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The reason why we should modify our teaching styles are, at least, ethical, social, cultural reasons and, of course, they all belong to our profession, or, better, to the way we perceive our profession, to the way we make researches, aim at scientific objectives, expect scientific results; in short, it belongs to our professional projects, therefore to the reasons why we study, plan, design researches, update our competences, have classes. If we all do not understand the impact of changes now, changes will introduce themselves, clearer and clearer, in a short time. Within this context, the role of the Sciences of Education is extremely important; actually, they are asked to confirm their interdisciplinary scientific nature; to demonstrate to be able to read present educational problems; to give, again, significant answers to the need of fostering, within all educational settings, interest, curiosity and motivation; to avoid the risk of being perceived as a set of technical sciences.

Background This study aims to evaluate differences in the clinical profiles and use of psychiatric services by people with schizophrenia with and without borderline intellectual functioning. Both groups in this study were receiving standard community psychiatric care. Methods A naturalistic sample of 372 people with schizophrenia completed the National Adult Reading Test. Data were collected prospectively over 18 months on psychiatric symptoms and service use. Three hundred and thirteen had normal intellectual functioning (mean age 43, range 20–76 years) and 59 had borderline or lower intellectual functioning (mean age 45, range 21–81 years). This was defined by a National Adult Reading Test error score of more than 40. Results People with borderline or lower intellectual functioning had a lower quality of life, more severe psychotic symptoms, reduced functioning and fewer antidepressant prescriptions. There were no significant differences in service use including hospital admission. Conclusions People with schizophrenia and borderline or lower intellectual functioning are a more disabled group within general adult psychiatric services who should be the focus of initiatives for improved service delivery.

Objective: Recent work has focussed on schizophrenia as a ‘deficit’ state but little attention has been paid to defining illness plasticity in terms of symptomatic remission. Method: A qualitative review of a recently proposed concept of remission [N.C. Andreasen, W.T. Carpenter Jr, J.M. Kane, R.A. Lasser, S.R. Marder, D.R. Weinberger (2005) Am J Psychiatry 162: 441] is presented. Results: The proposed definition of remission is conceptually viable, and can be easily implemented in clinical trials and clinical practice. Its increasing acceptance may reset expectations of treatment to a higher level, improve documentation of clinical status and facilitate dialogue on treatment expectations. The availability of validated outcome measures based on remission will enhance the conduct and reporting of clinical investigations, and could facilitate the design and interpretation of new studies on cognition and functional outcomes. While useful as a concept, it is important to consider that remission is distinct from recovery. Conclusion: The introduction of standardized remission criteria may offer significant opportunities for clinical practice, health services research and clinical trials.

Mental health care in the second half of the 20th century in much of the developed world has been dominated by the move out from large asylums. Both in response to this move and to make it possible, a pattern of care has evolved which is most commonly referred to as ‘Community Psychiatry’. This narrative review describes this process, from local experimentation into the current era of evidence-based mental health care. It focuses on three main areas of this development: (i) the reprovision of care for those discharged during deinstitutionalisation; (ii) the evolution and evaluation of its characteristic feature the Community Mental Health Team; and (iii) the increasing sophistication of psychosocial interventions developed to support patients. It finishes with an overview of some current challenges.

Since 2000 assertive outreach has been a requirement of community mental health provision in the UK. This has led to rapid proliferation of assertive community treatment teams offering a pure form of clinical case management to people with severe mental illness. The teams provide intensive support in obtaining material essentials such as food and shelter and place a greater emphasis on social functioning and quality of life than on symptoms. People with psychotic illness with fluctuating mental state and social functioning and poor medication adherence are most likely to benefit. Teams are ideally placed to monitor clozapine treatment in the community. Teams require a broad skills mix, and team members need some competence across a wide range of areas. Teams should include a psychiatrist or have regular access to one. Ideal individual case-loads are 10–12 patients. Around-the-clock availability is no longer considered essential, particularly in view of the rise of crisis resolution/home treatment teams.

