APPENDIX 26
Memorandum by Dr F Nintan, Local Health
Partnership NHS Trust (MH 62)
ABILITY OF CARE IN THE COMMUNITY TO CATER
FOR PEOPLE WITH ACUTE MENTAL ILLNESS
SUMMARY
1. The treatment of acute schizophrenia is hampered
by the four-fold variation in prescription of atypicals.
2. NICE guidelines for community treatment
of schizophrenia will reduce inequality of health care provision.
3. The development of community services
in the form of Community Mental Health Teams/Day Hospitals/Crisis
Intervention Teams/Out of Hours Services/Assertive Outreach Teams
has meant that intensive community support can be given to patients
who are relapsing. This has resulted in a significant proportion
of patients avoiding the demoralising and stigmatising effect
of being admitted to an acute in-patient unit directly enhancing
their satisfaction with services and self-esteem. With regard
to patients with schizophrenia, treatment of these patients in
the community has been significantly enhanced in the past decade
by the introduction of the novel/atypical antipsychotic drugs
such as Clozapine, Olanzapine, etc. The advantages of these novel
antipsychotics is that (a) they are more effective than the old-fashioned
conventional drugs such as Haloperidol or Chlorpromazine, (b)
they have fewer side-effects.
4. The issue of reduced side-effects is
especially important for community treatment as drugs with high
levels of side-effects are much more likely to lead to non-compliance
and thus relapse of illness. In particular a patient's first experience
of drugs can significantly shape their future compliance emphasising
the need for low side-effect drugs. In the past it was common
to treat an acute relapse of schizophrenia with the old-fashioned
drugs because of their tranquillising and sedative effects, but
nowadays one can use atypicals in combination with short course
of benzodiazepines. This combination capitalises on the greater
effectiveness of these drugs combined with their lower side-effects
and yet controlling acute distress in the community. It is thus
of concern that the use of the atypicals varies significantly
across the country showing major inequality of health care provision.
5. Graph 1 is based on atypical and conventional
neuroleptic drug prescriptions in England from sixty three Health
Authorities. The percentage of atypical prescriptions compared
with the total antipsychotic prescriptions varies from just under
three per cent to 13 per cent representing over a four-fold variation.
Among Regions the average prescription rate is 7.76 per cent but
varies from 4.95 per cent to 10 per cent ie a two-fold variation.
6. Graph 2 looks at the prescription of
atypicals per head of population for atypical neuroleptics compared
with the index of deprivation known as the York Index. The prevalence
of schizophrenia is about 0.8 per cent in inner cities and about
0.2 per cent in rural areas and the rising trend of the graph
reflects the increasing use of neuroleptics in more deprived areas
which is to be expected. Looking at areas of similar deprivation
one sees that the variation in the prescription of these drugs
is two-fold. When looking at Graph 3 which shows the prescriptions
per head of population for atypical antipsychotics, it can be
seen a variation in prescription is four-fold.
CONCLUSION
7. The undoubted benefits of atypical antipsychotics
are not being seen on a consistent basis at local level. There
is clear variability in the provision of these drugs even in areas
of similar deprivation leading to inequality of healthcare. These
drugs are particularly effective in patients with the negative
features of schizophrenia which account for about three-quarters
of all cases. It can be argued that the ideal percentage of atypical
prescriptions against all antipsychotic medications should be
around the 70-80 per cent mark, making the current 3-13 per cent
variation worryingly low.
March 2000
| 
