Michele Tansella

Lessons from community mental health to drive implementation in health care systems for people with long-term conditions

This paper aims to identify which lessons learned from the evidence and the experiences accruing from the transformation in mental health services in recent decades may have relevance for the future development of healthcare for people with long-term physical conditions. First, nine principles are discussed which we first identified to guide mental health service organisation, and all of which can be potentially applied to long term care as well (autonomy, continuity, effectiveness, accessibility, comprehensiveness, equity, accountability, co-ordination, and efficiency). Second, we have outlined innovative operational aspects of service user participation, many of which were first initiated and consolidated in the mental health field, and some of which are now also being implemented in long term care (including case management, and crisis plans). We conclude that long term conditions, whether mental or physical, deserve a long-term commitment from the relevant health services, and indeed where continuity and co-ordination are properly funded implemented, this can ensure that the symptomatic course is more stable, quality of life is enhanced, and the clinical outcomes are more favourable. Innovations such as self-management for long-term conditions (intended to promote autonomy and empowerment) need to be subjected to the same level of rigorous scientific scrutiny as any other treatment or service interventions.

Are community mental health services relevant in low- and middle-income countries?

Epidemiology and Psychiatric Sciences / Volume 23 / Issue 02 / June 2014, pp 115 118 DOI: 10.1017/S2045796014000067, Published online: 19 March 2014 Link to this article: http://journals.cambridge.org/abstract_S2045796014000067 How to cite this article: G. Thornicroft and M. Tansella (2014). Are community mental health services relevant in lowand middle-income countries? . Epidemiology and Psychiatric Sciences, 23, pp 115-118 doi:10.1017/S2045796014000067 Request Permissions : Click here

Childhood trauma and psychotic disorders: evidence, theoretical perspectives, and implication for interventions.

Il termine trauma psicologico sta ad indicare l’esperienza di un evento soverchiante ed incontrollabile, percepito come una minaccia al proprio senso di integrità personale o alla propria sopravvivenza (van der Kolk, 1987). Tale termine rappresenta un concetto relativamente nuovo nella storia delle scienze psicologiche. Per tutto il corso del XIX secolo, infatti, la parola “trauma” veniva generalmente utilizzata per indicare una ferita aperta o una rottura violenta della superficie cutanea, senza alcuna connotazione psicologica. Il termine trauma psichico fu introdotto per la prima volta nella letteratura scientifica verso la fine del XIX secolo dal neurologo tedesco Albert Eulenburg per riferirsi all’impatto psicologico degli eventi di vita stressanti sul funzionamento del sistema nervoso centrale (van der Hart & Brown, 1990). Il termine fece definitivamente il suo ingresso nel lessico psicologico grazie a Jean-Martin Charcot (che introdusse nuove entità diagnostiche, quali la névrose traumatique e la hystérie traumatique), Pierre Janet (il quale ipotizzò che la dissociazione fosse il processo psicologico fondamentale attraverso cui l’organismo reagisce alle esperienze sconvolgenti e dimostrò che i ricordi traumatici possono manifestarsi sottoforma di percezioni sensoriali, stati affettivi, rappresentazioni comportamentali ripetitive), e Joseph Breuer e Sigmund Freud (i quali differenziarono le nevrosi traumatiche dagli altri tipi di nevrosi sulla base della sintomatologia, gettando così le basi per la successiva esplorazione delle dinamiche dei meccanismi psicologici). Tuttavia, ad eccezione di alcune ricerche sulle “nevrosi traumatiche da guerra” durante e dopo la Seconda Guerra Mondiale (Kardiner, 1959) e qualche studio sui sopravvissuti ai campi di concentramento, l’effetto psicologico degli eventi traumatici ha ricevuto per oltre mezzo secolo scarsa considerazione da parte del mondo scientifico. Il tema riguardante il trauma psicologico ha conosciuto una improvvisa ondata di interesse verso la fine del 1970 con il lavoro di Horowitz et al. (1980) e con Psychological trauma refers to the experience of overwhelming, uncontrollable events that are perceived to threaten a person’s sense of integrity or survival (van der Kolk, 1987). This represents a relatively new concept in the history of psychological sciences. During the 19th century, the word “trauma” generally referred to an open wound or a violent rupture to the surface of the skin; it carried no psychological connotations. The term psychic trauma was first introduced in scientific literature in the late 19th century, by the German neurologist Albert Eulenburg, to describe the psychological impact of stressful life events on the functioning of the central nervous system (van der Hart & Brown, 1990). The term entered the psychological lexicon due in large part to Jean-Martin Charcot (who introduced new diagnostic entities such as névrose traumatique, and hystérie traumatique), Pierre Janet (who proposed dissociation as the crucial psychological process with which the organism reacts to overwhelming experiences, and showed that traumatic memories may be expressed as sensory perceptions, affect states, and behavioral reenactments), and Joseph Breuer and Sigmund Freud (who together distinguished traumatic neurosis from other forms of neurosis on the basis of its symptoms, giving rise to the psychoanalytic investigation into the dynamics of psychological mechanisms). However, excluding some research on the “traumatic neurosis of war” during and after World War II (Kardiner, 1959), and a few studies on concentration camp survivors, for more than half a century, little work was done to explore the psychological effects of traumatic life events. Interest in psychological trauma dramatically resurged in the late 1970s, with the work of Horowitz et al. (1980), and the studies on the impact of the Vietnam war. Hundreds of thousands of Vietnam veterans in the USA presented with serious psychiatric problems and a new diagnosis, posttraumatic stress disorder (PTSD), was cre-

Acute in-patient care in modern, community-based mental health services. Where and how?

