The problem in Britain
Forty percent of all disability in Britain is due to mental illness (WHO, The Global Burden of Disease). Similarly, 40% of people on incapacity benefits are there because of mental illness. The biggest predictor of distress in a person is believed to be a mental illness (Michalos, 2004). Depression and chronic anxiety form significant causes of misery. Current unhappiness would be a prior mental illness more than poverty. The Psychiatric Morbidity Survey of 2000 indicated that one in six persons had either depression or anxiety. However, the picture is not all that bad as evidence-based psychotherapies are able to reduce the number to half (Layard, 2006). 17% of disabilities are caused by depression and 12 % are formed by other psychiatric disorders while addiction disorders come to 10%. Statistics show that 0.5% of the 16.5 % of people suffering from mental illness have schizophrenia. Depression forms 2.5% and anxiety disorders 8.5 %. Only about 25% of people surveyed were taking treatment. The majority of the mentally ill prefer therapy, which is not easily available and so the number having treatments is reduced (Chilvers, 2001). The expenditure being utilized for mental illness is just 2% of the NHS and it is spent mostly for schizophrenia or manic depression though mental illness accounts for one-third of the disability cases.
A report in the Lancet indicated that the mentally ill were being neglected (BBC News 2007). The presence of mental ill-health can affect the physical well-being of people as social, mental and physical health are all intertwined (Tabish 2005 p.34). Medical help, social support and therapy may not reach the mentally ill for want of resources. 70 million people suffer from alcohol dependence, 50 million from epilepsy, 24 million from schizophrenia and another 20 million attempt suicide according to global statistics (Tabish, 2005). Higher rates of illness are seen more in people belonging to the lower socio-economic status by the social causation
hypothesis and can be related to the adversities associated with poverty (Yu and Williams 1999 p. 158). A poor person with schizophrenia would delay his treatment when compared to a rich person (Yu and Williams 1999 p. 152). A mental health policy can be successfully implemented only if organizational problems are resolved (Morris 2006 p. 243). Organizational factors must be well discussed in order to accord services of high quality (Southam-Geow, 2004).
Schizophrenia the disorder
Schizophrenia is a “severe form of mental disorder existing in all countries and cultures” (Frith and Johnstone 2003 p.1). It is a major mental disorder or psychosis which is a severe illness in which the patient loses touch with reality (p. 24). This patient sees imaginary visions or visual hallucinations or hears voices (auditory hallucinations). He also has delusions whereby he believes in things that cannot be believed as true. The illness is seen in one person in a hundred: they may develop the disorder once in a lifetime. The emotional and monetary costs are both severe. The illness causes distress in the form of severe suffering for the patient, his family and friends. The annual costs for care and treatment of schizophrenia in the United Kingdom in the 1990s were £397 million. The indirect loss due to loss of production has been estimated at £1.7 billion (Frith and Johnstone 2003 p. 1).
The risk of schizophrenia in the general population is 1%. It rises to 50% in the offspring of two schizophrenic parents and in identical twins (p. 93). The cause does not just lie in the genetic factors but also in the socio-psychological and biological factors. The investigation into these two factors in psychoses was done by Freud’s followers. The psychodynamic theories include those of individuals and families (Frith and Johnstone 2003 p.108).
Psychoses are triggered by life events that are stressful (p.109). The method of communication in some families conveys conflicting messages to the children. A lasting effect occurs and the children communicate in a weird manner which subjects them to the diagnosis of schizophrenia (Frith and Johnstone 2003 p. 111). Conflicts that are not resolved towards their natural conclusions, stresses and abnormal communication patterns lead the children into becoming negative social beings exhibiting withdrawal from society, hallucinations and delusions (p.115). Intellectual and social functions decline following the loss of will and poverty of thought (p. 123). The symptoms of the illness are diverse in nature (Frith and Johnstone 2003 p. 124).
Primary care and mental patients
Patients with mental disorders tend to meet primary care physicians as a first step to get help (Callahan and Berrios, 2005, p.140). A problem is the paucity of mental health specialists. This has provoked the Mental Health Services to take a challenging step. Over the years in the UK, with the notion that primary care physicians were the first people to meet and diagnose a mental health disorder, educational strategies were employed to help curb depression which was a common illness (p.140). Three stages were identified for changing the role of the primary care physician in the treatment of mental illness. When the third stage was reached, the physician was able to use screening questionnaires and treat the patient (Callahan and Berrios, 2005 p. 141).
