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July 2009 National Confidential Enquiry[ on their front page - go to 'latest news' top right ] unsettling and alarming news
It's not to be buried or disguised, but to be taken very seriously, now.
The families and friends of the victim and the perpetrator are all affected by this, their neighbourhood, all other families with members who have schizophrenia; secure Units and prisons that have the long-term custody of them.
If it's accurate, it demands a better service that can intervene early, and as important keep people with schizophrenia, in care and in touch
The Inquiry found that there had been an increase in the number of homicides committed by people with mental illness at the time of the offence from 50 to over 70.
There was also a a rise in the number by people with schizophrenia - from 25 in 1997 to 46 in 2004 and an estimated 40 in 2005.
1997 ... all 54 ..... 2004 all 70 plus - say 74
1997 .. SZ 25 ..... 2004 SZ 54
1997 = ano 29 .... 2004 ano 20 i.e other serious mental illness has gone down.
[ This is what I can't follow: general rise 54 -70+ = 16 rise - schizophrenia 25 -46 = 21 rise - i.e. from schizophrenia, sufficient in itself to account for all the increase ??
yet one query is answered like this - in those cases of homicides outside continuing care ,
.... ' depressive
illness was more common,
The diagnoses were extracted from the
psychiatric reports [ are these public documents - open in Court ? ]
which were written pre-trial,
to determine the mental state of the perpetrator
at the time of the offence. ]
Any previous contacts with the NHS Services is likely to be in those Reports, and maybe information within those Reports about GP contacts and the observations form there, should have led to more information being brought out by this Inquiry. It looks as though it received little ongoing ruminative reflection from monitors or this information would be available now.
Patients staying in continuing care show no such increase in these tragedies - but no reduction, which must be the aim.
Professor Louis Appleby, Director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, said:
There has been an unexplained rise in the number of homicides by people with mental illness and we now have to try to understand why this has happened.
It is important to emphasise that the increase has not occurred in mental health patients..... It is also important to keep these findings in perspective.
The risk of being a victim of homicide in England and Wales is around 1 in 1,000
[ what's the base line ?? ... around 1 homicide per 100,000 population makes 1 victim per 100,000 !!!?? .....!!! and the risk of being killed by someone with schizophrenia is around 1 in 20,000. [ Ed. I can't follow this. The following figures are very rough but in the right order ]
Take generally the rate by adult people - say 500 adult homicides out of 40,000,000 adults - I make it 1- 80,000
But the population of people suffering from adult schizophrenia is approx 200,000 . Maybe one third of these are unstable, 70,000
If 40 annually is from this population the figure for Homicide, then it seems the proportion is 1/1700 .
please can someone with a sense of statistics sort me out !
Professor Appleby is right to point out that the increase in homicides, where schizophrenia was the illness, came from those outside the NHS service.
But when the perpetrator was in the NHS service, the Reports after Care and Treatment Inquiries
are that the service was not up to the standards required to maintain them within the service.
Not a question of blame.
In all but a very few, at the time, the service failed to get involved,
or was only part involved, or only able to be part involved, with the resources available.
Medication was often inadequate or not maintained.
What should be done about this ? ? The current talk is for early intervention - meaning before the illness takes hold and wrecks the life - can this be done is doubtful still - but rather neglects those who have 'dropped out' or never been known to service - or have been discharged 'we have nothing further to offer'.
1, ...
Schizophrenia, homicide and long-term follow up 30 September 2009
From a current Mental Health Tribunal Review member - a psychiatrist, now retired from being a consultant in Rehabilitation
The increase in the number of homicides committed by persons suffering from schizophrenia, revealed in the 2009 Annual Report of the NationalConfidential Inquiry into Suicide and Homicide by People with Mental Illness, is a cause for concern.
The report suggests that the increase is accounted for by individuals not classified as 'patients', i.e. those who have not been in contact with services in the last twelve months.
If the total of the data is represented in the report, then one should be able to derive the number of 'non-patients' by simply subtracting the 'patients' from the total of the schizophrenia homicide group. That resulting figure not does appear to support the hypothesis.
It appears to show that all of the increase is due to 'patients'. That increase may be due to follow-up failings.
Assessing patients for Mental Health Review Tribunals, I have noted that many teams often simply discharge patients when they do not co-operate with follow up.
