y r t a h c y s P i CNS examination shows left-sided cerebral lesions (rare) or changes may be seen postmortem, eg in perisylvian regions unusual asymmetry of the ple- num temporale (Wernicke \200 \231s area), with cortical dysplasia and scarring. In vivo characterization of this asymmet ry is becoming possible.500 Perhaps dyslexia re \202 ects weak connectivity between anterior and posterior parts of th e language areas of the brain, and the angular gyrus. Positron emis- sion images show that when dyslexic adults perform rhyme judgments and verbal short-term memory tasks they activa te less than the full set of centers normally involved with these tasks. www.shianet.org/ r eneenew/hist.html Note that there is functional MRI observation of speci \201 c involvement of one subsystem of the visual pathways which prevents rapid processing of brief stimuli presented in quick temporal succession (magnosystem hypothesis).501 Tests The GAPS test aims to diagnose chil dren before school starts.502,503 Management Make sure the \200\230dyslexia \200\231 is no t from lack of teaching. The per- son may gain insight by discussing his or her problem wit h fellow suff erers, and by \201 nding out about past dyslexics such as Leonardo da Vinci . Special educational programs are available for addressing dyslexic problems, as the phone tic approach to learning to read usually presents problems. NB: \200\230wait-and-see \200 \231 is not wise \200\224studies support identi \201 cation before school with exercises i n sound categorization using rhyme and alliteration, with special teaching of letters.504 You may be asked about dietary supplements with highly unsaturated fatty acids (HUFA, eg Ef alex ). These do play a role in neurodevelopment, but evi- dence of bene \201 t in dyslex ia from large randomized trials is sparse.505 They ap- pear to reduce dyslexia-associated d elay in dark adaption.506 n=10 Patient pathways: descending the \200\230dark spiral \200\231 1 of madness, as tweeted fro m a straightjacket in 1855 The next pages concern the psychiatrist as jailer. To re \202 e ct on this let us follow one patient \200\231s journey, along the edge of chaos, to his str aightjacket via a series of verbatim tweets from the manic streets of Paris (with proposed timings). 3pm 397 Bought two velvet screens covered with hieroglyphic \201 gures \200 to consecrate the for giveness of heaven. Met my friend George \200 wet through and tired out laid on his bed. Marvelous goddess appeared to me saying \200\234I am the same as Mary, the same as your mo ther \200\235. Said to George \200\234Let \200\231s go out \200\235. 4pm 6pm 7pm 7.15pm Crossing Pont des Arts explaining the transmigration of souls to him. 7.20pm Tol d George \200 I have the soul of Napoleon in me commanding me to y r t a i h c y s P do great things. 7.30pm In the Rue Du Coq I bought a hat. While George is waiting for my change I went to th e Palais-Royal \200 everyone staring at me. 7.50pm A persistent idea is \201 xing itself in my mind \200 there are no more dead. 8pm Went through the Galerie de Foy saying \200 \234I have committed a sin \200\235. 8.10pm Somewhat interested in little girls dancing in rings. 8.15pm Caf de Foy \200 Dense crowd \200 nearly suff ocated. 8.20pm Extricated b y 3 friends \200 into a cab \200 taken to Hospice De La Charit . 3.02am Walking about vari ous wards \200 I \200\231m like a god with powers of healing. 3.05am Laying my hands on som e patients now. 3.20am Going up to a statue of the Virgin Mary \200 3.21am Taking off its crown of \202 owers in order to test the power in me. 3.29am Talking in an animated way o f the ignorance of men who think they can be cured by science. 3.40am Bottle of ether on the table \200 3.42am Drinking it in one gulp 3.43am Hospital as sistant with face like an angel trying to stop me 3.45am Tell him he does not understand my mission. 3.55am Doctors coming along. 4am 4.02am Thrusting me into a straightjacket G rar d De Nerval 6am Aur lia 1855 G rard De Nerval, whose tweets these are, was famous during his colorful life for extravagant orgies, eating ice-cream out of skulls507 and for taking his pet lobster for walks in the gardens of the Palais Royal on a blue silk lead. Harangue on the impotence of their art. Am in an asylum outside Paris \200 He hanged himself from a Paris street light in 1855.508 After his death his critics read an d reread his masterpiece Les Chim res (a fragment of which appears below), \201\201 procl aiming it to be an in \201 nite hall- ucination set in a jewel of immense value.509 We hon or G rard De Nerval here to remind ourselves that the next patient we imprison using menta l health