Dr Dennis Liu MBBS, PhD, FRANZCP Clinical Lead Senior Consultant Psychiatrist Playford Community Mental Health Service Northern Adelaide Local Health Network Clinical Senior Lecturer Discipline of Psychiatry School of Medicine The University of Adelaide Community Mental Health

The Pilgram Psychiatric Center in Long Island, NY, USA could house as many as 14,000 patients at a time (1940’s). Lobotomies and electric shock therapy were the norm.

Patients in steam cabinets in 1910.

The first prefrontal lobotomy in the United States was performed in 1936 on 63 year old Alice Hood Hammatt by Dr. Walter Freeman and Dr. James Watts. In 1960 Howard Dully received Lobotomy at 12 years old.

Reform movementEraSettingFocus of reform Moral Treatment1800–1850Asylum Humane, restorative treatment Mental Hygiene1890–1920 Mental hospital or clinic Prevention, scientific orientation Community Mental Health 1955–1970 Community mental health centre Deinstitutionalization, social integration Community Support1975–presentCommunities Mental illness as a social welfare problem (e.g. treatment housing, employment) Mental health movements

It refers to a system of care in which the patient's community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment. Community Mental Health

supported housing with full or partial supervision, psychiatric wards of general hospitals, local primary care medical services, day centres or clubhouses, community mental health centres, self-help groups for mental health. The services may be provided by government organizations and mental health professionals, They may also be provided by private or charitable organizations.

Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care, a system focuses on either keeping the total number of patients using services low or reducing the cost of the service itself. Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment.

The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless. While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbor negative attitudes toward those with mental illnesses.

Over the last few decades the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centers grew nearly four-fold. Unfortunately, this drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population.

Insufficient empirical research exists regarding the effectiveness of community treatment programs. Effective and insightful research will be crucial in not only evaluating, but also improving the techniques community mental health utilizes. With this seemingly unrelenting increase in demands for the mental health service, the question becomes what role community mental health services will play. The community mental health system's goal is an extremely difficult one and it continues to struggle against changing social priorities, funding deficits, and increasing need. Community mental health services would ideally provide quality care at a low cost to those who need it most.

Accordino, M. P., Porter, D. F., Morse, T. (2001) Deinstitutionalization of Persons with Severe Mental Illness: Context and Consequences Porter, R. (2006). Madmen: A Social History of Madhouses, Mad-Doctors & Lunatics. Stroud, Gloucestershire: Tempus Publishing. Donaldson, L. (2005). "Collaboration Strategies for Reforming Systems of Care: A Toolkit for Community-Based Action". International Journal of Mental Health 34: 90–102. World Health Organization press release (2007)

Recovery The concept of recovery describes a person’s own unique and personal journey to create a fulfilling, hopeful and contributing life and achieve his or her own aspirations, despite the difficulties or limitations that can result from the experience of mental illness. It does not necessarily mean the elimination of symptoms or a return to a person’s pre-illness state. South Australia's Mental Health and Wellbeing Policy - SA Health (2012)

7.3 million Australians (45% of the population aged 16–85) will experience a common mental disorder (a mood disorder, such as depression; anxiety or a substance use disorder) over their lifetime. Each year, 20% of the population in this age range, or 3 million Australians, are estimated to experience Mental ill health is the leading cause of non-fatal burden of disease and injury in Australia. The five leading causes of non- fatal burden of disease were anxiety and depression (14% of the non-fatal burden), Type 2 diabetes (8%), dementia (5%), adult- onset hearing loss (5%) and asthma (4%) National Survey of Mental Health and Wellbeing (SMHWB)

Integrated Team An integrated team is one where there is a shared responsibility for the provision of a range of clinical services to a defined population. The range of recovery-focused functions will include emergency assessment, crisis intervention, assertive care and clinical support as required. The team will also provide psychological therapies and other interventions.

General manager Team manager Clinical Lead Consultant Senior nurse Senior social wk Senior psychologist Senior OT Reg/RMO nurse social wkpsychologistsOT

Mr BR, a 19 year old, single man currently living in Elizabeth South with his father and three brothers aged 13, 15 and 21 years, in a housing trust home. First diagnosed with Chronic Paranoid Schizophrenia in March 2011, with reports of a progressive decline in his functioning from the age of 17 years. At the time he presented as thought- disordered with perceptual disturbance, bizarre behaviours and some sexually inappropriate behaviour towards his 11 year old neighbour’s daughter. Was commenced on a Community Treatment Order and given depot Risperidone and later changed to Paliperidone and Olanzapine.

Since that first admission he has had admissions in Geelong (after assaulting his mother) in January 2012, and another after appearing confused and perplexed at Adelaide airport. Subsequently he was non-compliant with depot injections in the community and lost to follow up after his father moved to Perth. Was admitted to the Lyell McEwin Hospital in December 2012, after presenting floridly psychotic with grandiose and magical delusions, thought disorder and having set fire in the back of property of his house. Was commenced on Clozapine together with a Zuclopenthixol depot.

History of daily cannabis use since the age of 17 years, since 18 years he had drunk three to four beers “when he could get access to it”, but denied any amphetamine use. No significant forensic history although there is a history of verbal threats towards his family since the age of 17 years, a significant assault against his mother, damage to property and some sexually disinhibited behaviour towards his next-door neighbour’s child on two occasions.

Presented as preoccupied, distractible with a significant paucity of information. At times there was perseveration of speech and ongoing mild thought disorder. No illness insight. “Nah, I don’t suffer from that”.