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Except in the rare instance of exchanging tissue between the two eyes of the same individual (autograft) anxiety symptoms racing thoughts buy emsam with paypal, corneal transplantation is an allograft with the attendant risk of graft rejection anxiety symptoms postpartum generic 5 mg emsam overnight delivery. However anxiety symptoms numbness in face buy 5mg emsam amex, due to anxiety quotes tumblr discount emsam 5 mg otc various factors that limit exposure to the foreign antigens and the immunological response to them, corneal allograft generates a relatively weak immune response. In contrast, in high-risk cases, such as inflamed or vascularized recipient corneas, 5-year survival is around 55%. The antigens responsible for the vast majority of the immune response are located on the endothelium. Whenever possible, corneal graft surgery is limited to anterior lamellar keratoplasty to minimize the immunogenicity of the graft tissue and the likelihood of rejection. Both humoral and cellular mechanisms have been implicated in corneal graft rejection. It is likely that early graft rejection (2–4 weeks from surgery) is cell796 mediated. Lymphocytes mediating rejection generally move inward from the periphery of the cornea, forming a “rejection line” that may be seen on the endothelium or the epithelium as they move centrally. The donor cornea becomes edematous as the endothelium becomes increasingly compromised. Late rejection of a corneal graft may occur weeks to months after surgery and may be antibody-mediated, since cytotoxic antibodies have been isolated from the serum of patients with a history of multiple graft reactions in vascularized corneal beds. These antibody reactions are complement-dependent and attract polymorphonuclear leukocytes, which can form dense rings in the cornea at the sites of maximum deposition of immune complexes. Treatment the mainstay of the treatment of corneal graft reactions is intensive topical corticosteroid therapy. Due to its lack of regenerative capability, endothelial damage is likely to be irreversible, leading to graft failure such that endothelial rejection requires more aggressive and prolonged treatment. Systemic and topical cyclosporine or tacrolimus also are effective in preventing and treating graft rejection. Of paramount importance in many systemic and ocular inflammatory conditions are T-cell–mediated immune reactions and cytokines. Immunosuppressants these include antimetabolites (azathioprine, methotrexate, and mycophenolate mofetil), T-cell inhibitors (cyclosporine and tacrolimus), and alkylating agents (cyclophosphamide and chlorambucil). The treating physician must be familiar with the ocular and systemic side effects of these medications, which are discussed in Chapter 15. For inflammatory diseases, a wide range of agents have been shown to be beneficial (Table 16–2). Examples of Biologic Response Modifiers (Biologics) for Ocular Disease Modes of Delivery In order to enhance anti-inflammatory effect on the eye and to minimize systemic side effects, alternative modes of delivery of these agents (apart from oral or intravenous) have also been studied. Intraocular methotrexate has shown vision improvement and 798 reduction of macular edema in uveitic patients. Sustained implants of immunosuppressants, as well as intraocular viral and nonviral gene therapies that deliver anticytokine agents, are being investigated in animal studies. Genetic predisposition to Stevens-Johnson syndrome with severe ocular surface complications. Symptoms are often nonspecific, and the usual examination techniques require modification. Development of the visual system is still occurring during the first decade of life, with the potential for amblyopia even in response to relatively mild ocular disease. Because the development of the eye often reflects organ and tissue development of the body as a whole, many congenital somatic defects are mirrored in the eye. Collaboration with pediatricians, neurologists, and other health workers is essential in managing these conditions. Similar collaboration is required in assessing the educational needs of any child with poor vision. Details of the embryology and the normal postnatal growth and development of the eye are discussed in Chapter 1. If any abnormality is identified, full ophthalmological assessment is required, for which the necessary instruments are hand light, loupe, direct and indirect ophthalmoscopes, and occasionally a portable slitlamp. Any congenital abnormality may be associated with nonocular abnormalities requiring further investigations. Pediatric Eye Examination Schedule 803 Vision Assessment of vision of the neonate is limited to observing the following response to a visual target, the most effective being a human face. Visual fixation and following movements can be demonstrated in most neonates; however, during the first 2 months of life, some do not demonstrate consistent fixation behavior