2000 - Hospital Care And Rehabilitation Services

Hospital and rehabilitationservices Ste{an Priebeand RosemarieMcCabe DeinslhL4ionali2ation has leit hospilalswith a moditiedrcle, in whjch coercionand violenceare a parlicularlycommon problem.Numeroussludies,oftenbasedon comprehensive dala sels, haveinvesligaledprediclorsof oulcomesuch as rehospitalizalion rale,duratioi of slay and violentincidents.The varianceexplainedby patientcharacbn$icsand baseline va.lableshas been Gther smal, however,rcnderingil of linle use lor prediclingindividualcases.Clinic€lpGcticein hosptals varies- evenmoreso in partialhospilalizalion prcgrammesand s@ms to dependmore on the ideologya.d policyol the hospilaland on lhe qualityol communityca.e servicesthan oa palienltactoG.How policyintetuenlions can inlluencepractice, however,a.d ultimatelyimprcveindividualoulcome,is slill poonyu.de'slood. In ihe rehabrlralonof sch'zophren'a pallenls,the relationof speciliccognitivedelicilsto dlfierenlial oulcomesmay tacilitalethe developmenlol ta€eled inlervenlions. However,advancesin empi cal researchwo'1hy of lhe prevailingoptimisn ii the lield arc slill eagerlyawaited though.In vocationalrehabilitation, individualplacementand supporlin @mpetiliveemploymenlhas been shoM to be a rnoreeilecliveallernative thanconventional strategies.In general,lhere is a irend lowards moreintensiveand programmes.cd, opn individualized specilicrehabilitation P s t h a i r1y32 1 5r 1 9 { . m m L i p p r c o { W n a m s & w i k n s .

ufll ror sm€ a,d communirr Fsy.h,arry.sr aadhdomew s aid the RoyaiLof,dm schm or Medcm E,sr HamMemm, HosAra Londd. rJK corcsponden.e10srelanPieb€. unllor sm€ and c.mnun i' Psychstfy,sl Badh. mew s rd the Roya Londm s.hm or Med€re. Easl Ham Memoial HosPia.Lond.nE? 8OR Lrk Ie +.4 ?0 3536 5r2; Fd .44 73 &5$ 5173 emar [email protected] cun.nr Opinionin PsychidrrylDcro 132rt2rg , 2@C LFpncofiwirams &wdkns

lntroduction d orld,deinsriruT h r o u g h o u rr h e N e s r e r n j n d u s r r i a l i z e w r i o n i l i z a r i o no f n l e n r a lh c . k h c a r c h a s l e d r o a r e d u c r i o n i n r h e n u m b e ro f h o s p ; r ab l e d sa n d r o r h e e s r a b l i s h m e n r o f v a r i o u sa n d o f i e n i n n o v r r i ! e o u r p a r i e n ra n d c o m n r u nin seryices. This has lcft !he hosp;ral ar rhe less glamorous end of rhe menral hcalrh ca.c specrrum. Nelerrhclcss, ;n !he care of parienrs wirh severe mcnlal rllness,rhis srill eats Dp rhc lion's share of direcr a n d s e n ' e sa n e s s e n r i a la, l b e i r m o d i 6 e d , f u n c t i o n . I n r e l a t i o n ! o l b e n u m b e r o l b e d s .r h e r e h a s b e e n a r e l a r i v ei n c r e a s ci n c o m p u i s o r ya d m i s s i o n sa n d c o c r c i o nt l ' 1 . D c s p i t e u s i m p o r r a n c eh. o s r i r a lr r c a r m c n r a p p e a E r o b e s o m c $ ' h a r n d e F r e s e a r c h e dN. h i c h i s .cne.rcd ;n dre pauciry of conrrollcd srudies rhar invesrisare rhc cffccrivencss of spc.ific licarmenr s r i , r c g ; c si n i n p d i j e n rf a c i l i r i e sR . c s c , r c hs c e n s r o f o c u s nrore on dcrerminxn!s of bed use and predicrors of o u r c o n r c i n D a r u r a l ; s r i cd e s i s n s .T h e q u , l i r ] o f s u c h s r u d r € s ,h o e e r e r , d e t e n d s o n r h e c o m p r e h e n s i v c n c s s and ac.uncy ot rhe a!ailable dala se!s, which show s i g n i 6 c a n r; n t e r n a i ; o n avl a r i a r i o n .