BACKGROUND: The application of statistical modeling techniques, including classification and regression trees, in the prediction of violence has increasingly received attention. METHODS: The predictive performance of logistic regression and classification tree methods in predicting violence was explored in a sample of patients with psychotic illness. RESULTS: Of 2 logistic regression models, the forward stepwise method produced a simpler model than the full model, but the latter performed better. The performance of the classification tree appeared to be high before cross-validation, but reduced when cross-validated. The standard logistic model was the most robust model. A simplified tree with extra weight given to violent cases was a reasonable competitor and was simple to apply. CONCLUSION: Although classification trees can be suitable for routine clinical practice, because of the simplicity of their decision-making processes, their robustness and therefore clinical utility was problematic in this sample. Further research is required to compare such models in large prospective epidemiologic studies of other psychiatric populations.

BACKGROUND: The social networks of people with mental illness have received much attention, but users of day care services have rarely been considered. METHODS: Users of day hospitals and day centres were surveyed cross-sectionally. Demographic and illness factors were tested for associations with network size, while intrinsic relationship factors were tested for association with confiding in a network member. RESULTS: There was some evidence that a longer duration of contact with services, more unmet needs, working, living in supported accommodation and needing help with psychotic symptoms were associated with having a larger network, while a longer duration of contact was associated with having more confidantes. Day centre users confided in people who were more likely to be friends or neighbours than professionals, and who were more likely to be the same sex. CONCLUSION: For people in day care, the stereotype that people with longer-term mental health problems are socially isolated is contradicted by this study. The limited role of professionals in providing confiding relationships is striking.

Schizophrenia is a chronic disabling disease which in the majority of cases requires long-term treatment with antipsychotic medication. Before the development of atypical antipsychotics, treatment choice was restricted to conventional (or typical) antipsychotics, which are known to cause a range of side effects including extrapyramidal symptoms. Although atypical agents provide a favourable alternative (advocated by the National Institute of Clinical Excellence in the UK), they are associated with side effects. These differ between agents, but can include weight gain, sedation and hyperprolactinaemia. Aripiprazole is a newly available atypical antipsychotic for the treatment of schizophrenia. With the apparent imitations of currently available medications, aripiprazole provides clinicians with another treatment option. The purpose of these guidelines is to outline the consensus reached by the Schizophrenia Innovation Working Group on best practice in prescribing and appropriate use of aripiprazole in the UK.

Background: In view of the increasing integration of health and social care, there is an urgent need to know how health service day hospitals and social service day centres are being used, and by whom. Aims: We aimed to compare users of day hospitals and centres in terms of their social networks, needs for care and demographics. Methods: A cross-sectional, comparative study of service users at two day hospitals and four day centres compared their social networks, needs and characteristics. Results: Day centre clients had much larger social networks, including a threefold difference in total contacts and two-fold difference in confidants, but had more needs for care, particularly relating to psychological distress. They were also older on average than day hospital patients and were a more long-term group. Conclusion: It is vital to understand differences between health service day hospitals and social service day centres given the increasing integration of health and social care. The present study shows that the two user groups are significantly different. It is unlikely that the needs of most day care users could be met by either service interchangeably.

Objective: To examine the dental health of community dwelling people with schizophrenia and to compare results with those in the general population. Method: Dental health of 428 people with schizophrenia in six different areas of the UK was assessed by a self-report questionnaire. Results: Compared with the general population, significantly more of the younger patients were edentate (3–39% vs. 1–20%) and fewer had more than 20 teeth (70% vs. 83%). None of four dental health targets had been achieved in the patient population. More patients had last visited the dentist because of trouble with their teeth; fewer had visited for a check-up. Fewer patients cleaned their teeth daily; this group had more negative symptoms. Conclusion: The dental health of people with schizophrenia is poor. Community mental health teams should encourage them to attend their community dentist regularly.

BackgroundThe role of journals in disseminating research to clinicians is increasingly debated. Current measures of esteem for journals (e.g. impact factors) may not indicate clinical penetration.AimsTo assess the perceived importance of different mental health journals to psychiatrists' clinical practice and compare this with impact factors.MethodRandom samples of psychiatrists providing child and adolescent, adults of working age and old age services chose up to ten journals read or consulted with regard to their clinical work, ranking the top three. For these journals, comparisons were made with impact factors and importance as outlets for UK psychiatry research.ResultsA total of 560 questionnaires were completed (47%). Two membership journals (the British Journal of Psychiatry and the BMJ) were most read and highest ranked. Associations between impact factors, clinicians' ratings and importance as outlets for psychiatry papers varied.ConclusionsThe results could lead to reconsideration of the importance of some journals. Academic assessments of the status of journals should not be assumed to reflect their influence on clinicians.