The program is planned to increase the knowledge of primary care physicians. Their attitudes towards psychiatric illness were to be changed and their interviewing skills were to be sharpened. Practical options for treatment were to be arranged and reimbursement schedules fool-proof (Callahan and Berrios, 2005 p. 145). A major problem in the program was the cost-effectiveness. Nobody was sure about it (p. 144). The training of the physicians was to be useful and not an eye-wash. Interventions were to be evaluated so that feedback would provide information to further strengthen the implementation.
The program which focused on the treatment of depression soon brought other psychiatric illnesses into it. Socio-economic problems, issues about reimbursement and the role of the patient were evaluated in the program. The later evaluation was done on the correctness of the criteria for diagnosis. The therapy was effective (Callahan and Berrios, 2005 p. 146).
Research on theories of schizophrenia
Schizophrenia is a complex disease (Beebe, 2003). Several factors influence the illness leading to many models having been described by researchers. Biological and environmental models have been described by Beebe in her article (2003). She has detailed the stress-diathesis model of vulnerability also.
- Biological models: Neurochemical dysregulation or anatomical changes in the brain are the arguments behind many of the biological methods. The neurotransmitter model by Carfagno et al (2000 as cited in Beebe, 2003) elaborates the chemical transmission that occurs at the prefrontal cortex, hippocampus, and temporal lobes of the brain; the enhanced activity of the dopamine receptors in these brain regions is believed to cause the hallucinations and delusions (Turner, Fedtsova and Jeste, 1997 as cited in Beebe, 2003). Antipsychotic medications like Haldol and Mellaril block the action of the dopamine receptors and also increase dopamine destruction while atypical medications like Risperidone cause an antagonistic action and effect a reduction in symptoms.
- Executive function model: The executive function model highlights the neurocognitive deficits which are the features of the pre-frontal brain system dysfunction. Schizophrenic patients have difficulty executing supervisory level functions or executive functions. These include the ordering of sequential behaviors, performing goal-oriented plans, continuing a task that has been interrupted, monitoring one’s own personal behavior and “associating knowledge with required responses” (Beebe 2003).
- Environmental model: Environmental models focus on interpersonal relationships where stressors and moderators have an influence on the course of schizophrenia (Beebe 2003)
- The vulnerability model: Many researchers believe that complex interactions among “biological, environmental, psychological, and cultural factors” lead to schizophrenia (Beebe 2003). Stressful life events and mediation processes lead to the illness when combined with biochemical vulnerability. The stress diathesis model has been conceptualized by Kaplan and Sadock (1998 p. 59 as cited in Beebe 2003)
Significance of research in the design of a Health Policy for schizophrenia
The vulnerability model explains the various social, biological, environmental and cultural circumstances that could trigger a schizophrenic episode. This explains why schizophrenia cannot be considered a mere illness in itself. Singular therapy for the illness is insufficient for preventing an episode or rehabilitating a patient. Conditions like housing, a job, a family, social support as necessary, free medicines and psychotherapy, education where necessary are some of the requirements of a patient to get back on his feet. The Mental Health policy must consider the management of a schizophrenic patient in totality. If only some of his requirements are fulfilled, he may slide back and become ill again. Such a patient costs the exchequer much more than if he is rehabilitated.
The Mental Health Policy in the UK
The evolution of the present pattern of services
The National Health Services was set up in the post-war welfare state in Britain in 1948 to implement the improvement of health and welfare through public services (Kemp 1993 p. 392). Mental health problems are prevalent in the UK but they cannot be totally resolved due to a continuous discussion on the concepts which are not acceptable to the users. The dissidents do not like the use of the word “illness” and prefer the word “distress”. The change would allow the personal or social context to be removed and would solicit medical therapy rather than psychosocial therapy. They also believe that the word “distress” is broader in concept (p. 393).
Over the years and now
In 1980, a quarter of the population had some psychiatric problem (250 in 1000). Of these, more than 90% (230) saw a general practitioner for relief. Slightly less than 50% of these (about 140) were found to need treatment for mental illness. The number peaked in the 1950s and declined gradually in the 1980s. A higher turnover was however noticed probably implying the attitude of the people who prefer short stays. High-security special hospitals had 1700 patients and the regional secure units had 650 (Kemp 1993 p.393). About fifteen thousand people were compulsory admissions under the Mental Health Act. Drug addicts and alcoholics were also handled under the Mental Health Act. However, this idea was not accepted by a large population.
Specialist facilities have now taken over the job of de-addiction and treatment. Genderwise, women were more likely to visit the GP or a hospital for treatment than men in a ratio of 3:2. Under the age of fifteen, boys were being admitted more.
