192s A newparadigm: psychiatric disablements

home support are at least as effective for the patient as traditionalhospitalcare and follow-up, reducethe burdenon the family,and arealso moreeconomical.

An analysis of the data of the case register of the South VeronaCommunity Psychiatric Service (CPS) on home visiting during aIO-year period 0982-91) will be discussed in the presentation.South Verona CPS is a comprehensive and integrated community­based mental health service where staff members are divided intothree multidisciplinary teams, each responsible for a subsector ofthe catchment area. They work both in the hospital ward and in thecommunity. While not yet offering a 24-hour a day mobile crisisteam, the service provides at-home interventions during workinghoursand ongoing care as needed. Case registerdata showthat whilean increase in out-patient community care and day care was takingplaceover the years, there wasa parallel fall in the use of publicandprivate hospital beds. Results of this study show that home-basedcare increasingly providedin the 1982-91 periodto all SouthVeronapatientswas associatedwith a decreasinguse of hospital beds.How­ever, differences across age and sex groups appeared: the increaseof home-based care regarded older females,but not youngerfemalesand males. and was associated with a decreasing use of hospitalbeds in female patients (all diagnoses) and in female patients withaffective disorders and with other diagnoses, but not in those withschizophrenia and related disorders. In addition. the apparenteffectof this approach over the years was a distinct improvement of ourpsychiatric service in termsof workers' clinicalskillsand therapeuticeffectiveness.

COST BENEFIT STUDY OF DAY CARE - TilE EFFECT OFAN ATTACHED COMMUNITY PSYCHIATRIC NURSE

F.Creed. Department ofPsychiatry. RawnsleyBuilding. ManchesterRoyalInfirmary. OxfordRoad.Manchester, GB-MI3 9WL,GreatBritain

Previous studies have demonstrated that 30-409::of admissions to apsychiatric in-patient unit with acute illnesscan be treated in a well­staffedday hospital. In thiscost effectiveness study, 179patientswithacute psychiatric illness were randomlyallocated to day hospitalorin-patient treatment. Nearly half the sample had schizophrenia. Thegroupswerewell matchedon baseline characteristics andclinicalandsocialoutcomewere similarat twelve months.exceptthat in-patientsimproved significantly faster thanday patients(p < 0.05) and burdenon relatives was significantly less in the day hospital group at oneyear (p < 0.05). Direct costs to the hospital were,on average, £2.786(SE ...) per patient cheaper for day hospital treatmentcompared toin-patienttreatment.

Patient travelcosts were significantly greater for day patientcareand there was a significantly greater loss of informant's income.When all direct and indirect costs were considered, day hospitaltreatment still proved to be £1,590 (SE = ..) cheaper. In addition todemonstrating that day hospital treatment is cheaper than in-patientcare, this study highlights the veryconsiderable distress experiencedby carersof peoplewith acute psychiatric illness.Thismayamounttoactual psychiatric disorder in the carer; it resolvesmoresatisfactorilywith day hospital treatment than in-patient treatment. By contrast,acute psychiatric disorder appears to resolve faster in the in-patientunit. These findings only apply to those 40% of patients presentingfor admission who can be treated in the day hospital and requirefurther study if we are to define optimal use of day and in-patienttreatmentfor acute illness.

FROM EMERGENCY TO SOCIAL PSYCHIATRIC SERVICECENTERS; THE AMSTERDAM EXPERIENCE

BertholdP.R. Gersons. Department ofPsychiatry; AMClUniversityofAmsterdam. Tafelbergweg 25. JJ50 BC Amsterdam. Netherlands

Outreaching emergency psychiatry has been the keystone in Dutchmental health to prevent admissions in mental hospitals. There wascomprehensiveness of acute service with its strong connection withpre- and aftercare. The expansion of the ambulatory mental healthcenters(RIAGG's)in the eighties, nowserving3%of the population,resulted in a disconnection of the acute services from continuity ofcare for chronic patients in the community. The mental hospitals inreaction to theambulatory expansion haveset upacutewardsto admitpatientsas shortas possible. Thispolicywasviewed asa 'principle' ofcommunity mental healthcare. The unforeseen resultwashoweveranenormousincrease of 100% in ten yearsof the numberof admissions.The settingup of socialpsychiatric servicecenters withcontinuityofcare,tailored treatment, partialhospitalization andrelatedto shelteredlivingarrangements and day-activity centers for a catchmentarea of100.000are the new solutions to offer in- and outpatient acute careagain relatedto the principles of continuity, Fromresearch it becameclear mostoutreaching servicescould be betterviewedas a repetitionof interventions for chronic patients. Continuityof care is now seenas the tool to counter the need for acutecare. In Amsterdam5 SocialPsychiatric ServiceCentersare operating. replacing the old hospitalsandofferingambulatory and inpatientcare.

TENSIONS AND CHALLENGES IN THE PROVISION OFEMERGENCY MENTAL HEALTH SERVICES

Michael Phelan. Consultant Psychiatrist, Riverside Mento! HealthTrust. Charing CrossHospital. London W88AF, UK

Inevitable conflicts arise when trying to provide emergency mentalhealth services. As a result patients often do not have a smoothpathway into care, and crisis services receive fierce criticism fromservice users. Difficulties facing those responsible for the provisionof emergency care include: lackof anyagreeddefinitionof whatcon­stitutes a psychiatric emergency; rising demand as services becomemore accessible and less stigmatising: economies of scale forcingout of hours services to be centralised and anonymous; limitedmultidisciplinary working and a 'lack of senior staff working withpeople in crisis. Numerous models of emergency care have beendemonstrated to be effective in specificsettings.To provide effectiveroutine services it is essential that there is close integration betweenemergency services and other aspects of the local community ser­vices, and that servicesare plannedon the basis of the needs of thelocal population, rather than applyinga universal modelof care.

835. A new paradigm: psychiatricdisablements

Chairmen: C Pull, T Ustun

DISABILITY IN THE GB SURVEYS OF PSYCHIATRICMORBIDITY

RachelJenkins. Department ofHealth, Wellington House. 133-155Waterloo Road. LondonSEI BUG

Datawill be presented fromthe GB surveysof psychiatricmorbidity,