Purpose of review: Multidisciplinary teams in mental health have developed in parallel with the demise of large asylums in the developed world. Their growth has been pragmatic, largely atheoretical and relatively unresearched, reflecting the clinical view that input from a variety of professions is required to meet the needs of patients suffering from mental illness. Despite the ubiquity of multidisciplinary teams, little research has evaluated what components of teamwork (e.g. team meetings) are more effective. Recent findings: A recent Cochrane review demonstrated that a team approach was beneficial to healthcare processes in general medicine, and several studies have suggested that multidisciplinary teamwork improved patient and carer outcomes in elderly psychiatry. Research has also demonstrated that quality of life in severely mentally ill substance abusers increased with a shift from interdisciplinary to multidisciplinary practice between health and social care professionals. Summary: Expert opinion and clinical experience (and limited research) suggest that teamwork is beneficial to both patients and carers. However, it is self-evident that multidisciplinary teamwork is costly and not without its own problems. In a climate of limited resources, it is reasonable to question the effectiveness (cost and otherwise) of multidisciplinary teamwork in mental health. The current research and clinical interest in comparing different types of teams could be significantly advanced by targeted studies on the costs and benefits of some of the core components of teamwork. Such research is required to promote much needed improvements. © 2004 Lippincott Williams and Wilkins.

BACKGROUND: In view of the plethora of different community-based mental health services, there is a clear need for a classification based on service components rather than labels. Moreover, the sustainability of experimental services beyond their research studies is rarely reported. METHODS: As part of a systematic review of home treatment for mental health problems, authors of all included studies were followed up for data on service components and sustainability. Associations between components were explored. RESULTS: There was evidence of a core group of components co-occurring in home treatment services: regularly visiting at home, taking responsibility for health and social care, having smaller caseloads, multidisciplinary teams, integrated psychiatrists and a high proportion of contacts at home. Fifty-four per cent of services no longer existed, of which almost half had ended by the study's publication date. There was a significant association between sustainability and the study's hospitalisation outcome. CONCLUSIONS: Some of the related service components presented here were associated with reducing hospitalisation. This group cannot, however, be used to provide a new taxonomy of services. It is imperative that future studies prospectively record and report service components to enable better classification. It is of concern that policy is currently predicated on research findings regardless of whether or not the experimental service was sustainable.

There are four services providing mental health care to the people of Kumasi, Ghana. This study aimed to identify previous help sought by patients presenting to the services for an initial assessment. New patients presenting to each of the four services were asked about distance travelled, previous help sought and time since symptoms of illness started. Staff also recorded basic demographic details and clinical diagnoses. Of the 322 patients presenting to the four sites,only 6% had seen a traditional healer whereas 14% had seen a pastor before presentation. There was a greater delay in presenting to that service if the patient had seen a traditional healer or pastor. Many patients had previously used one of the other mental health units in Kumasi. It is possible that fewer patients with mental health problems present to traditional healers in modern, urban Africa compared to rural areas. More patients consult with pastors than traditional healers and liaison with these groups may improve mental health care. It is important to maintain liaison between the four services as patients presenting to one clinic may have presented previously to another local clinic.

Objective: To examine the association between co-morbid personality disorder (PD) and suicidal behaviour over a 2-year period in a sample of patients with psychosis. Method: A total of 670 patients with established psychotic illness were interviewed using a battery of instruments including a screen for co-morbid PD. The prevalence of attempted and completed suicide was measured over the next 2 years using multiple data sources. Logistic regression was used to examine whether those with co-morbid PD were at greater risk of suicidal behaviour compared with others. Results: One hundred and eighty six patients (28%) were rated as having a co-morbid PD. After adjusting for all covariates, patients with co-morbid PD were significantly more likely to attempt or complete suicide over the 2-year period (adjusted odds ratio: 1.87; 95% CI: 1.02–3.42). Conclusion: Co-morbid PD is independently associated with an increased risk of suicidal behaviour in psychosis. Early assessment of personality status should be part of the routine assessment of all psychiatric patients.