Hospital care V r h i l e m o s t o f t h e r c s e a r c hp c m i n ; n s r o h o s p i r a l c a r eh a s f o c u s e d o n t h c a n a l y s i so f p d i i c n ! c h a r a c r e n s o c rso prcdicl oulcome, this work is wcll complcftented by s r u d i e s a n a l y s i n go n a m o r c s l o b a i l e v c l , r h e i n r c F dependenct'belween rhe uril;arion of hospi!rl and c o m r n u n i r l b a s e ds e n , i c c s . Bed use ancl duration of stay C h a r a c r e r i s r i cosf p r r i e n r sr r c a r e di n i n p a l i e n ru n i r s .r h e r r o p o i i i o n o f c o ' n p u l s o r ; l ya d m i l r e dp a r i e n r sd, u r a l i o no f s i x r , a n d d i s c h a r s ed e s r ; n a t i o nc h a n g eo v e r r i m e 1 2 , 3 j , a n d m . \ ' v a ^ ' g r c a ! ' \ d e p e n d i n eo n r h c l v p c o f h o s p i l a l . f , , n , 1 , n g , , r u n q c n , . ncrh\ b . r , r . ' e I . ' i co' f . o m r l u n i ^ , , r c s c r v i c c s a n d h o s p i l a l p o l i . ] - 1 4 - 7 . 8 ' 1 .A n ! n a h s i s o f regiondl d;ffcrcnccs ;n Fjiland 19"l revealed rhar n u m b c r o f b c d s a n d a d n r i s s i o nr a t e s ,r e a d m r s s r oanr c s . c o n r p u l s o n t r c a t n r e n rr n d o u l p a r i c n r c a r e a r e s r r o n g h inreiclependeni. Aiicftprs ro proJile frcqucnr usels of i n p a l i e n ! s c n , i c c sl i c l d c o n s ; s r e n 6 r n d i n g s iy o u n g a n d predominlndy male parienrs \yirh a psychoric/nrood d i s o r d e ra c c o u n rf o r o v e r h a l f o f m u l l i p l e a d m i s s i o n s ll0.lll. In addirion. number of p.evious ddmissions, s c \ c r ; r v o f j l l n e s s[ ] 2 1 , 1 1a n d c o c x i s r e n c eo f a p h \ ' s i c a l i l l n e s s .p r r ! j c u h r l \ i n d e p r c s s c dp a r i e n r sl l 5 l , a r e a l s o p r e d j c l i v eo i d r r r a r i o no f s t a Y .

