The effect of personality disorder on clinical outcome, social networks and adjustment: a controlled clinical trial of psychiatric emergencies.

One hundred psychiatric emergencies presenting to an inner London teaching hospital had formal assessments of psychopathology, personality disorder (using both ICD-10 and the Personality Assessment Schedule), social networks and social functioning before being randomly assigned to a multidisciplinary community-based team (Early Intervention Service (N = 48) or conventional hospital-based psychiatric services (N = 52) and treated for a period of 12 weeks. The ICD-10 classification yielded a higher proportion (50%) of personality disordered patients than the Personality Assessment Schedule (34%) and those from ethnic minorities (mainly Afro-Caribbean) and upper social classes had a lower incidence of personality disorder. Social networks were smaller in personality disordered patients and there were fewer attachment figures. Improvement in social function, and to a lesser extent with depressive symptomatology, was better in patients with no differences were found between the numbers and duration of social contacts in the two services and it is concluded that the better outcome in the community-treated patients was independent of changes in social networks.

The consequences of an open referral system to a community mental health service.

The first 590 patients referred to a community mental health service (the Early Intervention Service) in an inner-city district were separated into groups based on their referral source. The service has an open referral system allowing any agency (including patients) to contact the service by letter or by telephone, and priority is given to patients with serious mental illness. The results of open referral showed that the number of referrals was adequate for the service to process, the proportion of inappropriate referrals was similar in all referral agencies, and milder cases of mental illness were referred more often from doctors than from other agencies. It is concluded that an open referral system is likely to be more sensitive to need and has some advantage over closed referral arrangements in inner-city areas.

Early intervention in psychiatric emergencies: a controlled clinical trial.

In the UK, psychiatric care of patients with acute and chronic disorders has increasingly moved from hospital to the community. We have evaluated in a controlled trial patients with severe mental illness, who were assigned to early intervention by community services or to standard hospital treatment. 100 patients aged 16 to 65 years presenting as psychiatric emergencies to an inner London teaching hospital were randomly allocated to a multidisciplinary community-based team (n = 48) or conventional hospital-based psychiatric services (n = 52) and assessed over a 3-month period. Ratings of psychopathology and social functioning were made before treatment and after 2, 4, and 12 weeks by independent assessors. 85 patients completed all assessments, and all patients had evaluable data beyond 2 weeks. 3 patients died during the study, 2 from natural causes and 1 from an accident. Patients referred to the community service showed greater improvement in symptoms and were more satisfied with services than those in the hospital-based service. Patients treated in the hospital-based service spent eight times as many days as psychiatric inpatients as those treated in the community-based service. Patients both prefer and seem to benefit from community-based psychiatric care, and our early-intervention community service might be a good model for such care.

An agenda for care programming and care management.

Lack of central clarity within the implementation guidance (HC(90)23/LASSL (90)11) and differing time scales for implementation have led to a lack of consideration of the relationship between the care programming approach (CPA) and care management (CM). Instead, says Steve Onyett, there appears to be a short-sighted scrabble to achieve the requirements of the care programming circular at the expense of rational longer-term planning. This article has two aims: to argued that there is no sensible long-term basis for differentiating the CPA and CM, and to set out a longer-term agenda for their development.

The benzodiazepine withdrawal syndrome and its management.

The literature on benzodiazepine dependence and withdrawal is reviewed with an emphasis on social and psychological considerations. The problems of when to prescribe, identifying withdrawal symptoms, effective communication with the patient, the structure of withdrawal programmes, and the use of drugs, psychological approaches and other services are discussed.