Objective. To investigate the impact of training CMHT members in the practice of Individual Placement and Support on the vocational status of long-term patients. Method. Six CMHTs received vocational training by a work co-ordinator; four continued with standard care. The best vocational status of the 1037 subjects was ascertained after one year. Factors associated with improvement in vocational status were identified. Results. There was no difference in change of vocational status. Age, previous employment and diagnosis influenced outcome. Conclusion. Training in IPS at team level did not improve employment status. A dedicated, vocational worker appears to be essential for successful IPS.

Objective: To compare patterns of clinical activity amongst existing staff in two inner-city community mental health teams before and after their enhancement with extra resources using a new activity schedule containing 11 comprehensive and mutually exclusive practice categories. Method: Patterns of clinical activity amongst existing members of two inner-London community mental health teams were compared before and after the addition of extra resources. Results: The amount of time spent in face-to-face contact with patients and carers showed no meaningful change following team enhancement. Patterns of clinical activity amongst team members remained relatively static. Conclusion: Adding resources to community mental teams without considering how to target the time released amongst existing staff may reduce their capacity to work more innovatively.

(2002). Impact of the Community on Intensive Community Care. International Journal of Mental Health: Vol. 31, Mental Health and Disability in Europe—2, pp. 66-77.

Laugharne R, Byford S, Barber JA, Burns T, Walsh E, Marshall S, Tyrer P. The effect of alcohol consumption on cost of care in severe psychotic illness: a report from the UK700 study. Acta Psychiatr Scand 2002: 106: 241–246. © Blackwell Munksgaard 2002. Objective: Alcohol misuse in psychotic patients is common and leads to poor treatment outcome. This study examines the relationship between alcohol consumption and cost of care in patients with a severe psychotic illness. Method: Patient care was evaluated over 2 years for 708 patients. Patient reported alcohol consumption was evaluated at initial interview. The outcome measure was cost of care over2 years. Results: There was no difference in mean cost of care between non-drinkers, moderate and heavy drinkers. Increased alcohol consumption (measured as a continuous variable, adjusted for baseline characteristics) was associated with lower cost of care. Conclusion: Heavier alcohol consumers did not incur more treatment costs and may, indeed, cost less than other patients. This may reflect higher levels of drinking being associated with better overall functioning, poorer engagement with services or exclusion from services.

BackgroundSerious violence is an unusual but significant correlate of psychosis, and leads to the need for specialist secure psychiatric services. Most such service users have previously used general psychiatric services.AimsTo examine diagnostic and socio-demographic differences between high-security psychiatric service users from their peers in community services.MethodTwo groups of patients with psychosis were compared: a national sample of high-security hospital residents, and a sample of patients in contact with general psychiatric services.ResultsSchizophrenia was the almost invariable diagnosis for all special hospital patients. White patients in the community sample were significantly more likely to have affective components to their illness compared with African–Caribbean patients; unlike those in special hospitals. There was a small excess in the proportion of African–Caribbean patients in the special hospital group, controlling for diagnosis, gender and locality. Men were overrepresented in this group.ConclusionsAmong patients with psychosis, having a diagnosis of schizophrenia and being male increase the likelihood of special hospital admission. Suggestions that ethnic minority patients are much more likely to have engaged in serious violence and need high-security placement were not borne out.

SummaryThe use of psychotropic medication is an important part of most psychiatrists' clinical practice. We propose here that psychiatry needs to give more prominence to psychopharmacology in order to ensure that psychiatric drugs are used effectively and safely. The issue has several ramifications, including the future of psychiatry as a medical discipline.

Summary Homelessness has serious implications for the health of individuals and populations. Primary health-care programmes specifically tailored to homeless individuals might be more effective than standard primary health care. Standard case management, assertive community treatment, and critical time intervention are effective models of mental health-care delivery. Housing First, with immediate provision of housing in independent units with support, improves outcomes for individuals with serious mental illnesses. Many different types of interventions, including case management, are effective in the reduction of substance misuse. Interventions that provide case management and supportive housing have the greatest effect when they target individuals who are the most intensive users of services. Medical respite programmes are an effective intervention for homeless patients leaving the hospital. Although the scientific literature provides guidance on interventions to improve the health of homeless individuals, health-care providers should also seek to address social policies and structural factors that result in homelessness.