and following (smooth pursuit) eye movements may be coarse and jerky. External Inspection the eyelids are inspected for growths, deformities, lid notches, and symmetric movement with opening and closing of the eyes. The absolute and relative size of the eyeballs is noted, as well as their position and alignment. The size and luster of the corneas are noted, and the anterior chambers are examined for clarity and iris configuration. The pupils are normally relatively dilated until 29 weeks of gestation, at which time the pupillary light response first becomes apparent. It is important to carefully examine the pupils of any infant with ptosis, looking for anisocoria, as Horner’s syndrome, while usually benign, can be due to neuroblastoma. Ophthalmoscopic Examination 804 the red reflex is examined with a direct ophthalmoscope. Any abnormality requires direct and/or indirect ophthalmoscopy through dilated pupils. They may have adverse effects on blood pressure and gastrointestinal function in premature neonates and those with lightly pigmented eyes, for whom combined cyclopentolate 0. In neonates, the optic disk may appear gray, resembling optic nerve atrophy, but if so, there is gradual change to the normal adult pink color by about 2 years of age. Fundal hemorrhages are present in up to 50% of newborns, usually clearing completely within a few weeks and leaving no permanent visual dysfunction. In addition to fundal abnormalities, ophthalmoscopy reveals corneal, lens, and vitreous opacities. It is best not to wait until the child is old enough to respond to visual charts, as these may not furnish accurate information until school age. During the first 3–4 years, estimations of vision generally rely on observation and reports about the child’s behavior both at play and during interactions with parents and other children. However, seemingly normal visual performance is possible with relatively poor vision. The influence of visual impairment on motor and social development must always be borne in mind. The pupillary responses to light are only a gross test of visual function and are reliable only for ruling out complete dysfunction of the anterior visual or efferent pupillary pathways. Binocular following and convergence are best examined first to establish the child’s cooperation. Each eye should then be tested separately, preferably with occlusion of the fellow eye by an adhesive patch. Comparison of the performance of the two eyes will give useful information about their relative acuities. Resistance to 805 occlusion of one eye suggests that it is the preferred eye and the fellow eye has comparatively poor vision. In nystagmus with a latent component (increased intensity with occlusion of one eye), occlusion of either eye is likely to be resisted because of its adverse effect on visual acuity. Manifest nystagmus may be indicative of an anterior visual pathway disorder or other central nervous system disease (see Chapter 14). After 3 months of age, strabismus, detected by examining the relative position of the corneal light reflections, may be indicative of poor vision in the deviated eye, particularly if this eye does not or is slow to take up fixation of a light upon occlusion of the fellow eye (see Chapter 12). The developing sensory system can be assessed by the quantitative techniques of optokinetic nystagmus, forced-choice preferential looking methods, and visually evoked responses (see Chapter 2). Although visually evoked potentials have suggested that normal adult visual acuity is attained before 2 years of age, this is probably an overestimate and it is likely that 3–4 years of age is a more accurate estimate (Table 17–2). Forced-choice preferential looking methods provide reliable and relatively easy assessment of visual acuity in preverbal children, even in the very young. Usually, at the firstor second-grade level, the regular Snellen chart may be employed. Stereoacuity can be shown to develop in most infants beginning at 3 months of age, but clinical testing is not generally possible until 3–4 years of age. Absence of stereopsis, as judged with the Random Dot “E” test or the Titmus stereo test, is suggestive of strabismus or amblyopia and should prompt further investigation. Refraction Objective refraction is a crucial part of pediatric ophthalmic examination, especially if there is any suggestion of poor vision or strabismus.