2t5

94iar, commonrty and plblic heallh psychiatry

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N o r d i c c o m p a r a r n , es r u d r [ 8 ' ] i d e n r i f i c d a n d i a l i o N e d u p , g r o u p o f p a r i c n . sw h o D s e do n l y i n p a l i c n r .\e (i.e. 12% of a toral conorr or nes, ( u n ' n r s , O \ c ' a l l .r h r \ g , n r t r c \ c i v e dc \ r n p r t i c n ,r a r e rhan drose \r,ho used bodr inparienrand ourparicnr se^'rccs, suggesring rha! drerc is a groLrp of predomin a n d y n r a l c p a r i e n r sN i r h d c p c n d e n c i e sa n d f u n c r i o n a l D . \ c h n : . ! \ v l , o r r e s " c r d l l ) i 5 o l a r c da . nd nor jn tonrrcr \\1rlr ourp.oenr seryices. I-ikewise, paricnrs vho d;s, c h a r s e dr h e D r s e l v cfst u n r i n p a r i c n !c a r ea g a i n s rm e d i c a l adlice failed ro cngagc u,ith sen,iccs 1161.The! atso t e n d e d r o b c m l l e $ i r h d u d l d i a g n o s e sn, o r e s e v e r c p s \ c h o p a r h o l o s ya n d h i g h e r r a r e s o f . c h o s p i r a l i a r ; o n during 1 nrondr follou' up. Conrinuir\ of cxrc, berwecn 'nparicnr and ourparicnr seftings I171, and flex;bte. !r!ensrye comnluniry care, includins 2.{-h cmersency sc^iccs, may help ro rarser dresc djfficul.ro-cnsage s.oups and provide morc cffccrive care. \.lorc rnrensrvc o u e d r i e n r c a r e h a s i n d e e d b e e n f o u n d i o b e r c t d r e dr o d e c r e a s e dr e a d m i s s i o nn r c s 1 9 " 1 . Coe.cion and aggressaon l n a r y p i c a l i n r e g r a r e dh c a k h c a r e s l s r c n r , r h e n r o s r I i c . t u c n r s i l e s o f a s s a u l ta r c p s , v c h i a r r i n c p a r i e n r$ , a r d s , s l r c r e h a l f o f r i l l s s a u l r so c c u ' I I 8 , l 9 l . T u , o i $ u e s p r e ! a i l i n l h e r e l c v a n rI i r c ' a r u r e r a r t e m p rt so c h a r x c i c r j z e paienrs {,ho arc violenri .nd slrff rrain;lr9in and m a n a g e m e n ro f v i o l c n c c . l \ ' l a l ep a r i e n i ss , i r h c o t u o r b i d p s \ c h o s i s a n d s u b s r a r c e u s e d ; s o r d c r so r p c l s o n a t i r y d i s o r d e . sa r e m o r e l i k c l v r o p e r p e r r a r ea s s a u t r[ 1 9 , 2 0 ] . R c p c r i r i v e l yv i o l e n r p a r ; e n l sw , h o r e D dr o b c o l d e . , h a v c a h r s r o r yo f v ; o l c n c ca n d b e i n v o l u n i a r j l yd e l x i n e d , m a y a c c o u n tf o r m o r e t h a n r w o r b ; r d so f a l l v i o l c n ! i n c i d e n r s 1 2 l l . O n l v a w e a k a s s o c ; a l i o hn a s b e e n f o u n o D e N , c e n a g g r c s n o na r d d r e a m o u n r o f p h y s i c a ls p a c e , I e a d i n g N ; j n r a n a n d R e c r o rl 2 2 l r o . o n c l u d e r h a r ' p s v c h o t o s i c a l s p a c e ( c . g . p . i v a c ) ) m . \ ' b € m o r e s a l i c n ri n i . i g g c d n s

I n j u n c s a . e n o s r c o n r m o na n o n g n u r s i n sp c r s o n n e lL l 8 l0 " l r n u . . p l ' o n . . r l 'r d u t p . ) . l , i a r r i ! r ' " , c c \ r ( p h \ s i c a l l ) a s s a u l r e dd u r i n g . r v p i c a l r r a i n i n g p e ' i o d o f a \ c ! i 5 1 2 3 1 .f t i s s i d e l ! a s r e e d r h a ! l r a i n r n g i n ! h c n ) r n a g e n r c n ro f r i o l e n r b c h a v ; o r r i s o f r e n r n r d e q u a r c , bnd. n'ore ..ren,Jrr appr"r,l'ro rr,:inrnC ir rrn"nI n , , , , . r d J f o c r , . d [ . . 1 8 _ _ 0 , 2 ] , 2 4 1t r.e r n c r e " , c i r c o e r c i ! e a c r i ! i ! ; e s l 1 ' 1 , r h e s f t i k i n s d i l f e r e n c c sr n r h e usc of conpulsol c!re acrosspslchiarrrc scnrces t 2 5 . , 2 6 1 .\ h a r r a o e n 1 5 p c r c e i ! e a s c o c r c i \ c 1 2 7 l a n d r h e n e g a n \ c c m o r i o n a lj n r p a c ro f p s v c h i a r r i ca d m i s s r o . o n p a r i e n r sl 2 8 l , r e d l l f a c r o r sd r a r s h o u l d b c a d d r c i s c d i n s G | f ! ' r i n i n g . C c r r a i n l ! . q u r l i N o f s r r f n n gi s s u p p . , s c d r o b e a p r o r e c r i \ ef l c r o r , a n d i n c r e r s e dc x p e n d i t u r c o n s r a f f i n s h a s b e e n l i n k e d r o l c s s f r e q u e n t a s s a u i rr n a n I n r a n e n r u n ' r t 1 9 j . H o s e r e r , r h e r er p p e a r s r o b c l i r r t e | , F , i . n n r i d r o r l r J c . l n f n , c n . r n o\ \ r e m a r . rLe \ n E

of spcci6c inre^ cnrions (aparr frcnr sccl',sion t29l) for trrr i s k p a r i c n t s .I h i c h , c o n r b i n c d $ i r h 3 d c q u a r es ! : r f f i n s r n d ' r a f f t r . r i n i n g .n r r g l r t e f l e c r a d " . l . n e r n a s s r r r , r r r e