Deinstitutionalisation
The continuous debate of deinstitutionalization has led to researchers putting forth a series of conflicting ideas on the issue of the services for the mentally ill. The role of institutions has been a bone of contention. The nineteenth-century saw the introduction of the public asylum. In the 20th century, psychiatry became a specialty within medicine. The asylum disappeared and patients became admitted into hospitals that had the other specialties. However, the segregation of mental health services which was the practice till recently has undergone a transition. The recent trend is to combine the psychiatry services with the programs for provision for the poor and the physically ill (Kemp 1993 p. 395).
The Mental Health Act of 1983
A sustained campaign led to this Act which changed many of the provisions of the earlier policies (Kemp 1993 p. 396). The civil liberties of the patients were taken into consideration; the conditions for compulsory detention and treatment were changed and other new developments were brought in. The funding problem was addressed. Priority care services and acute care services were classified separately. Though the mental health services were classed with the acute care services, funding was on a different scale. Long-term care and support are the responsibility of the local authorities in the form of home support, day centers, hostels and supported housing (Kemp 1993 p. 396). The care and support are facilitated by the local taxes, central government grants and charges from some services. The Local Authority Social Services plan and provide social care by the requirement of the NHS and Community Care Act of 1990.
Current picture
Mental health services are very much a part of the NHS. GPs, outpatient clinics and inpatients are having free treatment services except for some medicines. Relevant legislation and funding are the responsibility of the central government. The NHS is funded through taxes that are passed to subordinate authorities to the district level. Regional specialties including forensic psychiatry and medium secure units, drug and alcohol services and specialist units for adolescents are being provided (Kemp 1993 p.397). Voluntary agencies like the MIND (National Association for Mental Health) have “supported housing, employment projects, advocacy and befriending schemes, counseling, carers’ projects, and social support” (p.397). The expanding private for-profit sector has “nursing homes, residential care, and hospital services” which cater to mentally ill patients. As no insurance is provided for the mentally ill by private companies, the problem of having two levels of treatment has arisen: one for the rich and the other for the poor.
Service delivery structure
GPs are the main “gatekeepers”. On average, four visits are made to them a year. The patients attain mental health through referral by compulsory admissions (through arrests by police with a social worker), voluntary hospital admissions or by referral to the outpatient clinic in a hospital through emergency services or from community mental health centers or social services departments (p. 398).
The elderly
Older people are a larger population now in the mental hospital beds due to the increased longevity, mostly affected by senile dementia. This demographic aging increases the need for services specifically aimed at this population. The demand for informal carers is enhanced. The Government policy is to provide services whereby the aged dementia patients are able to live in their own homes till death. “Community psychiatric nursing, home helps, meals-on-wheels, day centers, and in some instances respite services for carers” are some of the services (Kemp 1993 p. 398). These services are yet to become uniform as the local authorities have not made these services available in many areas. The government is attempting to bring an end to the situation of non-uniformity. It is by allowing the health authorities and social services to purchase the services rather than be providers alone. Reorganization of these services is on the card (Kemp 1993 p.398). An organization theory forms the basis of the implementation of new treatments in mental health policies, technology transfer, the quality of service and outcomes. “Organizational effectiveness, employee work attitudes and productivity, as well as staff turnover” is essential (Ostroff, Kinicki, & Tamkins, 2003).
Mental health personnel
GPs, nurses and other health professionals like clinical psychologists and therapists form the personnel involved with mental health care. The social services staff, NHS trusts and the public also work in harmony (DoH, 1999). Registered mental nurses are trained for managing mental patients in hospitals as the tradition in Britain is to have trained nurses for treating them (Kemp 1993 p. 398). The recent trend is to have trained community psychiatric nurses. Social work mental health specialists are another group that is now in the community. Psychiatric social workers are a group that handles the social work training courses. The Children’s Act of 1989 and the Community Care Act of 1990 have seen the evolution of many personnel to deal with mentally ill patients. Adults’ and childrens’ divisions of the social service department with a distinct mental health specialization are also found now (Kemp 1993 p.399).