Nel corso degli ultimi anni ha avuto luogo nei paesi occidentali un acceso dibattito tra coloro che sostengono la necessità di fornire l’assistenza psichiatrica all’interno dell’ospedale e coloro i quali propendono per un’assistenza psichiatrica fornita principalmente o esclusivamente a livello territoriale, finendo col porre questi due modelli in antitesi tra loro. Questa falsa dicotomia è oggi in realtà superata da un approccio che contempla un’assistenza psichiatrica che vede la presenza di servizi di comunità accanto ad una moderna componente ospedaliera: sia le evidenze disponibili che l’esperienza clinica accumulata nel corso degli anni forniscono prove a sostegno di un approccio bilanciato, che integra elementi sia di tipo ospedaliero che comunitario (Thornicroft & Tansella, 2002). In un sistema di cura bilanciato il fulcro assistenziale è costituito da servizi forniti all’interno dei normali contesti comunitari, collocati il più vicino possibile alla popolazione servita ed in cui il ricovero in ospedale può essere attivato rapidamente, ma soltanto in caso di necessità. I pazienti che necessitano di una valutazione clinica urgente o quelli che presentano gravi patologie di natura organica in comorbilità con disturbi psichiatrici o coloro i quali manifestano gravi scompensi psicopatologici associati a turbe comportamentali o quelli che manifestano elevato rischio suicidario o aggressività o coloro i quali presentano una condizione neuropsichiatrica acuta richiedono, spesso, immediati interventi ad alta intensità assistenziale forniti nei reparti ospedalieri (Thornicroft & Tansella, 2004). Un sistema di cura bilanciato non può essere concepito senza letti per acuti, collocati – secondo l’orientamento prevalente – all’interno di piccoli reparti di degenza dell’ospedale generale. In Italia, la scelta di fornire l’assistenza psichiatrica per acuti esclusivamente all’interno dell’ospedale generale, piuttosto che in contesti extraospedalieri autonomi, rappresenta uno dei principi guida della legislazione psichiatrica. All’epoca in cui la legge venne approvata, la separazione rappresentava una delle caratteristiche salienti del manicomio (tenere i Over recent years in western countries an ongoing debate has concerned the issue of mental health care provision in hospitals vs. primarily or even exclusively community-setting forms of treatment, with the two types being frequently viewed as mutually exclusive options. Yet, this false dichotomy should be replaced by an approach that integrates community services with modern hospital care: both the research evidence available and accumulated clinical experience support a balanced approach that incorporates elements of both hospital and community care (Thornicroft & Tansella, 2002). In fact, a truly comprehensive care system focuses on providing care in normal community settings located as near to the population served as possible, and where hospital admissions can be arranged promptly, but only when necessary. People who require urgent medical assessment and who are suffering from severe and co-morbid medical and psychiatric conditions, severe psychiatric relapse and behavioural disturbance, high suicidality or assaultativeness levels, or acute neuropsychiatric conditions will usually need immediate, high-intensity support in acute in-patient units (Thornicroft & Tansella, 2004). Hence, a balanced system of care cannot be conceived without acute beds being provided (based on a widely held view) within small general hospital units. In Italy, the decision to provide in-patient mental health care exclusively within general hospitals rather than in separate settings constitutes a leading principle of the nation’s mental health care legislation. At the time the law was enacted, a key feature of asylums was that of segregation (leave mental patients out of sight, due to their “unacceptable” behaviour), whereas currently a key characteristic of a modern balanced mental health service is that of integration with the mainstream general healthcare system. In-patient psychiatric units located within general hospitals therefore represent the less stigmatizing option for patients requiring acute and intensive mental health care; and the Italian mental health law

The ethical base of mental health service research. Recent developments in mental health service research in the UK.

After the developments in mental health services in the UK in the last 40 years there has been an increasing focus on identifying and targeting the needs of the severely mentally ill (SMI). Political concern about the possible risks of community care have resulted in an emphasis on administrative and legal means of ensuring continuity of care and close clinical supervision of this SMI group. A number of experimental community‐oriented mental health services have been shown to be cost‐effective compared to hospital‐based treatment. The further development of comprehensive community mental health services will depend on demonstrating whether this can be generalised to routine clinical settings. In this context we shall present the design of the PRiSM study, a prospective controlled trial of the cost‐effectiveness of community mental health teams for the SMI in South London.