Care-management for mental illness

Care-management for mental illness

3 Postgraduate psychiatric training in Japan SIR-Communications via research outputs are crucial for researchers in any science, and psychiatry is no...

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Postgraduate psychiatric training in Japan SIR-Communications via research outputs are crucial for researchers in any science, and psychiatry is no exception. New knowledge and understanding of a disease process or mechanism, or improved treatments derived from the area of research are, however, not solely of interest to researchers. Clinicians are also expected to keep up with research developments. Experiences and approaches during postgraduate training greatly influence the trainee’s attitude towards clinical practice thereafter. Along with expertise in psychiatry, basic skills also need to be improved to enable trainees to interpret research findings. If psychiatric training varies according to teaching hospitals, and if some provide only limited training, then doctors will face difficulties in communicating with and exchanging experiences with their colleagues. For example, if diagnostic practice varies widely between centres, then patients with similar conditions may be diagnosed differently, and consequently treated

differently. There is


nationwide, uniform training in Japan. Each is independent. However, there is some

teaching facility

standardise postdoctoral training. What needs emphasis, however, is that training facilities provide equal opportunities for learning and that trainees are required to achieve a consensus for diagnostic classifications. In Europe, harmonisation of psychiatric practice seems a major issue.’ Some workers have recognised2 that if diagnostic practice remains diverse, not only will clinical work be affected, but also research might convey misleading information or be misunderstood. Psychiatry in Japan has long been influenced by German psychiatric practices, but methods from Scandinavian countries and France, together with those derived from the WHO diagnostic classification systems (ICD-10)3 and American psychiatric associations (DSMIV),4 have also been introduced. Diagnostic practices seem to have diverged across psychiatric training facilities in Japan according to the attitudes towards foreign concepts, and there is poor agreement even on routinely used conventional diagnoses among Japanese psychiatrists.s Psychiatry in Japan is now subdivided into various branches, and training schemes should therefore be more flexible. For example, trainees might rotate among universities. Such an exchange of trainees would facilitate communication, help trainees to learn of each other’s ideas movement to

and clinical skills, and further vitalise collaborative research activities. The lack of definitive biological markers in mentally ill people has created a diversified nosology. Disputes about the superiority of one system over another are redundant and will delay research developments. Disharmony of this kind leads to confusion among not only clinicians but also mentally ill people and their relatives; this is a tremendous tragedy. We need to have "a common language"2 (ie, international consensus) in which productive breakthroughs in psychiatric problems can be brought out and shared among us all; this is important at the international level. It is therefore especially important to establish working agreements about main concepts within any individual country. Japan is no exception.

4 5

World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: WHO, 1992. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV™, 4th ed. Washington, DC: APA, 1994. Kitamura T, Shima S, Sakio E, Kato M. Psychiatric diagnosis in Japan: 2, reliability of conventional diagnosis and discrepancies with research diagnostic criteria diagnosis. Psychopathology 1989; 22: 250-59.


SiR-The limited effectiveness of care-management shown in the randomised trial by Marshall and others (Feb 18, p 409) is disappointing but to call it "a disastrous mistake" (editorial, p 399) seems unduly pessimistic. Caremanagement is merely a process to coordinate care and can only be as good as the sum of the services available in a locality. Proper interpretation of the results of this trial requires further information about the nature of the intervention (core staffing level of the case-management team; its hours of operation; patient caseload; working relationship with health providers) and about the level and range of services available to both the case-manager and the control group. Marshall and co-workers cite the failure of Franklin et al’ to find significant differences in their trial of case-management, but they do not point out that the control group in that trial had access to a community mental-health centre with an aggressive hospital aftercare programme. The amount of practical support and advocacy provided in the Oxford trial was left to the discretion of individual case-managers; this approximated to 20 min per client per week. However, practical support was a key component of the community-based support programmes shown to be effective for severely mentally ill people in randomised controlled trials.2--1 Case-management with low caseloads was an integral part of these programmes. Admittedly such care is not standard in the UK, but it seems perverse to recommend abandoning care-management rather than changing everyday practice. The underlying principles of care programmes in the aforementioned trials have been widely adopted in America and Australia, and are beginning to influence the delivery of mental-health care in the UK too.