Satisfaction F o r a t l e a s r 2 5 r ' c a r s ,p a n e n t s ' s a r i s f a c r i o nh a s b e e n r e g a r d e da s . r c l e v a n ro u r c o m c c r i r e r ' o n f o r e l a t u a r i n g psychiarric rrc,rnrenr, so how sarisfied arc parienrs !irh ti\'.hrrotr hu\piral"i,(, Inr mrjoric) or taficnr\ Jre expli.idy saris6ed,bu! rhis 6nding is mc.ninglcss because dre orcan sarisfa.rion score on ,ny scate is a p p . o x i n , r e l ! r w o - r h i r d sr o w a r d sd r e p o s i r i l e c n d o f r h e scale for \'harcvd is bcing assessed,and ps),chiarric p a r i e n s r c n d r o e x p r c s ss r r j s f a c r i o nw i ! h a n ) , r . c a r n c n ! . Ii has been reperredly rcporred i30.1 rhar scurc t s y c h i a r r i ci n p a r i e n r s y, o u n g e r p a r i e n t s .r h o s e d e r a i n e d i n v o l u n r 3 r i l ya n d , i n p a r r i c u l a r .p i r i c n ! s $ i r h . h i s h c r dcfilee of depressivc mood arc comp.rJr|!e^, tcss sarisfied e,irh rcarorenr. Fo. ;dcnrifting dissxrisfacrion, i r \ c c n . n r L C \ \ a Dr o . , t 1 ( ( , 6 ( J l ) J . k a b n - r p c r n c n r a s p e c r so f d r e i r c a r m e n r u D d s r e v a l L r a r i o nt 2 6 , . ] 0 . 1 . ( l o n r i n t r i r yo f c a r e , p r o v i s i o n o f i D f o r m a r i o na n d c r ; s i s carc havc bcen idcnrificd as areasdrdr pjiienrs arc radrct d n s a t i s f i e d{ , t r h 1 2 6 , 3 1 1 . A l i h o u s h m o s r s l u d i c s o f s a i i s f a c r i o nN i r h s e n i c e s c o n r i n u er o a s s e s s a s f a c r i o ni n o n c s a n r p t ea r a s ' r g t e p o i n r o f r i m . I 3 0 ' , 3 1 , 3 2 1r.n d n r c r h o d o l o g i c apt. o b l e n r s s D c h a s s c l c c r i o nd r r o u s h n o n r e s p o n s cl . t 3 l a r c p . o b t e n r a l c , c o m t a ' a r i v c s ( r d i c s . , f s r r i s f a c r j o , Lr c , r o r c i n i b r m a r i v c .P s \ c h i i r r i c p a r i c n r s{ , c r c s i s n i 6 c a r t h l e s s \at|\6ed si,l, '("rr,.n, rhan uc,( no,.ri\)LnrJ.r m e d i c . l p a r i e n r st 3 a l . I n s r u d i c sr h d r c o n u a r e d p s y c r i a dic seNices paricnts havc been hosd\, lur nor c o n s i s r e . d v f. o u r d t o b c n o r e s a r i s G e d rsirt s.nic(. !nLl pr rdl l,u:p Jl/Jfiun ,hrn $rrh r,^.t,rel cat. t26). Partial hospitalization P a i r ; a l h o s p i r a l i z a l i o ins a \ ' ! g u c r e ' j n ! h a r i s u s c d f o r d c s c r i b i n g! c r \ d i f f e r c n r r . c a i n r e n rp r o g r a m r i c s .l h e r ma\ bc rn alrcrnariye ro acurc inpiticnr cxrc or p t u v i d c s t c c ; 6 c f i e d r n r c n rf o r d c f i n c d s r o u p s , s u c h a s p a r i e n ! s \ i r h c b s c s s icr < o n p u i s i i c d r s o r d c , I 3 5 1 . J I c n c e ,c h a m c r e r i s r ; cosf p a r i c n r sa n d s c \ c n r \ . , f i l l n c s s ! a ^ m o r e ; n d a ! h o s p i r a l st h u n i n r n p a r r c n r u n r t s

t36'1. A srudr rhar comp.red shoir{crm residcnlj!,ca,c an! a c u r . p s l c h i a r r i ch o s f i r a i r r e a r n r c n r1 3 6 . . 1s h o $ e d i h a r d r c s r o f a c i l i r i e sa d m i r c d p a r j c n r s\ i r t r s i n i t a r t c r c t s o f d l s r u r b a n . c .R . r r h p r o 8 r a n r m e sl e d r o a s j g n r f i c x n !rn d c . , n p a r a b l cc l i n i c a l i n r p r o l c m c n r . T ' c a o n e n r c o s 6 , n r.sid€nral carc $crc rpproximarel\ hitf drosc of rhc h . , s p i t asl c r r n g . h o $ c \ c r .