laws deserves our in \201 nite respect, however rough their diamonds appear to be . \201\201 1 Un arc-en-ciel trange entoure ce puits somber, Seuil de l \200\231ancien chaos dont le n ant est l \200\231ombre Spirale engloutissant les Mondes et les Jours! Around this tunnel plays a strange rainbow arc On the edge of primeval chaos whose hollow f orm is the spiral dark That swallows up Worlds and Days! Translation JML Compulsory treatment: law in England AC AMHP approved mental health professional ASW approv ed social worker CTO community treatment order ECHR European Convention on Human Rights ECT GSCC General Social Care Council IMCA IMHA LHB Before reading the subsequent pages which r e \202 ect the 1983 Mental Health Act it is vital to understand how the Act has been amend ed and added to by the 2007 Mental Health Act \200\224which does not replace it \200\224but rather sits beside it. Imperatives governing use of Mental Health Acts (required in the 20 07 act) \200 Respect patients \200\231 past and present wishes and feelings. \200 Minim ize restrictions on liberty and involvement of patients in planning, de- 398 (1983, 2007) approved clinician LSSA MCA Mental Capacity Act 2005 MHAC Mental Health Act Commission MHRT Mental Health Revi ew Tribunal NHSFT NHS foundation trust primary care trust PCT responsible clinician RC resp onsible medical offi cer RMO SCT supervised community treatment SOAD Second Opinion Appoint ed Doctor local social services authority electro-convulsive therapy independent mental capacity advocate independent mental health advocate local health board veloping and delivering care and treatment appropriate to them. Avoid unlawful discrimination. \200 Pay due attention to the eff ectiveness of treatment. \200 Respect the views of carers and other interested parties. \200 Respect for divers ity, including, in particular, diversity of religion, culture and y r t a h c y s P i sexual orientation (within the meaning of the Equality Act 2006). Patient wellbeing and safety, and public safety need balancing. 2007 Mental Health Act In 2 007, three key measures were introduced: 1 Community treatment orders (CTOs) allow compulso ry treatment in the com- munity. As a safeguard, there is a duty to consider what risk ther e would be of a deterioration of the patient \200\231s condition if he were not detained (a s a result, for example, of his refusing the treatment he requires for his mental disor- de r). CTOs have the same duration and renewal periods as section 3 (p400): 6 months initially , then renewed for 6 months, then renewed annually. 2 The criteria for a CTO is that the patient is detained after an application for admission for treatment, and it is necessary for his health and safety or for the protection of othe r persons that he receives treatment, which can be provided outside hospital (subject to a power of recall). CTO roles: \200 Ensuring the patient receives the treatment stipulated. \200 Preventing harm to the patient \200\231s health or safety. \200 Protection of other s. 3 People diagnosed with severe antisocial personality disorders are now within the scope of mental health law and can be detained even if they have committed no crime, if they are deemed a danger to themselves or others. Other provisions: A new statutory advocacy servic e for detained patients, and: \200 Children are protected from being put in adult wards ( section 140). \200 2 professionals from diverse disciplines must now agree to detention r enewal. \200 No ECT can be given in the face of capacitous refusal, other than in emer- g ency. Emergency ECT can only be given if it is immediately necessary to save life or immedi ately necessary to prevent a serious deterioration. 16- and 17-year-olds \200\231 capacitous refusal of treatment cannot be overridden by paren tal authority; a SOAD is needed for ECT to be given; and there must be a referral for a MHR Tribunal annually for patients who do not request a hearing. \200 There is a new \200 \230treatability \200\231 test, ensuring compulsory treatment must be of \200\230therapeut ic bene \201 t \200\231. The wording is: \200\230Any reference in the Act to medical trea tment, in relation to mental disorder, shall be construed as a reference to medical treatme nt the purpose of which is to alleviate, or prevent a worsen- ing of, the disorder or one o r more of its symptoms or manifestations. \200\231 Patients may be transferred from one place of safety to another. The hope is that patients detained by police offi cers on section 136 will be quickly trans- ferred from a police sta tion to a therapeutic environment.510 399 Procedures governing use of compulsory powers (2007)511 Stage 1 Preliminary examination: De cisions to begin assessment and initial treatment of a patient under compulsory powers must be based on a prelimi- nary opinion by two doctors and a social worker (or another suitabl y trained mental health professional) that a patient needs further assessment or urgent tre atment by specialist mental health services and, without this, might be at risk of serious harm or pose a risk of serious harm to others. Stage 2 Formal assessment/initial treatment under compulsory powers: A patient will be given a full assessment of his or her health and social care needs and receive a formal care plan; the initial period of assessment and tre at- ment under compulsory powers is up to 28 days; after that, continuing use of compulsory powers must be authorized by a new independent decision making body, the Mental Health Tri bunal, which gets advice from independent experts as well as taking evidence from the clini cal team, the patient his or her repre- sentatives, and other agencies, as appropriate. Stage 3 Care and treatment order: The Tribunal (or the Court in the case of mentally disord ered off enders) can make a care and treatment order to authorize the care and treatment sp eci \201 ed in a care plan recommended by the clinical team. This must be designed to give therapeutic bene \201 t to the patient, or to manage behavior associated with mental diso rder that might lead to serious harm to other people. The 1st 2 orders can be up to 6 month s each; sub- sequent orders may be for periods of up to 12 months. NB: one new provision is that it is now possible for people with dangerous personality disorders to be detained bef ore a crime has been committed. Methodology/criteria for using CTOs (community treatment or ders) \200 A SOAD certi \201 cate must be issued authorizing the treatment. The SOAD is appointed in the normal way by the MHAC. The criteria for the SOAD authori- zation is simpl y that \200\230it is appropriate for the treatment to be given \200\231. With SOADs, the c ertifying doctor has a duty to consult 2 statutory consultees but no duty to consult the pa tient or the responsible clinician. y r t a i h c y s P The treatment is immediately necessary and the patient has capacity and consents to its administration; or \200 The treatment is immediately necessary and the patient lacks capacity, but a deputy or the court of protection consents to it on his or her behalf. The patient lacks capacity and may resist the treatment, but force may be justi \201 ed as proportionate response to the likelihood of serious harm to the patient, and the treatment is either immediately necessary to save the patient \200\231s life; or (not being irrevers ible) is immediately necessary to pre- vent serious deterioration; or (being neither irreve rsible nor hazardous) is immediately necessary to alleviate serious suff ering; or (being n either irre- versible nor hazardous, and the minimum interference necessary) is imme- diate ly necessary to prevent the patient from behaving violently or being a danger to her/himsel f or others. Compulsory hospitalization Provisions under the 1983 Act (in England) \200\207The patient must have a mental disorder and need detention for treatment of it, or to protect himself o r others, before compulsion may be used (if volun- tary means have failed). Admission for a ssessment (Mental Health Act1 1983, section 2) \200 The period of assessment (and treatme nt) lapses after 28 days. \200 Patient \200\231s appeals must be sent within 14 days to t he Mental Health Tribunal 400 (for 2007 law, see p398) (composed of a doctor, lay person, and lawyer). An approved social worker (or the nearest relative) makes the application on the recommenda tion of 2 doctors (not from the same hospital), one of whom is \200\230approved \200\231 u nder the Act (in practice a psychiatric consultant or senior registrar). The other doctor s hould ideally know the patient in a professional capacity. If this is not possible, the Cod e of Practice recommends that the second doctor should be an \200\230approved \200\231 doc tor. Section 3: admission for treatment (for \211 6 months) \200 The exact mental disord er must be stated. \200 Detention is renewable for a further 6 months (annually thereafte r). \200 2 doctors must sign the appropriate forms and know why treatment in the communit y is contraindicated. They must have seen the patient within 24h. They must state that trea tment is likely to bene \201 t the patient, or prevent deterioration; or that it is necess ary for the health or safety of the patient or the protection of others. Section 4: emergen cy treatment (for \211 