Introduction
It is understandable that throughout medicine the treatment of acute disorders has a greater emotional appeal than the management of long-term disability. Psychiatrists in particular should be able to understand the strong motivational bias that ensures that attention is paid to patients in crisis and with emergencies. It is the chronic patient who gets neglected.
The hospital system is geared to the needs of acute disorders. As the patients are discharged into the community so the links with their specialists become more tenuous. Where general practitioners are well trained, they can take over the patients’ care, but this transfer is in itself fraught with danger. Although many hospital specialists (including myself) have undertaken an early apprenticeship in general practice, it is unusual for the hospital specialist to become a full-time family doctor at a mature stage. Professor Francis Kellerman, a specialist in diseases of the chest, did just that. He has written about his experiences recently (Kellerman, 1983) and I should like to quote his comments about patients with psychiatric disorders:
The most frustrating surprise concerned the mentally ill. There is no doubt that when the NHS [National Health Service] was introduced a drastic reform of the care and treatment of the mentally ill was long overdue, and in quick succession a number of mental health acts were passed, putting many wrongs right - and just as many rights wrong.
Before the recent mental health acts, the mentally ill were cared for in mental homes [mental hospitals].
Today, with the help of a combination of powerful psychotropic drugs, they are’ cured’ in the hospital and then go home - often against the better judgement of the consultant in charge.
At home, because of non-compliance, or a number of other factors, they relapse. This may take weeks, months or years, but in my experience, in the more severe forms of psychoses, the relapsing rate is nearly 100 per cent.
It is not surprising that a large number of patients fall out of the care network. Chronic psychiatric subjects roam the streets, dressed in shabby clothes, rummaging in dustbins and occasionally shouting out loud to nobody in particular.