BackgroundIndividual placement and support (IPS) has been repeatedly demonstrated to be the most effective form of mental health vocational rehabilitation. Its no-discharge policy plus fixed caseloads, however, makes it expensive to provide.AimsTo test whether introducing a time limit for IPS would significantly alter its clinical effectiveness and consequently its potential cost-effectiveness.MethodReferrals to an IPS service were randomly allocated to either standard IPS or to time-limited IPS (IPS-LITE). IPS-LITE participants were referred back to their mental health teams if still unemployed at 9 months or after 4 months employment support. The primary outcome at 18 months was working for 1 day. Secondary outcomes comprised other vocational measures plus clinical and social functioning. The differential rates of discharge were used to calculate a notional increased capacity and to model potential rates and costs of employment.ResultsA total of 123 patients were randomised and data were collected on 120 patients at 18 months. The two groups (IPS-LITE = 62 and IPS = 61) were well matched at baseline. Rates of employment were equal at 18 months (IPS-LITE = 24 (41%) and IPS = 27 (46%)) at which time 57 (97%) had been discharged from the IPS-LITE service and 16 (28%) from IPS. Only 11 patients (4 IPS-LITE and 7 IPS) obtained their first employment after 9 months. There were no significant differences in any other outcomes. IPS-LITE discharges generated a potential capacity increase of 46.5% compared to 12.7% in IPS which would translate into 35.8 returns to work in IPS-LITE compared to 30.6 in IPS over an 18-month period if the rates remained constant.ConclusionsIPS-LITE is equally effective to IPS and only minimal extra employment is gained by persisting beyond 9 months. If released capacity is utilised with similar outcomes, IPS-LITE results in an increase by 17% in numbers gaining employment within 18 months compared to IPS and will increase with prolonged follow-up. IPS-LITE may be more cost-effective and should be actively considered as an alternative within public services.

BACKGROUND: Research shows considerable variability in the effect on relatives of patients' mental illness but the determinants of relatives' experience remain unclear. We investigated the influence of demographic, social and clinical characteristics on relatives' experience when conceptualised using a stress-appraisal-coping paradigm. METHODS: Our sample was drawn from relatives of patients recruited to the UK700 case management study (n = 154). Demographic, social and clinical data were collected from patients, and relatives completed the Experience of Caregiving Inventory and the General Health Questionnaire. We predicted that patients' symptomatology in particular would influence relatives' experience, and that relatives who appraised caregiving more negatively and less positively would experience greater psychological distress. RESULTS: Linear regression analyses revealed that relatives' appraisal was not predicted by patients' symptomatology. Instead, relatives appraised caregiving more negatively if the patient was unemployed or younger, and less positively if the patient had been ill for longer or had poorer social functioning. Little of the variance in appraisal was explained by these variables, however. Consistent with the stress-coping model, relatives' negative appraisal was a strong predictor of psychological distress and accounted for a substantial proportion of its variance. Positive appraisal did not predict psychological distress, however. None of the demographic, social or clinical characteristics tested had any significant effect on relatives' psychological distress once appraisal was adjusted for. There was an unexpected positive correlation between the two appraisal scales, with relatives who appraised caregiving more negatively also appraising it more positively. CONCLUSIONS: Our results support a stress-coping model of caregiving but further research is required to determine more influential predictors of relatives' appraisal. Our findings indicate that interventions aimed at patients' social functioning and relatives' negative appraisal of caregiving may assist in reducing relatives' psychological distress.

Background: This paper presents the quality of life (QOL) outcome results from the UK700 randomised controlled trial of case management. Method: A total of 708 patients with severe mental illness were randomly assigned to intensive and standard forms of case management in four sites in the UK. QOL was assessed using the Lancashire Quality of Life Profile, which provides a self-reported objective and subjective appraisal of eight life domains (finances, work, leisure, family, social relations, living situation, safety and health). The outcome after 2 years was examined using univariate and multivariate analyses. Results: Significant improvements in QOL over the 2 years were observed. The QOL outcome did not differ significantly by case management treatment conditions or by diagnosis. A better outcome was associated with improvements in depression and with the location (site) of treatment. In one site there were significant improvements in all eight domains and overall QOL, with moderate or better effect sizes (> 0.4) in three domains and overall QOL. Conclusions: Depression should be assessed when subjective QOL measures are used. Better means for describing service organisations and the context/place in which they operate should be developed in order to explain more of the variance in QOL outcomes.