72h) \200 The admission to hospital must be an urgent necessity. \200 May be used if admission under section 2 would cause undesirable delay (ad- y r t a h c y s P i mission must follow the recommendation rapidly). An approved social worker or the nearest relative makes the application af- ter recommendation from one doctor (eg the GP). The GP should keep a supply of the relevant forms, as the social worker may be unobtainable (eg with another emergency). It is usually converted to a section 2 on arrival in hospital, following the rec- ommendati on of the duty psychiatrist. If the second recommendation is not completed, the patient sho uld be discharged as soon as the decision not to is made. The Section should not be allowed to lapse. Detention of a patient already in hospital: section 5(2) ( \211 72h) \200 The doctor in charge (or, if a consultant psychiatrist, his or her deputy, applies to the hospital administrator, day or night. A patient in an A&E department is not in a ward, so cannot be detained un- der this section . Common law is all that is available, to provide temporary restraint \200\230on a lunatic who has run amok and is a manifest danger either to himself or to others \200\231512 while awaiting an assessment by a psychiatrist.513 \200 Plan where the patient is to go before the 72h has elapsed, eg by liaising with psychiatrists for admission under section 2. Nurses \200\231 holding powers: section 5(4) ( for \211 6h) \200 Any authorized psychiatric nurse may forcibly detain a voluntary \200 \230mental \200\231 patient who is taking his own discharge against advice, if such a disch arge would be likely to involve serious harm to the patient (eg suicide) or others. \200 During the 6h the nurse must \201 nd the necessary personnel to sign a section 5 application or allow the patient \200\231s discharge. 1 This Act operates in England; Scottish law is diff erent. The situation in the UK is chan ging and these pages should be read along with current legislation in the area where you ar e working. Section 7: application for guardianship Enables patients to receive com- munity care if it cannot be provided without using compulsory powers. \200 Application is made by an \200 \230approved social worker (ASW) \200\231 or \200\230nearest relative \200\231 401 and also needs two medical recommendations. The guardian, usually a social worker, can require the patient to live in a speci \201 ed place, to attend at speci \201 ed places for treatment and to allow authorized persons acc ess. Renewal of compulsory detention in hospital: section 20(4) \200 The patient continues to suff er from a mental disorder and would bene \201 t from continued hospital treatment. Further admission is needed for the health or safety of the patient \200\224which cannot be achieved except by forced detention. Section 25: supervised discharge This is as a result of the Mental Health (Patients in the Community) Act 1995 \200\224incorporated within the 1983 Act. \200 It allows formal super vision to ensure that a patient who has been detained y r t a i h c y s P for treatment under the Act receives follow-up care. The application is made at the time of detention for treatment by the Re- sponsible Medical Offi cer. It is supported by an ASW and a doctor involved in the patient \200\231s treatme nt in the community. A supervisor is appointed who can convey the patient to a place where treat- ment is given. Section 117: Aftercare & the Care Program Approach (CPA) Section 117 requires provision of after-care for patients who have been detained on the \200\230long sections \200\231 (3, 3 7, 47, or 48). The CPA is not part of the Act but stipulates that no patient should be disc harged without planned aftercare: the systematic as- sessment of health and social needs, a n agreed care plan, the allocation of a keyworker, and regular reviews of progress. Section 136 (for \211 72h) allows police to arrest a person \200\230in a place to which the publ ic have access \200\231 who is believed to be suff ering from a mental disorder. The patien t must be conveyed to a \200\230place of safety \200\231 (usually a designated A&E departm ent \200\224better than a police station; a police station is rarely a place of safety and most people dying in police custody will have mental health problems and will have been on the receiving end of excess force employed by under trained offi cers). In a hospital there can be a full assessment by a doctor (usually a psychiatrist) and an approved social worke r. The patient must be discharged after assessment or detained under section 2 or 3. Sectio n 135 This empowers an approved social worker who believes that someone