The 'positive attitude of hope and recovery', adopted by some community teams and encouraged in New Ways of Working (2009), (NWW), fails to acknowledge the typically chronic or relapsing course of schizophrenia.
NWW also appears to discourage consultant psychiatrists from engaging in long term follow up by talking of a 'shrinking and more focused role for senior professionals, shedding repetitive activities or doing them more smartly'.
These approaches and the fragmentation of services into myriad teams risk losing opportunities to form and maintain therapeutic relationships with patients and their families and to gain understanding of the long term course of patients' illnesses.
It can subsequently become a bewildering task for families of discharged patients, or for concerned others, to get help.
When they do make contact, this will often be with professionals unknown to the patient and to whom the patient is unknown.
Given increased investment and increased numbers of psychiatrists, documented in NWW, it is difficult to see why psychiatrists and other professionals should have less time to allocate to the important task of maintaining links with this high priority group.
The 2007 Progress Report on New Ways of Working says: 'The aim is to achieve a cultural shift in services that enables those with the most experience and skills to work face to face with those with the most complex needs'. Schizophrenia is a severe and usually chronic or recurrent illness associated with a high suicide risk and relatively high homicide risk.
It is commonly associated with substance misuse.
Long term prophylactic medication and psychological and psychosocial interventions can reduce relapse rates.
Long term medical treatment carries risks of adverse effects.
Consultant psychiatrists are commonly among the longest serving members of their teams. The complex elements of schizophrenia and the advantages of long term follow-up provide an important and valid role for psychiatrists.
The Confidential Inquiry should gather data on how many of those with schizophrenia, committing homicide, have been under psychiatric care, how and why they ceased to be so, and in how many cases others had been trying to involve psychiatric services prior to the homicide. There may be a lesson from this that long term follow up of patients with schizophrenia is justified, even if the patient appears well. " From a letter in the British Journal of Psychiatry: the home journal of the Royal College of Psychiatrists
2.
However, the < NAME="key question">key question is, what happens once the patient is engaged? [ by Assertive Outreach Teams - AO for short ]
I believe the focus of the team should then swiftly move towards recovery and social inclusion.
The most important characteristics of this would include a strengths-based approach and a focus on helping patients back to employment,
whether voluntary or paid.
Other characteristics would include a clear relapse prevention plan made in collaboration with the patient and a strong network of supported accommodation.
Occupational therapists (OTs) are invaluable in promoting such approaches in psychiatric care,
both in terms of social inclusion and potentially in leading on return to work initiatives.
Similarly, strong links with the local authority are important in ensuring a good network of supported accommodation.
This is facilitated by the presence of social workers with such links within the team.
However, it is interesting that in surveys done of AO team composition, it is the nursing profession that predominates.
OT and social work input remains limited, while psychology input is concerningly rare.
AO as an intervention has worked well abroad but needs to be modified to suit the needs of the UK population.
The modification required, in my opinion, is a stronger focus on recovery and rehabilitation.
This can be facilitated by ensuring that Occupational Therapists and Social Workers are an integral part of AO teams.
It intuitively makes sense that a strong recovery approach, clear relapse prevention plans
and good supported accommodation that is available for the patient who needs it,
should together reduce admissions and bed usage.
This is the AO model that needs to be evaluated in well-designed randomized controlled trials."
... letter tpB J Psych from a consultant psychiatrist [ Shetty ] in an Assertive Outreach and Rehabilitation Team
and this in response ...
A response letter from Camden Services : Killaly;on line letter B J Psych October.
The 36 month outcomes of the REACT trial (Killaspy et al, 2009)
that assertive community treatment (ACT) shows no clinical advantage over support from standard community mental health teams (CMHTs)
bemuses ACT proponents. ...
... A consistent finding in studies of ACT is that it is more acceptable to "difficult to engage" clients than standard care, but although UK ACT services are engaging clients, as Shetty rightly states, they are not building on this to deliver the evidence based interventions likely to improve clinical outcomes. In some cases this is due to inadequate specialist staffing, though this was not an issue in the REACT study. A survey of 222 English ACT teams in 2003 found that only half had a psychiatrist, one fifth had a psychologist and very few had a substance misuse or vocational rehabilitation specialist. In addition, only 12% were operating with high model fidelity and many did not operate outside office hours (Wright, personal communication). A comparison of ACT in London and Melbourne, Australia, found that London teams had around one quarter of the input from a psychiatrist, only half operated outside office hours (vs most Melbourne teams), only one third made the bulk of their contacts away from the office (vs. the majority of Melbourne teams) and they scored lower for caseload sharing (Harvey, personal communication).