Hospitala.d rehabitirationseruicespnebeandMccabe 2j? Seryice developdent S n r d i c si n v e s r i g a t i n gh o q ,o u t c o m eo f h o s p r r a cl a r c ( e . g . duralion of sur, rehospiralizarnrnrares,violenr assauhs) nny bc predicred bv paticnt characreristicsand other b a s e l i n ev a r ; a b l c sv i e l d i n ! c r e s ! i n gr c s u l r s - ' f h c a n r o u n ! o f v a r i a D c ce x p l a i n e d b y s u c h p r e d i c l o r si s u s u a l l y r c , o s m a l l b ) f a . r o b e u s e df o r p r e d i c d o ni n i n d i v i d u s l c a s e s . h o $ c \ c r l l J . . { 7 1 T h e ! , r i ! r , o n ; n ( l i n ' c r l p r r c r i c c" e e m \ ro dcpend less on parienr characicrislics,and more on the rype of hospital and rls polic!. Precisel\, $'har inpatienr and panial hospiralizarionp.ogrammes prc,vide, ! h c , r ' l r e a t n i e n i i d e o l o g v ' ,c h a r a c t e r i s r ; cosf r b e s e t t i n g and the t.earnren! conponen$ are ofren poorl) described in .csca'ch papcrs. Thus. inlcrpr€!rlion of findings and delelopmeni of programmes are rendered difficulr.

c o m b i n i n g d t e r r v o s i d e , b v - s i d ei n a s j n g t e r e s c a r c h