The National Service Framework for Mental Health
This is a blueprint for the adult workers for the next 10 years (Thornicroft 1999). The framework plans to enhance the quality of the services provided for mental health patients. Standardization of the provisions for the patients is expected through it. Variations are to be removed so that all mental patients get the same extent of provisions. Promotion of mental health and management will be standardized nationally and service models defined. Programs are to be implemented with a focus on local delivery. Milestones are to be established and high-level performance indicators against timescales are being determined. The services included are the “health promotion, primary care services, local mental health and social care services, those with mental health problems and substance misuse, and more specialized mental health services, including all forensic mental health services” (Thornicroft 1999). The framework intended to meet the shortfalls in the NHS and correct them as much as is possible: “the insufficient involvement of users and carers; stigmatizing public attitudes, poor agreement on service aims and boundaries, patchy and sometimes limited provision of services, lack of financial resources, workforce problems and lack of clear accountability”(Thornicroft, 1999)
Seven areas were identified for improving the national standards (Thornicroft, 1999). Mental health was to be promoted for all people through the involvement of the individual and communities and discrimination against individuals was prevented. The primary health care team was to be able to identify and assess mental health needs and offer effective treatment and if necessary refer the patient. The patient must be able to use the local services and the NHS-MH directly. The patient with severe mental illness must be able to have a written care plan which must be reviewed at times by the care coordinator. Access must be available to a hospital bed if necessary. Carers are to be cared for simultaneously. Preventing suicides is another major step in the program (Thornicroft, 1999).
This framework is believed to work as it has been drawn up after building a base of evidence. All people of the working-age with mental health problems have all the relevant services and the monitoring is to be done at frequent intervals. Staff is being trained to build an efficient workforce. Mental health disorders are to be identified at the primary care level (Thornicroft, 1999).
Saving Lives: Our healthier nation (OHN)
This is a White Paper, a health strategy of the Government. Saving lives, promoting healthier living and reducing inequalities in health were to be the ideas behind this White paper. Reducing the gap in health is the prime aim of the paper. “Air pollution, unemployment, low wages, poor housing and crime and disorder” were the issues to be addressed. The strategy implies that people can improve their own health through appropriate physical activity, consumption of a better diet and abstinence from smoking. Service re-engineering, an innovative program, has been developed in order to improve the access of people to care. The NHS Direct is a helpline manned by nurses who give advice and provide ample support over the telephone (DoH, 1999). The Integrated Care pathways which were established by the Buckinghamshire Partnership Project investigated the working of partnerships. Joint investment plans integrated health, housing and social care for the aged people including the mentally ill in 1999 and adults with mental illness in 2000 (DoH, 1999).
The NHS Plan
Mental health has a high priority in this plan. Hospital-based services are being replaced by community-based care (DoH, 2000). Our Healthier Nation is a program where mental health is again a priority. It has a strategy that changes the determinants of health. The Information for Health allows us to study the level of knowledge of people and their participation in the policy building and planning of services enables us to know about their requirements. Working Together helps us use the strategies for promoting mental health through enhanced consultation and participation, the confidence to speak without fear of victimization and using policies good for the family (DoH, 2000).
Making it happen
Mental health is being promoted by combining policy initiatives, preventing duplication and building partnerships. Mental health promotion could help solve other initiatives like reduction of inequalities, the raising of educational standards, improvement of health, removing social exclusion and increase work opportunities and independence (Department of Health, 2001). The other initiatives too could help improve mental health in turn. The three regeneration policies of Health Action Zone (overseen by a partnership board), Education Action Zone (local partnerships) and Employment Action Zone (local contractors through bids) help the individual to seek employment at the individual level, be educated at the community level and avail of health service at the strategic level. The New Deal for Communities includes all these Action zones and it is managed by the Government. The New Deal for Disabled People is managed by the local authorities.
International Approach
The World Health Organisation Healthy Cities took the initiative to improve health at a city level (DoH, 2001). Mental health promotion policies were to be developed. Data were to be collected and shared. The action was to be taken to improve mental health and prevent mental illness. Research on mental health and promotion was to be encouraged. The European Commission was to incorporate mental health into the Public Health program. The community health monitoring system was to include mental health as a component. The impact of community services on mental health was to be studied. A recommendation was to be drawn up for the promotion of mental health (DoH, 2001). NHS bodies are to comply with the European Convention of Human Rights and the Human Rights Act of 1998. Health delivery will focus on “prohibition of inhumane or degrading treatment, prohibition of detention, right to respect for family and private life, right to marry and found a family and the definition of mental disorder: (DoH, 2001).
Conclusion
The Mental Health Policy must be so defined as to accord quality services to a patient with schizophrenia, ensuring social support, freeing him from poverty, enhancing his prospects for a job, given housing if he does not have one, education if he is willing, apart from freely available treatment and psychotherapy.
References
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