is being ill-treate d or is neglecting himself to apply to a magistrate to search for and admit such patients. The ASW or a registered medical practi- tioner must accompany the police. English Mental Health Act Law relevant to consent Capacity entails being able to grasp and retain information relevant to a deci- sion, and to weigh it as part of a process of making that decision.514 Mental Capa- city Act 2005 Consent to treatment comes in Part 4 of the M ental Health Act; it applies to: \200 Treatments for mental disorder. \200 All formal p atients unless detained under sections 4, 5, 35, 135 and 136. The Act doesn \200\231t apply to those subject to Guardianship or Supervised Discharge, who have the right to refuse tre atment, except in emergencies. 402 Where a person is deemed to have given their consent to treatment under Section 57 or Secti on 58, the person can withdraw that consent at any time. The treatment must then stop and t he appropriate procedures followed, unless discontinuing treatment would cause \200\230ser ious suff ering \200\231 to the patient, in which case continued treatment may be justi \201 ed. Section 57: treatments requiring consent and a 2nd opinion Some treat- ments are d eemed so restricting that patients cannot automatically have them even if they do consent. Also, 3 people (1 doctor and 2 others who cannot be doctors) must certify that the person c oncerned is capable of understanding the nature, purpose and likely eff ects of the treatme nt and has consented to it (competence). They are appointed by the Mental Health Act Commis sion. Treatments falling into this category are destruction of brain tissue, or func- tioni ng and implantation of hormones to reduce male sex drive. Section 58: treatments requiring consent or a 2nd opinion Applies to people who are detained under certain Sections without consent, or where the person is not able to consent, eg to ECT or drugs for a mental disord er if 3 months since the person \201 rst had the drugs during their current period of de- tention under the Act. In the \201 rst 3 months the treatment can be given without conse nt. The 3-month period starts from when drugs are \201 rst given. y r t a h c y s P i If the person is capable of understanding the nature, purpose and eff ects of the treatment and consents to it, the Responsible Medical Offi cer (RMO) must certify that understanding and consent are present. If the person is capable of understanding the nature, purpose and likely eff ects of the treatment and doesn \200\231t consent to it, or has \200\201capaci ty so cannot consent, then a doctor is ap- pointed by the Mental Health Act Commission to g ive a 2nd opinion. She must consult 2 professionals involved in the patient \200\231s treat ment; one must be a nurse. The certi \201 cates must state the treatment plan in precise t erms, eg the num- ber of ECT treatments. If the plan changes, new certi \201 cates are required. The provisi ons of Section 58 don \200\231t prevent urgent treatment (sect 62). Section 62: urgent treatment The requirements of Section 57 and Section 58 need not be foll owed for urgent treatment to save the patient \200\231s life or to \200 Prevent seriou s deterioration, so long as the treatment is not irreversible. \200 Alleviate serious suf f ering (if the treatment isn \200\231t irreversible or hazardous). \200 Prevent the pati ent behaving violently or endangering self or others, so long as the treatment is neither i rreversible nor hazardous, and is not excessive. Section 37: Hospital Orders made by Courts This allows a Court to send a person to hospital for treatment, or to make the person subj ect to Guardian- ship, when the outcome might otherwise have been a prison sentence. The Or der is instead of imprisonment, a \201 ne, or probation. The person concerned \200 W ill have been convicted by a Magistrates Court or Crown Court of an off ence punishable wit h imprisonment (except in the case of murder, where the Court has to impose a sentence of l ife imprisonment in all cases). May not have been convicted, but may be charged with an imprisonable of- fence. Without con victing the person, the Court can make a Hospital Order under Section 37 if there is mental illness or severe mental impairment. The initial period is 6 months from the Order \200\231s date. It can be renewed under Secti on 20 for 6 months and then annually. The Court must be satis \201 ed that There really is a mental illness, as evidenced by 2 doctors who must agree at least in part as to the type of mental illness or impairment present and \200 The nature and degr ee of the mental disorder makes it appropriate for the person to be