Practicalities of care closer to home: seven key questions for community psychiatrists

SUMMARYThis article aims to clarify what ‘care closer to home’ means to a community psychiatrist. Care closer to home can be operationalised as primary care liaison and the article reviews experience across England of how a liaison service can work with the recently organised primary care networks. Key competencies needed for liaising with primary care are discussed using seven questions, including bias mitigation, reducing bed-days, consultation skills, knowledge of emerging treatments and reducing administrative overheads while improving access.

The Public Psychiatrist as a Leader

One of the many areas in which a community psychiatrist can impact patient care is through providing clinical and administrative leadership. The actions of leaders have consequences, both good and bad. Good leadership in a public mental health organization can be felt even among staff who rarely interact with the executive team. People understand the vision of the organization, and they feel engaged in achieving the organization’s goals and are committed to the organization. Poor leadership impacts morale and leads to high turnover and poor quality of care. This chapter discusses some of the leadership roles available to the public psychiatrist. It incorporates case scenarios that one may confront as a community psychiatrist in a leadership role. This chapter fosters consideration of individual paths to public psychiatry leadership by using several successful community psychiatrist–leaders as examples. The chapter concludes by discussing various ethical issues related to leadership that may arise.

The Public Psychiatrist as Clinical Team Member

Patients served in community mental health settings often have multiple psychiatric, physical health care, and psychosocial needs. Because of this complexity, clinical care by a multidisciplinary team is required. This chapter describes team member responsibilities and the role of the community psychiatrist within the various treatment team structures that community psychiatrist might encounter. Contemporary treatment planning, including wraparound services, the resiliency/strengths model, use of peer services, and cultural competency, is described. In contemporary community psychiatry, the patient is an integral part of the team, and so person-directed treatment planning is discussed as well as the recovery movement and its implications for psychiatry. The chapter discusses how to foster cross-discipline collaboration and describes the importance of systemic thinking and approaches to patient care. Examples of the treatment team process are provided.

Community psychiatry

An inpatient admission to a psychiatry ward has a high cost both eco­nomically and psychologically. While it is necessary at times to treat someone in hospital, the majority of the work in maintaining good men­tal health is done while the patient is living their usual life with its highs, lows, and challenges. Community psychiatry aims to manage people with mental illness in their own environment. There are many benefits to this, including promoting a sense of normality, allowing for continued support from family and friends, and helping to bridge the change between ill­ness and recovery. Because of this, community psychiatry covers almost everything in psychiatry and is as much a speciality of exclusion as a spe­cific group: no under 18s (child and adolescent), over 65s (psychiatry of old age), addictions (substance misuse), or the law (forensic psychiatry). But a community psychiatrist can’t be too exclusive because local differ­ences, based on what other dedicated services are available, and sub­threshold presentations mean that a good working knowledge of most conditions is essential. In many ways, community psychiatrists are the GPs of the speciality. The only way to manage such a large and varied workload is to make good use of the multidisciplinary team (MDT): community psychiatric nurses (CPNs), occupational therapists (OTs), speech and language therapists (SALTs)—the list of acronyms is endless but essential. A good community psychiatrist has a team they can rely on to help keep a watch­ful eye over their clinical population; managing their day-to-day care and anticipating problems before a relapse develops. The balance between giving space for recovery and monitoring to ensure efficient treatment is hard to achieve but gratifying when it occurs. Part of the skill set of a good community psychiatrist is an understand­ing of the research statistics: prevalence of disorders, treatment rates, and prognosis. These allow for faster diagnosis and evidence-based treatments to speed up recuperation. The minutiae of these facts aren’t needed, but a broad understanding helps shape assessment and management.

Coping with a coroner's inquest: a psychiatrist's guide

SummaryDuring the period 2000–2004 the average annual suicide rate in England and Wales was 10.2 deaths per 100 000 population over 10 years of age. About a quarter of those who take their own lives are in contact with mental health services in the year before their death. This means that an average in-patient, sector or community psychiatrist is likely to experience the death of at least one patient by suicide in most years. Suicides by patients cause considerable distress for the psychiatrist that is unlikely to resolve until after the coroner's hearing. This article discusses suicide prevention and provides guidance for psychiatrists on preparing for a coroner's inquest following a patient's death that may have been by suicide.

The community psychiatrist in 2008: anachronism, Cinderella or pioneer?

Contemporary psychiatry in the UK is practised in an era where the deinstitutionalisation programme is virtually complete. The vast majority of the large mental hospitals (once called asylums) that dominated mental healthcare have closed to be replaced by a complex network of community services (including a ‘virtual asylum’ of residential and nursing home provision). Psychiatrists of past generations recall the excitement (and concern) associated with the concepts of ‘community psychiatry’ and ‘community care’: some, including me, were appointed to post as a consultant community psychiatrist. In the era of ubiquitous community care is the community psychiatrist an anachronism? Or does the recent call for in-patient psychiatry to be recognised as a specialism (Dratcu, 2006) imply its obvious corollary, the specialist community psychiatrist?