Cognitive rehabililation An arcr drar has receiled much aftcnlion in recenr \ears n c o g n i r i v c i m p a i r n r e n r i n s c h i z o p h r c n i aa n d r h e conesponding rchab;liurion efforrs. Arlcmrxs ro rclare pro6lcs of cosnirjve deficirs ro differenrial ongoing. Whicl impairmen$ are rclarcd ro which o , , I c o m e ,r e m J i n \e l u \ i \ e , h u u e \ c r . E v c ^ s : v e n e u r o p \ \ . 1 ' o l o p , c J li * . $ m e n ' "f r(hrzuplIcnia td-,cnr\ dr adn;ssion and regularlv rhcreafler failcd ro reveal an\ differences between discharged and nondjscharged p a r i e n ! so n . n ! n l c a s u r e se, x c e p r a p e r c c p r u a d l isorgan i z a r i o nr a s k 1 5 l l . T h u s , a l r h o n g hr h c i d e ao f i d e n r i f y i n g indnidual cosnuire deficusand rher afphing specinc r e n r b i l ' r u r i o n\ f f d r ( t s r e sa r c u r d ' n s l ) Aris;ng from suryeys and qualiry manasemenl proB c l l a c k . / z l 1 5 2 " 1p o i n r c do u ! , O p r i m i s m h e so u r p . c e d g f a n r m e s .r e c o n r m e n d a t i o n h save been published on p r o a r e s s .A s l o n s a s t h e r e a r e p r o b l e m s; n i d c n r i f y i n g dischargc policies [38,391,improv;ns pharmacorherapyin r e l c l a D r r a ' a c 6 f o r . c h r b i l i i d r i o n ,c u t r c n r s l r l r c g i e sr h a r h o \ p i r a l s 1 4 u l . a m u r c r B U r o u ! J p p r o a c h r u a 5 \ r s n r n t s f o c u s o n e n h a n c i n sc o s n i r i v e f u n c r i o n i n gm a y n o r b e obseaation levels t411, and how ro coDducr propcr a p p r o p r ; a r c .I n s r c a d , i r n l a y b e m o r e b e n e f i c i a l r o p h v s i c a l e x a m i n a r i o n sI a 2 l . T h e r e a r e s u g g e s t i o n sf o r s$aresies for Drinimizing cognirivc load spcc,alrst modrer/baby un;ts 1431,a rcccnlralizsrion of u | u m n e n s r i n q l u r . r a ' h e rr h a n r u c m t r ' n g ' o r c t r , r . f o r c n s i c h o s p i r a l sl a a l , a n d a m o r e p r o m i n c n r r o l e f o , d c 6 c l t s{ 5 2 " 1 . C i v e n I h a t i r h a s n o t y e t b e e n s h o q ' nt h a ! lidbon r\vclriau^t. rn qulkrnewrthgcnc'alp'.crron.h anrcliorarion of dcfi.irs is cssenlial for successful r e h a b i l i r a t i o nr.h i s a p p e a r sr o b c a p r D d c n rs m t e g y . llsl and in sene'al hospinl ser!;nss [a6]. lrnprovemenr r n d I n " n . r ( m e n ro f q d r l i r ) u i h o \ t i r a l ( h r l ' e o r l , c ,h a n d .c o g n ii r e I ' c h r \ ; ^ r r J i n r . ^ c n r i , n . i m p o r t a n t ; s s ! e . a n d h o s p i R l sm a y h a v e r o i m p l e m e n r s u b s t a n r i acl h a n g e si n o r g a n i z a r i o n and policy ro adapr a r e $ e l l e s u b l i s h e da s a D e f f e c l i v ef o r n ro f r r e a r m c n rf o r successfully !o rhe chansins marker place and ro mccr p c r s ; s r c n t , L d i r o r yh a l l L r c i n a r i o nU s .n r i l n o \ ' , r c a r n r e n r t h e d e m a n d s o f f u n d e r s I + 7 1 .A s m a l l - s c a l cs r u d y I 4 8 ' l hds bccn dclivcrcd on .n individual basis. In a dcmonslrared drar a Dorsmoking policy on an acure trard p r e l r n r ' n a r yn, o n c o n t r o l l e ds r u d v t 5 3 ' 1 ,g ' o D p i . c x r m c n r w a s n o r a s s o c ; a r c dw i r h s c v c r i c \ o r i m p r o v e m e n t o f x s a l e s s c o s d ! a l r e r n . t i v e l c d t o s i g n i f i c a n rc h a n g e si n p s \ c h o p d r h o l o s i c asl y m p r o m si n s m o k e r sa s c o n p a r e d p c r c e i l c d p o N c r o t a n d d i s t r e s sc a u s e db \ v o i c e s .T h i s u n d e . l i n e s$ a r p r a s m a r i cs o r r c g i c sr h a ! d o n o r r e l y o n i c m c d , , d n g r l r e s u s p c c l c d u n d c r l ) ' i n gd e f i c r m a v b c I n s e n e r a l , h o $ , c v c r .h o s p o U c ) i n r e n e n r i o n s m a , \ ,h c a d c q ! I c p r o g r e s sf o r t h c r i m c b c i n g . dcsigned and inrplenrenredfor improv;.9 clinical pracrcc and srill appear poon\ Service developmenr u n d c r s r . , o da n d u n d c L r c s c a r c h e dl .v l o ' c o ! € r . a d e q u a r e F o r r h e r e h a b i l i i a r i o no f p x r ; e n i s \ v i r h s e \ e r e m e n r a l n.c,l,nd. lnr a\ic\\,nS the r\\o(rauunLer$een i,,r.N(nr l l n c . . . p ( . , i _ " J , ' .". n , l p r u E ' r m n r ch\r v c b c . n l . r , , t i " p o l i c v rions on a l c v c l , c l i n i c a l p r a c l i c ea D d i n d i v i d u a l m r n \ a r c r s . \ \ ' o r k i D p r o s r c s si n c l u d e sr h e r r a i n i n s o f our.omc hrve nor ver been full)'developed [49.50] r e h a b i l i r a r i o nt c a . r s [ 5 J , 5 5 j .r h e u s c o f r c c h n o l o g ; c s; n \ l e r h o d o l o g i c d l l vr i g o r o u ss r u d i e s ,i n c l u d i n s c o n r r o l l c d p s v c h i d r i c r c h a b i l i r r r i o nl 5 6 l . n d i n d i r i d u a l l ! r a i l o ' c d t l i a l s ,\ y h i c h x . c { ; d c l v r e s a r d e da s l h e g o l d s r a n d a r di n r c h a b i l i u r i o np r o s r a m n r c si - s 7 1b. u r r h i s l v o r k h a sn o r \ c ! other arcas of health se^,ices .esearch. to rcsi lhe been properl\ cvluated. A porenrirldavb,ck of such cffccrivcness of well defined hospral rrearnrenr prop i o g r a m n c si s r h a t r h e r f u n c r i o nl a r g e l ! i . d c p e n d e n r l \ g r ! m n r e s a r e l v i d e l y n r j s s i n g .T h e ! m a r - . f o r r a r i o u s of orhcr nienral hclldr senjces. leading ro furher p r l c i i c a l , n d e r h i c a lr e a s o n sb, e d i f f i c u k i o c a r ^ o u ! . b u r f r a g m e n r a t i o on f c a r e .R e h a b i l i r a t i o sn e n i c e sm a v b e n e f ri s e e m d e s l r a b l ef o r i n r p r o ! i n gr h e q u a l i r \ o f h o s p r r . l c a r c . l i c , ' n e m p l o \ 1 n g p r o s u t u c r s( i . e . f o r n 1 c rc o n s u r n e n o f s c n i c c s )a ss r a f fm e n b e r s . i n p o s r se q u a l r o n o n c o n s L , m e r 'fhs Rehabilitationservices ma\ require organizarionrl fro\ider posrs [581. R o t h t h e o r e r i c a cl o n . r ; b u r i o n sa n d m o r e p r a c r i c a li n r c r , c l ) a n g e s; n r h c s c r \ i c c a n d a s h i f t i n f i e a g c n c r ' sc r r l t u r e . lenrions are $ell reprcscnledin curcni pslchiariic T h i s , h o \ c ! c r , m a r p o s i r i ! . 1 ! i m p a c ro n r e s p e c ri o $ a r d s r c h a b i l ; r a r i o nr e s e a r c h .\ i ! h s o m e g r c u p s a d n r i r a b h p r ! i c r r s i n d p a r i c n r s c r p c c r a r i o n so f c a r c .