As this chapter is concerned with broad population needs anxiety symptoms and causes emsam 5 mg online, we have used the 1988 Working Party definition anxiety symptoms unreal buy cheap emsam 5mg on line, which includes patients with heartburn anxiety symptoms hypertension discount emsam 5 mg visa. Particular concerns in managing dyspepsia are therefore the cost-effective use of resources anxiety 4 year old boy best emsam 5mg, the appropriate choice of potentially curative treatments (Helicobacter pylori eradication) rather than symptomatic therapies (acid suppression), and the need for prompt diagnosis of upper gastrointestinal malignancy. Patients with dyspepsia can be divided into subgroups on the basis of final endoscopic diagnosis, but if we are to accept that endoscopic diagnosis is not cost-effective in all patients, a sub-category ‘uninvestigated dyspepsia’ is necessary to consider what management is appropriate for patients presenting with a new episode. Uninvestigated dyspepsia: patients presenting with a new episode who have not had endoscopic investigation. Helicobacter pylori and nonsteroidal anti-infiammatory drugs are the predominant causes. Non-ulcer dyspepsia: patients without peptic ulcer, malignancy or oesophagitis on endoscopic investigation. The terms incidence and prevalence are difficult to apply in this context, because of the problem of classifying patients with a history of symptoms, who are currently asymptomatic, but are at high risk of further episodes. The proportion of patients undergoing endoscopy where a peptic ulcer is detected has fallen dramatically in the past 12 years from 20% in 1989 to 10%. The fall in peptic ulcer disease may be due to a reduction in recurrent ulcer disease as H. Oesophagitis is present in 20% of patients at endoscopy, and may be rising with time, although the condition may be more frequently diagnosed with the availability of effective treatment in the form of proton pump inhibitors. The incidence has been declining steadily, with a concomitant rise in adenocarcinoma of the oesophagus. Non-ulcer dyspepsia accounts for 60% of cases at endoscopy, and is the commonest sub-category. Services available and their costs Consultations for dyspepsia account for between 1. Factors predicting consultation are worry about serious disease, such as cancer or heart disease, and the availability of effective medical therapy. The costs and numbers of prescriptions for dyspepsia have risen steadily over the past eight years. In 2000 there were 539 gastroenterologists working in England and Wales, and it has been estimated that 50% of their workload is accounted for by dyspepsia. Serology is available in most areas, but has poor predictive value where the prevalence of H. Both urea breath tests and stool antigen tests are much more accurate, but either involve the ingestion of a test dose of (non-radioactive) labelled urea and the collection of breath samples for analysis in a mass spectrometer, or collection of stool samples. Most patients are unsuitable for surgery, as the disease is too far advanced at detection, and long-term survival even after surgery is poor at less than 20%. Effectiveness of services and interventions Uninvestigated dyspepsia: Symptom patterns are not sufficiently predictive or specific to be of value in managing patients with dyspepsia. Trials comparing acid suppression therapies in uninvestigated patients are either lacking or for short-term outcomes only. Management based on an initial endoscopy may be associated with a small reduction in symptoms (12%) compared with empirical acid suppression. There is no evidence as to whether ‘test and treat’ is cost-effective compared to empirical acid suppression as an initial strategy. Non-ulcer dyspepsia: One trial found that antacids were no more effective than placebo, a metaanalysis of trials found no significant reduction in symptoms with H2 receptor antagonists, although the trials were small and of poor quality. Given the uncertainty in trial data, and the potentially important clinical differences between patients, it is important that the response to treatment of all non-ulcer dyspepsia patients is carefully monitored. Quantified models of care When the risk of malignancy is low: A discrete event simulation model indicates that endoscopy is not cost-effective in these patients. When the risk of malignancy is high: Patients in whom malignancy is suspected should all receive prompt endoscopic investigation. However, patients with overt symptoms such as weight loss or dysphagia are likely to have inoperable cancer. If malignancy is to be detected early, endoscopy needs to be performed in patients without overt symptoms, but at high risk. Recent data, combined with an economic model, suggests that restricting endoscopy to patients with continuous epigastric pain and/or symptoms of less than one year’s duration (in addition to those with alarm symptoms) would improve the cost/life year gained from fi50 000/life year to fi8400/life year in men. Gastric cancer is less common in women and investigation cannot be justified on economic grounds until age 65. This vague description is fitting for a constellation of symptoms that has no universally agreed definition. A review of the literature identified 1 23 different descriptions of dyspepsia and since this review there has been a further international expert 2 meeting to try and reach a consensus. All agree that dyspepsia is a group of symptoms that is thought to arise from the upper gastrointestinal tract and most imply that the term represents a symptom