OBJECTIVE: Case management studies from Europe and the United States continue to yield conflicting results. At a symposium at the World Psychiatric Conference in Hamburg in 1999, researchers from four European countries explored the possible reasons for differences in outcome. They also examined reasons for the differing foci of case management studies across the different cultures. The authors summarize the symposium's findings. METHODS: Individual case presentations were given of studies and services from the United Kingdom (three studies), Sweden (two studies), Germany, and Italy (one each). Outcomes, methodologies, and national service context were examined. RESULTS AND CONCLUSIONS: A significant influence of national culture is evident both in the acceptability of case management and in approaches to researching it. Case management is perceived as an "Anglophone import" in Italy but is now national policy for persons with severe mental illness in the other three countries. Studies from the United Kingdom emphasized methodological rigor, with little attention to treatment content, whereas those from Sweden accepted a less disruptive research approach but with a more prescriptive stipulation of treatment content. Studies from Italy and Germany emphasized the importance of differing descriptive methodologies. Marked differences in the range of social care provision were noted across Europe. Overall, European researchers are less concerned than U.S. researchers with studying the impact of case management on hospital use.

Objective: To explore the stability of conclusions from mental health services research across differing care systems. Contradictory results in different countries for similar studies of programmes for patients with schizophrenia have usually been attributed to poor replication. This paper explores whether these differing results can illuminate aspects of schizophrenia by examining the interaction of the disorder with the care context as an alternative explanation. Method: The findings of a large UK random controlled trial of intensive case management with such patients is compared to previous UK and US studies. Results: Reduction of case-load size of psychotic patients did not significantly reduce their need for hospitalization in the context of locally available co-ordinated care. Conclusion: There is more to be gained in understanding complex disorders such as schizophrenia by interpreting the impact of context on treatment study outcomes than by simply dismissing contradictory findings as failures of implementation of either research or clinical practice.

Aims and MethodInformation concerning team staffing, keyworker case-loads, and keyworker diagnostic case-mix was collected from six community mental health teams caring for 1651 patients to establish the clinical burden across teams and professions.ResultsTeam case-loads varied from 427 to 121, an average of 275 patients. Over half the patients were female, and psychotic disorders constituted 44% of the sample. The most common diagnoses were schizophrenia (28.6%) and depression (23.6%). Keyworker case-loads varied across both teams and professions, averaging 30 patients per full-time equivalent. Psychiatrists' case-loads were the largest. Diagnostic case-mix varied with profession. Community psychiatric nurses had the largest proportion of patients with psychosis (73.8%).Clinical ImplicationsMulti-disciplinary community mental health teams have a shared view of appropriate work distribution. Consultant psychiatrists may underestimate the resources required by patients with non-psychotic disorders even in inner city areas.

Qualitative interviews were carried out with 24 Asian in-patients and carers to gain insight into their experiences of mental health services. The term ‘ Asian’ was problematic and respondents sometimes emphasised that although Asian, they might also be British and practice a variety of religions. Issues raised were frequently relevant to psychiatric patients in general but several important areas of concern relating specifically to religious and cultural differences such as food, washing facilities and privacy emerged. There was also a perceived lack of communication between both patients and carers with professionals. There was little evidence that these patients either somatised their problems, disagreed with their diagnosis and the appropriateness of receiving medication or considered that there was excessive stigma associated with receiving psychiatric treatment. However, they preferred the terms ‘ depression’ or ‘ behavioural problems’ to mental illness. Respondents requested more than one type of therapy to include both medical and additional treatments such as psychotherapy or herbalism.