Several solutions to the care-management dilemma are in the editorial, but it does not discuss the that case-management and care programming could be more closely integrated within the current system. A purchaser-provider split now operates within many social services departments. Joint commissioning between health and social service purchasers can ensure that services develop in response to well thought out strategies; this can include the requirement for multidisciplinary working between health and social service providers. In this context, care-management can be implemented as a team rather than an individual responsibility.s Perhaps the biggest challenge to those implementing care-management is to recognise that major cultural shifts are required to redefine service objectives and to create an appropriate service infrastructure that supports rather than hinders those objectives.

suggested possibility


Noriyoshi Takei Genetics Section, Department of Psychological Medicine, Institute of Psychiatry, King’s College Hospital, London SE5 8AF, UK




Os J, Neeleman J. Caring for mentally ill people.

BMJ 1994;




Os J, Galdos P, Lewis G, Bourgeois M, Mann A. Schizophrenia sans frontieres: concepts of schizophrenia among French and British psychiatrists. BMJ 1993; 307: 489-92.




Department of Public Health Medicine, Suffolk Health Authority, Ipswich IP3 8NN, UK

1 1

for mental illness

Franklin JL, Solovitz B, Mason M, Clemons JR, Miller GE. An evaluation of case management. Am J Public Health 1987; 77: 674-78. Stein LI, Test MA. Alternative to mental hospital treatment I. Arch Gen Psychiatry 1980; 37: 392-97. Hoult J. Community care of the acutely mentally ill. Br J Psychiatry 1986; 149: 137-44.

Marks IM, Connolly J, Muijen M, Audini B, McNamee G, Lawrence RE. Home based versus hospital care for people with serious mental illness. Br J Psychiatry 1994; 165: 179-94. Fuller Torrey E. Continuous treatment teams in the care of the chronic mentally ill. Hosp Commun Psychiatry 1986; 37: 1243-47.



analgesia is only effective for a few hours. The only sure way of avoiding the long-term harmful effects of neonatal circumcision is for doctors to abandon this unnecessary, intrusive, mutilating, and painful operation. John Warren Princess Alexandra Hospital NHS Trust, Harlow, Essex CM20



Circumcision SIR-Taddio and colleagues (Feb 4, p 291) are to be commended for their study showing the permanent psychological damage inflicted on infants subjected to unanaesthetised penile reduction surgery-ie, circumcision. It is both instructive and frightening that the severe and unalleviable pain of circumcision permanently alters the neural pathways in an adverse fashion. Where else might the clinician look for the signs of circumcision flashback? The suggestion that analgesia be used for circumcision is, however, incongruous with the results of Taddio and colleagues’ study. Investigations of the effectiveness of analgesia in circumcision show that at best, topical, caudal, or dorsal analgesia may cause infants to suffer only slightly less. For instance, Stang et al’ found that an injection of lignocaine hydrochloride reduced the plasma cortisol concentration slightly, but still left babies with a concentration of 331 nmol/L, whereas a contented child at rest has a plasma cortisol concentration of 28-138 nmol/L. Benni et aP found that EMLA (lignocaine/prilocaine local anaesthetic cream) could only reduce the circumcised child’s heart rate from 180 to 160 beats per minute. No infant’s heart should beat at 160 beats per minute, nor should his plasma cortisol concentration be 331 nmol/L. These rates are

consistent with




without anaesthesia,

circumcision will cause the psychoneural damage found by Taddio et al. Despite the obviously irrational cruelty of circumcision, the profit incentive in American medical practice is unlikely to allow science or human rights principles to interrupt the highly lucrative American circumcision industry. It is now time for European medical associations loudly to condemn the North American medical community for participating in and profiting from what is by any standard a senseless and barbaric sexual mutilation of innocent children. Paul M Fleis 1824 North Hillhurst Avenue, Los Angeles, CA 90027, USA



Stang HJ, Gunnar MR, Snellman L, Condon LM, Kestenbaum R. Local anaesthesia for neonatal circumcision: effects on distress and cortisol response. JAMA 1988; 259: 1507-11. Benni F, Johnston C, Faucher D, Aranda JV. Topical anesthesia during circumcision in newborn infants. JAMA 1993; 270: 850-53.