detained in hospital fo r medical treatment (that the treatment is likely to alleviate or prevent a deterioration o f the person \200\231s condition in the case of psychopathic disorder or mental impairment) and 403 Making a Section 37 Order is the best way to deal with the person and \200 A speci \201 c hospital is willing and able to admit the person within 28 days. Section 61: review of treatment Where a treatment plan is being carried out under Section 57 (or 58 without c onsent), the RMO must report to the Mental Health Act Commission if the period of detention is renewed under Section 20. \200 The Commission may demand a report at any other time i f it wishes. \200 The Commission can cancel the certi \201 cate under which treatment is given. \200 In the case of people subject to Restriction Orders a report on the treatmen t y r t a i h c y s P being given must be provided for the Commission: 1 6 months after the restriction order or direction is made, and 2 At times when the RMO reports to the Home Offi ce on the person \200\231s condition. Deprivation of liberty safeguards (DoLS) Use: eg after being admitted to a rest home during an infection when a patient lacked capacity, and the doctor \200\230 acted in his best interests \200\231. DoLS provide the person with a representative, and \200 DoLS allow a challenge in the Court of Protection against \200\230false imprisonme nt. \200\231 \200 DoLS give a right for deprivation of liberty to be reviewed regularly. Source: patient.co.uk/doctor/ Enriching consent: making decisions truly informed (GMC advic e)515 We mustn \200\231t assume that because a patient lacks capacity today for one issue t hat he will lack capacity on all issues. We must plan for changes in capacity. Extra suppor t will be needed for those with dementia and learning diffi culties. NB: where possible, us e multimedia formats to explain issues: we know these are better at making diffi cult decis ions truly informed.516 Children under 16 disagreeing with their parents517 Capacity matter s, not age. Parents \200\231 wishes are not supreme if the child has capacity (above). If y ou take a decision for a patient, you must have a \200\230reason- able belief \200\231 tha t capacity is lacking and that the act is in his/her best interests. Medicolegal issues \200\224use of Common Law in clinical situations Clinical situations Deliberate self-harm A dapted from Feldman 2000:518 \200\230A 30 year old male is brought to A&E after an overdos e. There is no history available and the patient refuses to say anything, other than he wan ts to be left alone to die. He refuses to give blood for a drug level and is refusing any t reatment. What should we do? \200\231 Should we assume he has full capac- ity? If so, he ma y die \200\224but autonomy is maintained. Or should the clinician act in the patient \200 \231s best interests (the doctrine of necessity) as part of their duty of care? Most people who self-harm are depressed \200\224but this does not prove incapacity. However, in the ac ute setting, Feldman asserts that \200\230there are usually good grounds for reasonable do ubt with respect to the patient \200\231s capacity to make a fully informed and reasoned ch oice, and to proceed with whatever action is necessary to save his life under the common la w \200\231. Restraint: The Mental Health Act is an enabling act (it needn \200\231t be used in all valid situations). Its use gives certain legal safeguards for patients and staff . \200\230A 40 year old female with alcohol problems has been admitted to hospi- tal followi ng a head injury 2 days ago. She has shown \202 uctuating levels of confusion, agitation and is now trying to leave the ward. \200\231 Here, due to refusal or lack of capacity, the transient nature of the disturbance, and the need for intervention, common law is applicab le. If stronger measures are needed, or the situation persists, it is wise to use the Menta l Health Act to detain a patient with delirium; however it is not commonly used. Seasonal aff ective disorder (SAD) Lying thus in the sun one is liberated from doubts and f rom misgivings; it is not that problems and dif \201 culties are resolved, it is that they are banished. The sun \200\231s radiation penetrates the mind \200 anesthetizing thought. AE Ellis 1958 Some people \201 nd that depressions start in winter, and remit in spring o r sum- mer. It is postulated that disordered secretion of the indole melatonin from the pin eal gland is to blame in some patients with SAD. Melatonin, the hor- mone of darkness, is s ecreted by the pineal only at night, eg at 30 g/night. Dysregulated circadian rhythms and novel antidepressants