Inadequate implementation of the ACT model, inadequate delivery of evidence based interventions, and similarities between key elements of ACT and standard care therefore appear to explain the variation in its effectiveness reported in the international literature. In the UK, ACT teams need to be staffed appropriately and operate with the critical components likely to result in improved outcomes. Otherwise, their lack of
cost-effectiveness (McCrone et al, 2009) will make them vulnerable to closure.
How to discover and retake these into the help needed.
For those in a system of living which provides for a regular attention and connection to activities in the week - a programme for their living, sustained and reliable, open to observation for early intervention, if necessary; here, the light touch is reasonable.
For the others, erratic and excluding themselves, it increasingly looks as though some kind of 'wardship' should be developed - CTO's but with clear reciprocal benefit in funding, appropriate residential support and occupational activities; guardianship with extra powers?
There is a difference from those in some residual illness , but who have a directed life that they are in charge of, that is one connected to some meaningful regular activity, a routine for themselves, maintained by them, observed by other people :
from those who do not have this, and are consequently open to times when the illness is in charge, not open to observation; there is no such programme onto which to re-engage and restore the commitment.
It is the latter who have to be kept in contact, sufficient to carry some form od surveillance and with the contact to a significant person in their lives, often a family member, able to do reporting in.
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.. July 11-17
neurogenesis - the capacity to make new brain cells. It was thought that this stopped after birth, except for the olfactory bulb [ the area for smell in front ot the brain - accessible ] and two areas :
1. the dentate gyrus in the hippocampus.
How might that be significant for schizophrenia. Recent study has found that where there is hyperactivity in an area of the hippocampus [ area CA3 ] in a sample of people with high risk factors behind them, there was 80% accuracy in predicting that those will proceed to shizophrenia - the positive prediction.
Where there is no such change in the hippocampus the prediction of not going on to schizophrenia was hust as accurate - the negative prediction
One other reason for this interest in the hippocampus is that the neurogenesis there has some role to play in managing what is to be remembered - in receiving, examining and distributing what is being perceived as novel to see whether it is relevant,and needs incorporating
Memory disturbance is common in schizophrenia [ Memory studies ] 2. The area adjacent to the lateral ventricles in the brain called the 'Sub-Ventricular Zone [ SVZ ] ventricles are the fluid cisterns within the brain, [ probably there to buffer against brain movement from external skull collisions - boxers, centreback footballers ? ]
There is now known to be a third area of activity in this area, only in primates and humans - the Outer sub-ventricular zone [OSVZ ] which similarly provides and sends on new cells to the frontal cortex - what are they doing ? if not to back up on living experience as it goes on ? *** N !!! Somebody who knows more, explain more please - by e-mail
comment please to davidwatch@btinternet.com?
The relevance for schizophrenia - maybe none - but one hard fact - the lateral ventricles are larger in many of those with Schizophrenia - never given a satisfactory explanation - what area of the brain gives way to allow for that enlarging - the brain cannot enlarge, confined within the skull: could it be a reduction or loss of the the SVZ and the OSVZ , which are the source of new brain cells, so that what depends on these new cells [ needed to codify new experience ?] ? Might this loss be behind Schizophrenia.
Recently a study of the new born of mums with schizophrenia - a higher risk group for the illness later - have more of babies with lateral ventricles larger than the equivalents in babies of mums without schizophrenia Hitherto in the brain it was until quite recently not able to distinguish new cells with a 'marker' . That is now possible. Neurogenesis cells are 'stem cells ' already being tried in spinal cord injuriea and the brain disease 'Parkinson's' disease. New research has taken fibroblast cells from the skin of patiients with Parkinson's, turned them into stem cells and on into Dopaminergic brain cells so as to be able examine why such cells fail in Parkinson's [ You can't take such cells from directly from the brain in someone in early Parkinson's ] Maybe similar research into schizophrenia one day. |