Aims and methodsStaff from five community mental health teams (CMHTs) were trained to use structured rating scales for akathisia, tardive dyskinesia and Parkinsonism. Detection rates of these side-effects were compared for the six months before and after the intervention.ResultsFifty-seven per cent of the target professionals participated, screening 200 (52%) eligible patients. This resulted in significant increases in the recording of all three side-effects as positive but no increase in their formal diagnosis.Clinical implicationsDetection rates of these side-effects can be increased to those predicted by research with significant reductions in drug dose and non-adherence and without clinical deterioration.

In the 1960s, most people with severe mental illness were treated in large mental hospitals, receiving all their care under one roof, ensuring its continuity and accountability. Deinstitutionalisation resulted in discharge into the community, where care was fragmented between many agencies, making continuity and accountability very difficult. Countless individual programs were developed with few links between them. Not surprisingly, deinstitutionalised patients, in an unfamiliar environment and with poor coping skills to navigate services, did not receive the care they needed.

Summary Background Case management has increasingly been the recommended approach to care for severely mentally ill patients since the number of psychiatric beds has decreased. Despite equivocal results, in the UK and Europe, this approach is becoming accepted policy. We assessed the effect of smaller case loads. Methods We randomly assigned 708 psychotic patients in four centres standard case management (355 patients, case load 30–35 per case manager) or intensive case management (353 patients, case load 10–15 per case manager). We measured clinical symptoms and social functioning at baseline, 1 year, and 2 years. The impact of treatment on hospital use was assessed at 2 years by subgroup analyses for Afro-Caribbean and for severely socially disabled patients. Analysis was by intention to treat. Findings There was no significant decline in overall hospital use among intensive-case-management patients (mean 73·5 vs 73·1 days in those who received standard care [SD 0·4, 95% Cl -17·4 to 18·1]), nor were there any significant gains in clinical or social functioning. There was no evidence of differential effect in Afro-Caribbean patients or the most socially disabled patients. Interpretation In well-coordinated mental-health services, a decline in case load alone does not improve outcome for these patients. Mental-health planners may need to pay more attention to the content of treatment rather than changes in service organisation.

The movement of care into the community for the mentally ill with severe and enduring problems has important implications for primary care services. This paper reports the findings from an interview with practice nurses working in south-west London, United Kingdom, who had participated in a randomised control trial to investigate the effectiveness of training and structured assessment on clinical and social outcomes of patients receiving maintenance medication of depot antipsychotics. The aim of the interview was to explore current practice, attitudes, confidence and priorities for training in relation to these patients. Thirty-nine nurses were interviewed. The majority of practice nurses received scant referral information and worked without protocols. Even though these nurses had received the training, and as a result of the study had increased awareness of the problems of the severely mentally ill, there was a significant relationship between inadequate knowledge of schizophrenia to carry out the task of medication management and lack of confidence. Although the small size of the sample does not permit generalization, important questions are raised for further practice development and research, including the future training needs of practice nurses and partnership relationships with mental health professionals for supervision and support.

Psychiatric services have evolved continuously since their inception. This evolution has accelerated recently, driven by various factors - increased understanding of psychiatric disorders and their treatment, the introduction of a welfare state, changes in societal attitudes, the move away from institutional care. With the move away from large institutions, systems of care have become increasingly complex, often with a number of different services operating in any one geographical area. Despite marked differences between services, all are characterized by multidisciplinary working, this is probably most evident in the community mental health team (CMHT). Increasingly, services have specialized, and the UK National Service Framework introduced the so-called 'functional teams' - assertive outreach, crisis resolution, and early intervention. Provision of these services does vary according to local need and resource. Different nations have developed services in different ways, and some noteworthy examples are presented. Finally, we briefly outline the key current issues in the organization of services, as we understand them. © 2008 Elsevier Ltd. All rights reserved.

Other than medication and access to in-patient care, there is little published consensus on the essential components of schizophrenia care. This paper reports a Delphi approach to the identification of these components. This approach identifies and measures the degree of consensus, using a structured iterative series of questionnaires by a group of experienced UK and Irish psychiatrists (n = 15) on the essential components. Pharmacotherapy, in-patient care and community mental health team (CMHT) staffing were explicitly excluded from the study. In total, 106 components were identified and their importance was rated twice. There was consensus on 92% of the components and strong consensus on 64%. The Delphi results were refined by the participants to produce 10 essential components of care.