public heallh psvchialrv ?1s 5dr5r. community and

A I o n s - s r a n d i n si s s u e i n v o c a t i o n a lr c h a b i l i t a l i o nh a s been s'hcdrer paticnts should be placed rn competroYe c m p l o - \ ' n r e n ra n d s u p f o r t e d d ) e l c , o r r v h e r h e r r h c - Y should par!icipare in stepNise vocational programmes. This issue wrs addresscdin a randc,mizedcontrolled trial conlparjng individurl placement and suppon slth t r a d i r ; o n a l v c E a t i o n a lr c h a b i l i t a t j o n[ 5 9 " ] . l n d i v i d t t a l s i n $ c ; n d ; v i d u a lp l a c e m c D ar n d s u p p o r !c o n d ; r i o nw e r e a s s ; s r c db y a n e m p l o v m c r r s p e c i a l i s r$ i r h i n l h c c o m nrunir\ nien!l1i heallh ream m glin comPc!;tive emPlo!menr, and rcceived unl;m;tcd ongoing supPon Pa(icipanrs in rhis programme were morc likcly to be c o m p e r i r ; v c l ve m p l o y e d l h d n i n d i v i d u a l sr e c e i v i n ge n ' l ' . n c c d \ o , a u u n J . ' . 1 - l ' r l i r r u n n .I n " h ( h . r c p $ i ' e vocadonal services e.e'e dclivered by .ehabilitalion a g e n c i e s .T h e I a t t e r g r o u p $ e r e m o r e l i k e l v I o b e i n s h e l r e r e de m p l o y n c n r a n d s e e m e d! o g c i s r u c k i n r h e rr.rsirion from sheltered ro compeorve employmcnr. 'l'otal e a r n i n g s .j o b s a r i s f a c t i o n , n dn o n l m a r i o n a l o u F comes {,ere similar to' rhe rwo grotrps. Deke ct a/. 159"1 poinred out thal lhe answcr ro rhe q u c s o n . c e a r d i n gw h i c h p r o g a m m e i s b e r r e r d e p e n d s nor only on rhe dernonsrratedeffectiveness of intencn' D o $ c b c l ; e v ei r i s r i o n s ,b u r a l s oo n D n d e r l y i n sl a l u e s r bcrrcr ro inrcgrate peoplc wirh menral illness inro m d n . r ' e a n ,\ u ( r c , ) .o / d " q e w a n rr n m , i n r r i n\ c t a ' r r e $,o.k;ng scrr;ngs and keep them s€sresared from s o c i e r y : ' ( p . 6 3 2 ) . T h e v a l u e s t h a t $ i l l d c r e r m i D et h e f u o r c d c v e l o p m e D t o f r c h a b i l ; t a t i o na n d o f m e n u l h c a l n , a t e I n t s e n c mrl r c . e r b ) n o l ; ' i c r lp r o " c * c ' i n socie.-! as :r *holc. and b) thc conrmiss;one6of sen'iccs i r p a r t i c u l a rt 6 0 j . A m o ' e i n r e n s i v ed i s c u s s i o ni n r h e l i r e ' a r u . c o f r h e s e v a l u e s .r h e i ' c h a n s e so v e r t i m c a n d l h e i r c o n s i d e r a b l ed i f f e r e n c c sa c r o s sn a r i o n sm i g h r b e of {Jra! dcrermines helpful for a berrer undersranding h o w s c n i c e sm i s h t b e b e s ! r c h a b i l i r x r i o np r a c r i c ca n d o f d e n a n d s. d c v c l . r p e dr o m e e r f u I U r c