SIR-Taddio and colleagues report that neonatal circumcision affects pain responses in boys at vaccination up to six months later, and suggest that the pain from circumcision may have longlasting effects on pain response and/or perception. They recommend that analgesia should be routine for circumcision to prevent this possible longterm effect. However, there is no certainty that short-term local analgesia would do so. In neonatal circumcision there must be more than one component of pain. There will be acute pain when the foreskin is crushed by a clamp and then excised, and this pain would be reduced or obliterated by local analgesia. But, since the prepuce in newborn babies is adherent to the glans, circumcision involves tearing these layers apart, leaving the glans raw and bleeding. This raw surface must cause pain as it is abraded by soiled napkins for days after surgery. Local

Conflicting views


alleged plagiarism

SIR-Brahams (Feb 11 p 379) states that our protracted lawsuit "could strike a damaging blow to the tradition of generous exchange of ideas between scientists". We have no objection to voluntary exchange of information or papers between scientists. But when a colleague surreptitiously obtained two documents that we spent 18 months to devise, used them for his benefit and our detriment, and without acknowledgment, then the issues at stake are moral and ethical behaviours and not "exchange". Brahams refers to the University of Hong Kong (HKU) inquiry, conducted after the court decisions,’°2 that concluded there was no evidence to support the findings of the courts that Dr T H Lam had obtained our questionnaire surreptitiously, infringed copyright, and misused confidential information. The Vice-Chancellor of HKU decided that the allegations (ie, the findings of the courts) were "demonstrably false". The contrary findings of the university and the court hearings are partly explained by the fact that the HKU inquiry was a closed internal matter. We were not allowed to see or comment upon Lam’s evidence to it. HKU’s report that Lam got our questionnaires (versions KH3c and KH4d) from our research assistant is not supported by the court documents; she only used version KH4b. The research assistants did not sit at "neighbouring desks". Furthermore, Lam’s testimony was described in the court judgment as not "full or frank". HKU further claimed that their new findings were based on "new evidence". Prof Richard Peto’s analysis of dissimilarities at the trial was faulty on two grounds. He did not analyse the 14 versions of our questionnaire and the 4 versions of Lam’s that were in dispute. HKU refuses to show us the "new evidence". Brahams’ comment about Lam’s "crippling" legal costs is also misleading. From 1986 until the court judgment in 1992, Lam’s legal costs were paid by the Medical Defense Union, whereas we were financing the litigation ourselves. Brahams cites comments by some epidemiologists that our questionnaire was "inferior". The 1986 report of the US Surgeon General on The Health Consequences of Involuntary Smoking’ said that "The design of this study [ours] addressed the criticisms of other studies that an index of involuntary smoking exposures based only on spouses’ smoking habits is inadequate, and broadened the exposure assessment to include all locations of tobacco smoke exposure". Other reviewers of our research on passive smoking and lung cancer have said "I think we should encourage original research like that of Freedman 1983 on surrogates for ETS and Koo’s 1989 paper". If anyone uses his/her brain, skill, time, and labour to a questionnaire, poem, or design, it belongs to the If the creator wishes to share the fruits of his labour with others, that is his choice. As stated in a recent editorial in Nature5 about this case, "In Hong Kong and even elsewhere, it will seem a daring and even a foolhardy decision by a university (however properly arrived at) to fly in the face of a court decision, even in a civil suit ...

develop creator.