complex and not a diagnosis. Symptoms needed to be present for 4 weeks and included upper abdominal pain or discomfort, heartburn, acid refiux, nausea and vomiting. This classification further subdivided patients on the basis of symptom patterns into ‘ulcer-like’ (epigastric pain), ‘refiux-like’ (heartburn and acid regurgitation), ‘dysmotility-like’ (bloating and nausea) and 5 ‘unclassifiable’. The Rome I working group suggested that the key symptom needed to define dyspepsia was pain or discomfort centered in the upper abdomen and excluded patients with heartburn or acid refiux 4 as their only symptom. The upper abdominal symptoms needed to be present for more than one month and occur greater than 25% of the time to fulfil the criteria for dyspepsia. This important advance will make future non-ulcer dyspepsia trials more comparable but this definition is less relevant for uninvestigated patients. This chapter is concerned with population needs, where the diagnosis is often not established. Dyspepsia drugs have been the single highest cost prescription item in the past two years and 3% of the population may be taking long-term 7 therapy. In any six month period 40% of the population will suffer an episode of dyspepsia, and half of 8 those will consult their general practitioner. The frequent occurrence of dyspeptic symptoms, the widespread availability of empirical treatments and the high cost of definitive investigation mean that the guiding principle of managing dyspepsia lies in the cost-effective use of both treatments and investigations appropriate to an individual patient. This is in preference to first defining the cause of the symptoms by definitive investigation of all patients. Any assessment of health need relating to dyspepsia must consider both the management of previously uninvestigated cases, and cases where a cause has been established by gastroscopy. This paper attempts to categorise patients according to the potential risk of treatable disease and considers both the treatment of established causes of upper gastrointestinal disease and the evidence relating to the choice of management for uninvestigated cases. In the latter, both direct comparative research evidence and modelling based on case mix and the likely effects of treatments on underlying causes will be used. The two most important factors to consider are the role of testing and eradication of H. Of the conditions that may be detected, most interest has centered on peptic ulcer disease, as this condition may now be cured by the eradication of H. A number of strategies for managing dyspeptic patients incorporating non-invasive tests for H. The role of endoscopy in detecting early upper gastrointestinal cancer Some patients with dyspeptic symptoms will prove to have malignancy, principally adenocarcinoma of the stomach or oesophagus. Although most patients with dyspeptic symptoms present at an inoperable stage, 10 some patients may benefit from surgery if investigated promptly by endoscopy. This chapter considers in detail the evidence and potential for early diagnosis of curable malignancy by selective prompt endoscopy in specific subgroups of high risk patients. The focus of this chapter is on the cost-effectiveness of initial management strategies for dyspeptic patients in primary care. However, many patients consulting with dyspepsia are referred for investigation to determine the cause of their symptoms. A diagnosis can then be reached and patients will have one or more of the following diseases. Normal levels 14,15 of refiux provoke symptoms in a minority of cases, possibly due to increased oesophageal sensitivity. Peptic ulcer disease A peptic ulcer is defined as a defect in the gastrointestinal mucosa extending through the muscularis mucosae due to the acid-peptic action of gastric juice. These can be subdivided into gastric and duodenal ulcers, depending on the site of the defect. The traditional view that gastric and duodenal ulcers have distinct symptoms has been shown to be incorrect; indeed, symptoms are inadequate to identify patients 17 with ulcers. Non-ulcer dyspepsia Patients with dyspepsia symptoms with a normal endoscopy are often classified as having non-ulcer dyspepsia. The problem with this definition is that a proportion of these patients will have endoscopy negative refiux disease.
