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The Team for the Assessment of Psychiatric Services (TAPS) was established in May 1985 with the explicit purpose of evaluating the national policy of replacing psychiatric hospitals with district based services. TAPS' remit was to mount the evaluation with respect to the closure of Friern and Claybury Hospitals in north London. Funding was provided by the Department of Health and North-East Thames Regional Health Authority (latterly North Thames Regional Health Authority) with supplements from the King's Fund and the Sainsbury Family Trusts. During 13 years of research TAPS has employed more than 50 members of staff and associated researchers. A full listing is given in Leff (1997). This summary of the research is organised by topics. However, there was very close integration of the various projects.
To ascertain current levels of access to home treatment for those with acute mental illness and future plans of trusts and purchasing authorities to provide such services. Also, to assess the attitudes of these organisations towards this form of treatment. A postal survey of all mental health trusts and purchasing authorities within the UK was carried out.
One hundred and seventy-two trusts and 82 health authorities returned questionnaires, representing a response rate of 75% and 67% respectively. Only 27 (16%) of trusts provided home treatment but 58 (40%) had plans to do so. All health authorities and 97% of trusts were in favour of the principle of providing home treatment.
Despite the low levels of provision of home treatment trusts and health authorities were strongly in favourof it. There is likely to be a large increase in its availability over the next 12 months.
Information given to patients about side-effects of their medication plays a key role in future adherence. It is possible that when antipsychotic medication is prescribed routinely, insufficient information is given to them. In order to investigate the amount of information doctors feel they need to give to patients when they are prescribing conventional antipsychotic medication, all the clinical doctors at a large mental health trust were surveyed by anonymous questionnaire.
Overall, doctors said they gave large amounts of information to patients about possible side-effects of anti-psychotic drugs, but some side effects we discussed far more frequently than others.
The selectivity of information given to patients appears to reflect the doctors perception of what is important. This might not correlate with what the patient may wish to be told. Discussions with patients about side-effects may need to be more comprehensive than they currently are.
To evaluate prescribing and monitoring of carbamazepine and valproate to patients in secondary care psychiatric units. Review of prescription cards and medical case notes.
Prescribing details for 433 patients were recorded. Both carbamazepine and valproate were widely prescribed for indications not listed in their product licences. Plasma level monitoring was not frequently undertaken, particularly with valproate. Where plasma levels were measured, apparently sub-therapeutic prescribing was found to be common. For the majority of samples, it could not be established that a true trough level had been taken. Monitoring of blood function was highly variable. Overall, the quality of both prescribing and monitoring was poor.
Patients may receive sub-therapeutic treatment or experience unnecessary adverse effects. Prescribing and monitoring need to be more evidence-based in line with the ideals of clinical governance.
The Community Care Act came into effect in April 1993. In order to see what impact this would have on the discharge profile of dementia inpatients, prospective studies of inpatient discharges from a dementia assessment ward before the Act, and five and 41 months after the Act were conducted.
The proportion of patients discharged to their own homes and to residential/nursing homecare remained unaffected by the Act. Duration of hospital stay increased after the Act in 1993 and 1996 (P=O.02) largely due to delays in placement into care homes. Placement delay was increased both in 1993 and 1996, but by 1996 the difference was no longer statistically significant. Duration of hospital stay was unaffected by the Act for those patients discharged to their own homes.
The new care management process by social services was found to be associated with delayed discharges for people with dementia requiring residential/nursing home placements, thus causing pressures on beds and hig her in-patient costs.
The study aimed to identify factors delaying discharge of psychiatric inpatients from a learning disability service. A census was completed, categorising in-patients as unready for discharge (n=181); discharge planned within 12 weeks (n=22); or ready for discharge but experiencing delay (n=44), the latter were followed-up 16 months later.
Delayed patients were more disabled or disturbed and often awaiting adequate community provision. They were older, had been in hospital longer and were ‘informal’ admissions. At follow-up 23 remained in hospital, 21 of whom had been delayed by lack of placement.
De-institutionalisation has led to the expectation that more complex and challenging people be placed in the community. This study suggests the community to be, as yet, unready to cope with the needs of these service users.
A postal questionnaire was sent to 100 departments of psychotherapy within the UK in an attempt to gauge the use of psychotherapy services by patients in the third and fourth age.
Eighty-seven per cent of respondents felt that the needs of this group for psychotherapy were not met as well as those of younger people in their catchment areas. This is most marked in people over 65 years of age who are infrequently referred to psychotherapy departments. Suggestions are made for improving services.
The psychotherapy needs of this group need to be considered in service planning. All professionals need educating about the availability and applicability of the psychotherapies for the older patient. Without additional resources it seems unlikely that the needs of this patient group will be met.
A prospective study comparing initial electroconvulsive therapy treatment doses determined by empirical dose titration with estimates derived from two simple dose prediction methods and a fixed-dose regimen (275 mC).
Thirty-three patients had seizure thresholds between 25 mC and 403 mC. The dose titration method led to a mean initial treatment dose of 195 mC that was intermediate between those predicted by the age method (275 mC) and the half-age method (137 mC). Estimates were within acceptable limits in 33% of cases for the age method, 64% for the half-age method and 40% for the fixed-dose method.
Either dose prediction or dose titration methods may be more appropriate in different clinical situations. The half-age method appears to be a more accurate predictor of optimum initial treatment dose.
While specialist registrars in psychiatry are entitled to spend one-fifth of their working week engaged in special interest sessions, little has been published on how the time is used. In order to describe what happens in practice, we conducted a semi-structured telephone survey of trainees on the South-East Thames Higher Training Scheme in psychiatry.
The results indicate that while most trainees (78%) were satisfied with their use of special interest time, those using two sessions regularly for a defined training purpose were in the minority.
Use of special interest sessions is generally good in the scheme surveyed. If uptake of sessions is to be improved, there needs to be even better local support as well as existing national recognition of the educational rights of trainees. The local support should be at the level of both trust and training scheme.
Robert Burton was an Oxford clergyman and scholar. His book was first published in 1621. He adopts the title Democritus Junior after the Greek philosopher who was also “an expert physician, a politician, and an excellent mathematician“. Hippocrates described him as “a little wearish old man, very melancholy by nature”. In the preface, the author says: “I write of melancholy by being busy to avoid melancholy.” (Burton, 1621)