Sleep dis- turbance is often seen in depression, and manipulating the sleep \200\223wake cycle is one methodology for treating depression, so maybe dysregulated circadian rhythms really are causal. Our circadian rhythms are regulated by a core bio- lo gical clock in the hypothalamic suprachiasmatic nucleus. Its pacemaker ac- tivity is regula ted by light (and nonphotic modulatory pathways) via seroton- ergic input from the raphe, a nd melatonin originating from the pineal gland. We note with interest that agomelatine, a n ew antidepressant, acts as an agonist at melatonergic MT1 and MT2 receptors and as an antag onist at 5-HT2C receptors. It is known to resynchronize the sleep-awake cycle (in animals). 519 Treatment choices As a rule, the more that typical winter symptoms (hyper- somnia, carb ohydrate craving and weight gain) predominate, the more likely that light therapy should be a treatment of \201 rst choice. But if winter episodes are characterized by early mornin g wakening and weight loss, and especially if there are non-seasonal recurrences, tradition al antidepressants are advised. Light therapy \200 The antidepressant eff ect of light is potentiated by early-morning adminis- tration in circadian time, optimally at 8.5 hours a fter melatonin onset or 2.5 hours after a sleep \200\231s midpoint.520N=42 \200 A dose \200\223response eff ect exists between the amount of light administered in phototherapy an d the degree of improvement in depression (as measured on Hamilton ratings). 6h/day of incr eased light brought about a 53% decrease in scores, whereas treatments of 2h (or red-light treatment) produced only a 25% reduction. These eff ects were correlated with suppressed pl asma melatonin concentrations at 23.00h. Variables of uncertain importance in- clude: the t ype of light (device and spectrum), distance between patient and source, and the duration o f treatment.521 \200 Therapy should stimulate the nasal retina, as retinal ganglion cells projecting to suprachiasmatic nuclei are unequally distributed. 522N=8 \200 However, evi dence in this area is often contradictory, and it is probably un- wise to rush into recomme nding light for all patients whose recurrent de- pressions start in the autumn or winter. T his might have the undesirable ef- fect of enticing such patients to book unaff ordable win ter holidays to exotic locations \200\224with inevitable disappointments and recriminations . 404 The Rack y r t a h c y s P i Antidepressants Sedative antidepressants are usually avoided and selective serotonin reupta ke inhibitors (SSRIs) are often 1st choice. Newer antidepessants to consider: ago- melatine , an agonist of melatonergic MT1 & MT2 receptors and antagonist of 5-HT2 receptors. It appe ars to resynchronize disturbed circadian rhythms and to reduces depression.523 It also caus es less sexual dysfunction compared with SSRIs (5% vs 62%).524 Venlafaxine and reboxetine m ay also have a role. In pa- tients with established winter recurrences, it is usual to inst igate treatment as soon as symptoms re-emerge in the autumn and to phase out treatment in s pring. For patients who also experience non-seasonal episodes, year-round prophylaxis may b e deployed, sometimes regularly increasing the antidepres- sant dose during the winter mont hs. 525 405 Community care Since the early 1980s, most UK inpatients with psychosis have had the focus of their care moved from hospital to the community. The aim has been to save money and impr ove care, but in the UK this policy is now being partly reversed. Has community care failed , or have there been successes? Five questions keep recurring, each (ominously) pre \201 x ed by a \200\230Surely \200 \200\231 1 Surely hospitals will always be needed for severel y affected people? In general, the problem is not the severity of the mental illness, but i ts social context which determines if community care is appropriate. 2 Surely community care, if it is done properly, will be more expensive than hospital care, where resources can be concentrated? Not so \200\224at least not necessarily so. Some conc entration of resources can take place in the com- munity in day hospitals and mental illnes s hostels. It is also true that the \200\230bed and breakfast \200\231 element of inpatien t care is expensive, if the running and maintenance costs associated with deploying inpatie nt psychiatric services are taken into account. In most studies, costs of each type of serv ice doesn \200\231t diff er much, and sometimes good community care turns out cheaper.526,5 27 3 Surely there will be more homicides and suicides if disturbed patients are not kept in hospital? Off ending by the