Rimini, Italy
Objective: Cross-national comparison of law provisions can be very helpful in order to outline models and trends and to support in drafting new legislation.
Methods: A recent comparison of the texts of laws from all countries members of the European Union has allowed for an outline of models in regulating this complex issue in Europe. This work is an updating of a previous one conducted 18 years earlier, and gives way to considerations about historical trends in this area.
Results: Most countries have changed their legislation in the '90s, emphasizing a wider range of services involved in the provision of mental health care and protection of human and civil rights. Roles of the medical profession and of the judicial system in the pr~_zltues of involuntary treatments were found aggregating around two basic models: the medical model, with large discretionary power left to physicians, and the judicial one acknowledging full power in all stages of the process to the legal authority.
Conclusion: Cross national comparisons may be helpful to outline historical and cultural trends and to provide a framework for drafting one nation's laws. European countries have shown to attach great importance to legislation activities in the last two decades, which has been crucial in acknowledging consolidated changes and promoting new approaches.
S-63-04
Integrative treatment in schizophrenia
T. Bums. Department of Psychiatry, Univ, Oxford. United Kingdom
Objective: Despite the impact of antipsychotics the long-term course of schizophrenia has not been changed, nor has acceptable compliance over time or an acceptable quality of life been achieved for a substantial proportion of sufferers. Personal, social and clinical needs are intimately intertwined and clinical consensus is that an 'integrative' approach is needed. Research results for models of integrative treatment have often been contradictory and inconclusive. Most methodologies help little in choosing between proposed models. This reflects both differing methods of service description and differing healthcare contexts. This study attempted to identify the common ingredients of successful integrative treatments.
Methods: A systematic review of home-based care (broadly defined) for severe mental illness (predominantly schizophrenia) utilizing Cochrane methodology, augmented by the measurement of service characteristics in these studies (obtained by questionnaire based on an expert panel). These service characteristics were subject to cluster analysis to identify common practice in integrative services and then to regression analysis against reduction in hospitalisation to identify 'effective' ingredients.
Results: Five main components of practice were identified (multidisciplinary working, integrated psychiatrist, simultaneous health and social care, home visiting and smaller caseloads). Two (home visiting and integrated health and social care) were associated with improved community tenure.
Conclusion: It is possible to begin to identify the essential components of integrative treatment for schizophrenia. This requires exploring rather than discounting outcome differences in studies.
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