By using a confocal microscope instead of a slit lamp anxiety symptoms and causes emsam 5mg without a prescription, we incorporated the specular refection of the corneal endothelium into our backscatter measurements anxiety 13 discount emsam 5 mg on line. The specular refection induced a backscatter peak that slightly increased mean corneal backscatter anxiety free stress release formula buy generic emsam 5mg. This efect of the specular refection on mean corneal backscatter becomes 88 Chapter 4 larger in a thinner cornea venom separation anxiety cheap emsam 5mg mastercard, because in a thinner cornea, backscatter is averaged over fewer images. To our knowledge, diurnal variation of corneal backscatter has never been studied before. To minimize the efect of overnight swelling of the cornea, we started our measurements at least 2 hours after awakening. The characteristic diurnal variation of intraocular pressure we found is similar to that reported by others. After excluding light intensity variation and the so-called “learning efect” as confounding factors, a third potentially confounding factor remains. Repeated exposure of the cornea to preservatives in the anesthetic eye drop and the coupling gel may accelerate desquamation of the superfcial epithelial cells, subsequently increasing epithelial backscatter. To reduce interexaminer diferences due to the subjective demarcation of the stromal boundaries, we protocolized the backscatter measurements (Appendix, Supplementary S1. UsNormative database for corneal backscatter analysis by in vivo confocal microscopy 89 ing this protocol, we found that the posterior stroma was harder to demarcate than the anterior stroma. For corneal backscatter to be used in ophthalmic practice, however, these efects on corneal backscatter should be contextualized. When the patient’s sex and age are ignored, a generalized normal range for corneal backscatter may be used to detect corneal haze. The mean backscatter values of this normal range (Table 6) are somewhat higher than those reported by McLaren et al. Nevertheless, diurnal variation should be taken into account when considering improvement or progression of corneal haze. Some issues should be considered before corneal backscatter is applied in ophthalmic practice. In our opinion, corneal haze can be monitored with sufcient repeatability only if the central cornea is imaged and if the corneal haze is more or less homogeneous. When these conditions are met, corneal disorders may be monitored by mean corneal backscatter, whereas the other six backscatter variants may be used for specifc purposes. Mean stromal backscatter and subdivision into anterior, middle, and posterior thirds may be used to monitor the infammatory process in herpetic stromal keratitis (Figs. The powerful combination of corneal backscatter measurement with morphologic assessment of the corneal layers may improve treatment strategies in this complex chronic disease. All images (A–f) were acquired with fxed light intensity of 72%, after calibration of backscatter analysis. Age is a less signifcant factor, as its infuence is confned to backscatter in the anterior stroma. For research purposes, all three factors should be taken into account, whereas for use in ophthalmic practice, we suggest incorporating the efects of sex and age into the normal range for corneal backscatter and accounting for diurnal variation in the defnition for improvement or progression of corneal haze. Such a generalized normal range and minimum detectable change for each backscatter variant is easily accessible in a clinical setting. However, before backscatter measurement can be used to detect and monitor pathologic processes in the cornea, further research is needed. Acknowledgments the authors thank Sietske Huiskens and Elma Bras (Rotterdam Ophthalmic Institute) for excellent technical assistance, Netty Dorrestijn (Rotterdam Ophthalmic Institute) for organizing the referral of study subjects, and Tom van den Berg (Netherlands Institute for Neuroscience) for his helpful advice and suggestions in the preparation of this manuscript. Normal human keratocyte density and corneal thickness measurement by using confocal microscopy in vivo. Assessing smallest detectable change over time in continuous structural outcome measures: application to radiological change in knee osteoarthritis. Human corneal thickness and its impact on intraocular pressure measures: a review and meta-analysis approach. A population study of the normal cornea using an in vivo, slit-scanning confocal microscope. Normative database for corneal backscatter analysis by in vivo confocal microscopy 93 24. The relationship between diurnal variations in intraocular pressure measurements and central corneal thickness and corneal hysteresis. Quantifcation of stromal thinning, epithelial thickness, and corneal haze after photorefractive keratectomy using in vivo confocal microscopy. These deviations consisted of pseudoguttata, enlarged intercellular gaps, infltration of infammatory cells into the endothelial layer, loss of defned cell boundaries, spot-like holes, and endothelial denudation. All of these signs disappeared with appropriate antiviral and anti-infammatory treatment. Although endotheliitis-specifc alterations appear to resolve, the corneal endothelium can become irreversibly damaged. However, endotheliitis might go undetected when visualization of the endothelium is hampered by accompanying stromal edema and infltrates. It is clinically important to identify endothelial involvement in an opaque or scarred cornea, because secondary neovascularization and scarring can occur as a result of