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ro H shngr

J Tadir H p.iienrs

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tl^ M€re o M, wls

sl

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53 Wykes T, Pan A, La.dau S Goup tearneil or ludiory hallucinaroB sr i .Psych'alry|999175:laGl35' A permtrry Epo'l s pre*m€d ihar describes rhe elldve@ss or lroup

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35 Aysrtuky A, SareE S. M,idmeni K, vapdir T, T.iow G R()ssR Outiry oI rirechang* nons p*;nrs yidr obsBsm{ffpulsi€ di$de6 in a pada hGpiar'sartr FogEm P3t$iar s€fl 1999i3:412-414.

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32 Kasprcw Wt Frisron L, RGenher Rl wdr rcsidenl€ te.rhem. Psrchiar, S€d 1999i .4:5.405,1s. 33

The {ulu.e ot rhe

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psychBric h6pirar&rion

219

s|Jd,o|9anp?'cPplo.ol .e92. I 57_ h(MJ ! Gcr HosDr\,r:.r)

29 G,*nwo.d N, t(ey A, Bums T, Bnsrow M. S€dqwick P Sarslctioi wih h. par€nr psychiafic s€die: crari.nship to pari€nr.nd rstmenr r.dore. & J Psychiarryr 99q 3:r59-i63.

Paquii G, (€nnedy s, s€smaas

p.iebe and Mcoabe

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sryices

slmpbm sereny and insishr rhar were m,nl.ii€n

ar 3.monrh rotow up

54 Coms€n PW. Blirdins reams and Psychat O r993r3 re3 20! 55 Cdnlg.o F,W Mcc.acren SG Taning r4ms r rehabirbrion prcsians. Psrrhiar s 56 A^ihmy wA Psychiaic €hab tlaliohi{hnolcsy: opeBlionarsnqlhe bbcr bor or rh€ p6ycn,ah. rch.biiiaio pro@ss. New or Menra 8ealrh sed 57 Lambed _rS,Merborc v, Mad N. nrssi€ PsychianO r993r3,2rr $a $ '

pst hdrrrc €hab rr.r on rearmenr

solomonP.Dr.ner.consum€ OnMenrarHea[hS€d i993]79,65 77.

{PJwdere and consum6). makes anse and address imponad 'ssues soch as p€6onar/p,oiess,onar b.undanes r RR.A€.kerDR.HamsM B.ndGR.OuimbyE. A randoh'sen cr ni€ t'ai or suppod.d emproymnr i.. nner oi), p.rieds whh *verc m$rar d'sorden. Arch Gen Psrrhrar.y r gssr 56 627-633 lnis 's a rerhodor€erry reoous ta or a rehab iarion (hdviduar pracemenr and suppor) thar red r. ,ic€rsed Bles ar conpefi ve emproymenro€r tadiioia rc€rirul Etubi rarirn seftces "

60 Pre& S Wh'ch .E rhe aim ach€Ed? I,n Gemait Ps),.h3k Prar ree!: 26lsupp r):s36-s4o