mentally ill is of great public concern (60 homicides/yr in En gland). A cohort study however found rates of violent off ending are low and the strongest association with off ending was previ- ous off ending. Psychiatric variables were less impo rtant, with diagnosis and number of previous admissions showing no signi \201 cant associa tion. Substance misuse and sexual abuse are associated with increased off ending risk.528 y r t a i h c y s P 4 Surely if inpatient psychiatric beds are not available, however good the daytime team is in the community, some patients will still need some- where to go at night? The implication is that the skills available in bed-and- breakfast accommodation may be inadequate at time s of day when there is no other support, other than the general practitioner. Studies that have looked at this have certainly found an increase in non-hospital residential care in th ose selected for community care, and this increase may be as much as 280% over 5yrs. In the UK, new proposals guarantee 24-hour open access to skilled help, but it is not known what pressures this will put services under. 5 Surely community care will involve a huge bureauc racy in pursuit of the unattainable goal of 100% safety? This will be so if every patient h as a lengthy care plan and repeated risk assessments. Concern for safety may also spawn a n on-therapeutic custodial relationship. Advantages reported for community care are: better social functioning, satisfaction with li fe, employment, and drug compliance \200\224but in randomized studies in the UK these advan tages are not always manifest. Furthermore, trends have been repeatedly found indicating th at the longer studies go on for, the harder it is to maintain the initial advantages of com munity care. If it is hard for teams to keep up their enthusiasm during a trial, it will pr obably be even harder when the trial period has ended, or when team members are ill. These constraints may in part explain the observation that with inadequately funded and supervise d community care, patients can fail to get essential ser- vices, and when hospitals are bei ng run down, and a patient \200\231s condition wors- ens, so that \200\230sectioning \200 \231 followed by admission becomes impossible, the pa- tient is left in the community \200 \230rotting with his rights on \200\231. Assertive community care and case management is on e way out of this impasse (here a key-worker has direct responsibility for care plans). Thi s set-up helps ensure more people remain in contact with psychiatric services (NNT=15); thi s inevitably increases hospital admission rates.529,530 When combined with family therapy a nd social skills training results are good.531 Poverty and mental illness Social deprivation is positively associated with premature morta lity, and pov- erty makes almost all diseases more likely (but not Hodgkin \200\231s diseas e, eczema, bulimia, or melanoma).532 See Health and social class, p463. In the UK, the numb er of homeless people is 1 \200\2232 million. >30% suff er from mental illness (10% have sc hizophrenia), most do not know where to go for help, and most have no doctor. A 3-tier stra tegy may help. 1 Emergency shelters 2 Transitional accom- modation 3 Long-term housing. 406 The cost in health terms to society and the individual is enormous. Diseases and symptoms s uch as diarrhea, which may pass as a minor inconveniences to the well-housed, may be a majo r hurdle for the homeless, with severe social and psychological eff ects. Capture \200\223r ecapture techniques show that the unob- served population of the homeless is about twice th at observed. This method of enumeration collects samples (lists) and looks for tags (duplic ates) in sub- sequent counts, and from this determines the degree of under-counting. If all in the subsequent count are duplicates, then there is no underestimate of the original cou nt. Statistical techniques can allow for migration in and out of the population area.533 Th ese studies show that psychiatric morbidity is greatest in the observed homeless population s: the implication is that the psychiatric illness makes these people more \200\230visible \200\231. y r t a h c y s P In the UK, as in many other Western countries, what started out as an en- lightened policy of looking after people with mental health problems in the community (p405) has resulted in large numbers of psychiatric patients liv- ing on the street in great poverty \200\224reli eved by occasional admissions to often overcrowded acute units. This \200\230revolving doo r \200\231 model of care has failed many patients, not least because continuity of care is compromised. i