persisting or untreated endothelial infammation. Chronic endotheliitis can eventually lead to endothelial decompensation and the need for corneal transplantation. In specular microscopy, the afected endothelium is characterized by transient endothelial changes described as nonrefecting areas. Subsequent electron microscopy analysis of the endothelium of endotheliitis-afected rabbit corneas revealed cellular edema, enlarged intercellular gaps, spot-like holes, loss of defned cell boundaries, peripheral endothelial denudation, and infltration of infammatory cells into the endothelial layer. The afected eyes of patients with infectious keratitis (adenoviral, n = 8; bacterial, n = 13; fungal, n = 4; acanthamoeba keratitis, n = 17) and the afected eyes of patients with noninfectious corneal disease (contact lens overwear, n = 10; anterior uveitis, n = 10; corneal graft rejection after penetrating keratoplasty, n = 5; corneal graft rejection after lamellar table 1. Endothelial involvement in herpes simplex virus keratitis: an in vivo confocal microscopy study 101 keratoplasty, n = 1) completed this group. The protocol of this observational case series was approved by the local institutional review board and the medical ethical committee and was performed in accordance with the Declaration of Helsinki. The subjects’ corneas were viewed by either Confoscan 3, from May 2005 to April 2006, or Confoscan 4, from April 2006 to May 2008 (Nidek Technologies, Albignasego, Padova, Italy). The observed endothelial area was approximately 425x320 µm, with a 500X magnifcation and a lateral resolution of 0. In all Confoscan 4 examinations, a z-ring and an internal fxation target were used for image stabilization. The examination commenced when the central corneal endothelium was correctly aligned and focused. We used the full-thickness scanning mode with a 6-µm scan step during each examination. Because of uncontrolled subject movement during the 12 seconds of image acquisition, a single examination might show diferent endothelial areas of the central cornea. Instead of a round white dot in the center, they possess a line of increased refection on the border of the elevated dark area. Intercellular gaps are characterized by small black dots at the vertices of endothelial cells and by pronounced intercellular borders. Infltration of infammatory cells into the endothelial layer was seen 104 Chapter 5 figure 2. B, the same patient showed no signs of endotheliitis 3 weeks after initiation of treatment with appropriate antiviral and antiinfammatory medication. A, Focal rupture of Descemet’s membrane with signs of endotheliitis surrounding the lesion. Endothelial involvement in herpes simplex virus keratitis: an in vivo confocal microscopy study 105 mainly in patients with keratouveitis. These cells appeared as non-elevated grayish/black structures, approximately 13 µm in diameter. Spot-like holes appeared as dark, round defects in the endothelial layer, with the diameter of 1 endothelial cell (~20 µm), whereas endothelial denudation consisted of larger areas (>50 µm) with similar dark appearance. Except for endothelial denudation, all of these characteristic alterations disappeared within 1 to 3 weeks on the condition that appropriate antiviral and anti-infammatory treatments were prescribed (Fig 2). In addition to these known alterations, other less common lesions were identifed (Fig 3). Two patients presented with a focal rupture of Descemet’s membrane with signs of endotheliitis surrounding the lesion. The cells appeared in between large endothelial cells, and these alterations were permanent by nature. Endothelial ridges were seen in 5 patients, mostly when stromal loss was present.
And even though hospital resident numbers dropped by 24 per cent between 1980 and 1990 anxiety symptoms in toddlers emsam 5mg generic, psychiatric facilities still contained 36 per cent of all hospital beds by the latter year anxiety krizz kaliko lyrics purchase emsam cheap. In 1990 there were more than 50 anxiety icd 9 discount 5 mg emsam visa,000 psychiatric in-patients in England alone anxiety krizz kaliko emsam 5 mg cheap, at any one time. Moreover, despite a steady decline in the number of people occupying hospital beds since the 1960s, short-stay admissions rose dramatically, creating ‘revolving-door’ hospital care, rather than fully fiedged care in the community. The organization of mental health work 183 By 2000 there were just over 100,000 admissions to English psychiatric units. At the same time, these quick turnover units nearly always operate at 100 per cent bed occupancy. They are unable to provide either the stable place of residence offered by the old asylums or the continuity span required for a therapeutic community approach to be effective. They are often established in the face of opposition from conservative forces within the psychiatric profession (Goldie, Pilgrim and Rogers 1989) and are not included in official government plans for replacing asylum beds, as they were, for example, in Italy. As new services they have been subjected to greater scrutiny and evaluations than hospital-based services. New day places to replace hospital beds were not only slow in coming (between 1975 and 1985 only 9000 new places were made available (Audit Commission 1986)), they were overwhelmingly placed on hospital sites. Similarly, although there was a decrease in the number of in-patients, as out-patients they still attended hospital premises for their appointments. Domiciliary services – the visiting of people in their own homes by mental health professionals – today constitutes only a tiny proportion of this total. A more recent health economic review of spending on mental health services (Sainsbury Centre for Mental Health 2003) still indicates a strong inertia about resources being bound up with hospital-based activity aimed at coercive control. Government spending was increased after 2000, in order to expand mental health services but the report concludes that this intention is unlikely to be successful. Although mental health is designated as a priority in health policy, proportionally the growth in expenditure on it, compared to other forms of State spending, has been slower. As a result, in proportional terms, the share allocated by the local State to mental health services is now actually falling. Also there has been slow progress in the timetable to implement the National Service Framework for Mental Health (Department of Health 1999). The Sainsbury Report estimates that in order to meet the deadlines, current expenditure allocated by central government for mental health services would need to be doubled. Another factor indicating that mental health services continue to have a ‘Cinderella’ status relates to the range of peculiar costs or budgetary pressures experienced by them. These include debt repayment, staff shortages (which lead to expensive short-term agency payments) and the increasing prescribing costs, associated with the introduction of new and expensive psychotropic medications. A look at the breakdown of spending on mental health services reveals socio-political priorities. The table indicates that there is a socio-political emphasis on social control (the combined items on acute facilities, secure provision and mentally disordered offenders). These items account for nearly 40 per cent of government spending on mental health services. This can be compared with the amount spent on 184 A sociology of mental health and illness Table 9. Between them the items on new assertive outreach, crisis resolution, early intervention and services for carers, account for less than 7 per cent of spending. A final consideration about the problem of reinstitutionalization and the inertia of hospital-oriented State funding is the interaction of political interests which have impeded shifts to ordinary living and fuller citizenship for people with mental health problems. The old asylums were a total solution for the social problems associated with mental abnormality. In particular, they provided three main functions: • semi-permanent or permanent accommodation; • treatment; • social control. Whatever disadvantages the old asylum system had for their inmates (by creating a form of disabling apartheid) as well as advantages (see comments from Gittins earlier), the socio-political benefit for others was that a group of non-conformist, troublesome, worrisome and economically inefficient people were segregated. Mental abnormality was swept away or ‘warehoused’ out of the sight and mind the organization of mental health work 185 of the majority of free citizens. The three functions would still be required by society for both economic efficiency and the maintenance of a moral order but now they would have to be reconfigured or reconstructed. This political challenge has tempted cautious politicians to hold on to revised forms of institutional care and encouraged them with new forms of legal measures to ensure the coercive control of community-based patients (see Chapter 10). In addition, this new context of acute units provided the psychiatric profession with an opportunity to retain its traditional preferred link between power and beds. Families troubled by patients in their midst would also look to new forms of safe residential disposal. Thus, a confiuence of interests emerged in the final quarter of the twentieth century to retain a hospital focus to mental health work, despite the run-down of the asylum system. The interest groups just described have become immediately aggrieved about the inefficiency of the units compared to the old asylums, as the shift in scale means that the new units cannot replicate all the functions of the old hospitals. Some of these centred on requests for more beds (from psychiatrists and patientrelative pressure groups) or calls for a halt to the run down of the old asylums. Others demanded greater community support to reduce the need for admission (user groups). It can be seen then that the prioritizing of control, professional preferences to treat in in-patient settings and the continued need for people with mental health problems to be accommodated together place pressure upon smaller scale hospital facilities. This pressure created such political anxiety in the mid1990s that in Britain ministers opted to slow asylum run-down and keep high investment levels in beds (Department of Health 1997). In response, critics argued that the three functions noted above should be dealt with as separate policy questions: accommodation implies social housing not hospitalization; treatment needs to be cost effective and its appropriate siting clarified; and risk management should be dealt with rationally, not prejudicially (Pilgrim and Rogers 1997). The macro policy context together with the micro behaviour of professionals making and dealing with mental health referrals determine the pace and success of community care. A comparison of community-based care for those patients with a diagnosis of schizophrenia in Verona and South Manchester indicated that the organization of services in the former resulted in shorter hospital stays as a result of better integration between hospital and community services (Gater et al. Public health, primary care and the new technology revolution With the fragmentation of old structures like the asylums there has been greater attention paid to considering the cause and solution of mental health problems within a public health context. Previously, psychiatric epidemiology and the treatment of mental disorders were separated conceptually. With the 186 A sociology of mental health and illness rise of a ‘new’ public health, which integrates lay with traditional epidemiology, and the emergence of a strong primary health care agenda, epidemiology and treatment are coming closer together as the hospital disappears as the symbolic focus of treatment. Attention shifts instead to inequalities in mental health (discussed in Chapter 3), prevention and the notion of ‘positive mental health’. Alongside this within mental health policy, problem management stretches beyond the structural and organizational arrangements of traditional health services. The policy response to mental health problems here implicates local and central players, community resources, the environment and individual action. Thus, the focus has moved to incorporate aspects of employment, social, community and voluntary organizations in the prevention and management of mental health problems. Within this scheme where service contact is needed, primary care is privileged over specialist mental health services. That is, the optimal service response is cast in settings which are as close as possible to the place where the genesis of mental health problems originate and are expressed. A final and further change is related to the way in which new technologies and information systems have changed the organization of psychiatry. The widespread availability of technology, together with the community location of the overwhelming majority of patients, has changed the face of how mental health services are organized and delivered. This change, in turn, is likely to dramatically alter the power relationships between providers and recipients of mental health services. The proliferation of the use of new forms of mental health services is likely to be reinforced by the cultural shift towards the acceptance of evidencebased health care discussed in Chapter 8. For example, telephone counselling for patients with ‘minor depression’ from a primary care base has been found to be both efficient and effective (Lynch, Tamburrino and Nagel 1997) as has undertaking a psychiatric assessment and diagnosis over the telephone (Kobak 1997). Remote treatment of depression by telepsychiatry has been shown to be as effective as face-to-face therapy (Ruskin et al. The ambiguous legitimacy that mental health care professionals hold in the eyes of users is reinforced by research which evaluates the outcomes of services organized along different lines. A randomized controlled trial compared faceto-face meetings with professionals and another group who used an electronic self-help computer programme in the form of a ‘voice bulletin board’. Clients were found to be eight times more likely to participate in the computerized programme and were more satisfied than the group receiving face-to-face contact (Alemi et al. Remote treatment of depression delivered by means of telepsychiatry and inperson treatment of depression were found to have comparable outcomes and equivalent levels of patient adherence, patient satisfaction and health care costs (Ruskin et al. Professionals’ use of computer packages and the fashion for ‘stepped’ and collaborative care takes mental health care out of any one organizational context and introduces new problems in terms of the surveillance and ‘follow up’ of patients.
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