1 00:00:00,150 --> 00:00:07,980 Welcome to the Oxford Psychiatry Podcast series brought to you today by Daniel Maun, I'm an advance trainee at Oxford Deanery. 2 00:00:07,980 --> 00:00:15,780 Today I have Professor Tom Burns with me. He leads the social psychiatry group here at the Oxford University Department of Psychiatry. 3 00:00:15,780 --> 00:00:20,880 And I've actually been privileged to be involved with this over the past two or three years. 4 00:00:20,880 --> 00:00:27,000 He's here to talk to us today about his recently completed randomised control trial into community treatment orders. 5 00:00:27,000 --> 00:00:33,930 So hello, Tom. Hello, Dan. Thank you for joining us. Before we start, maybe we could go back a bit earlier. 6 00:00:33,930 --> 00:00:39,000 And and just for those who might not be familiar with social psychiatry, 7 00:00:39,000 --> 00:00:45,780 could you tell us a bit about what social psychiatry is or maybe what a social psychiatrist interests are? 8 00:00:45,780 --> 00:00:49,710 Yes, Social Security is hard to define, but very easy to recognise, 9 00:00:49,710 --> 00:00:56,460 essentially social psychologist or psychiatrist who are interested in people's relationships. 10 00:00:56,460 --> 00:01:02,070 That doesn't mean we are disinterested in the biochemistry and the physiology and genetics disorder order, 11 00:01:02,070 --> 00:01:07,740 but our primary interest is in how they react to the world around them. And that can be with their families. 12 00:01:07,740 --> 00:01:14,790 It can be with their communities. And in my case, it's particularly I'm interested in how they react with us as professional caregivers. 13 00:01:14,790 --> 00:01:20,670 Right. And in your recent editorial piece in the British Journal of Psychiatry, 14 00:01:20,670 --> 00:01:27,000 you argue that social psychiatry is not at the recognition or potentially the financial support it deserves. 15 00:01:27,000 --> 00:01:28,770 And it was a very interesting piece. 16 00:01:28,770 --> 00:01:37,260 And I just maybe like to ask you a bit more about the opportunities for developing social psychiatry as a as a discipline. 17 00:01:37,260 --> 00:01:43,350 Yes. What we what we wrote about in that editorial was actually slightly more, more, more dramatic than that. 18 00:01:43,350 --> 00:01:51,900 We argue two things. We thought that psychiatry is slowing down because it had begun to ignore the interpersonal dimension of our trade, our craft. 19 00:01:51,900 --> 00:01:59,970 If you want to call it that, because although the last 30 years have seen an enormous emphasis on pharmacology and biology, 20 00:01:59,970 --> 00:02:05,460 the reality is that psychiatry is a relationship based activity. 21 00:02:05,460 --> 00:02:12,480 All of our symptoms, all of our findings have to have social meaning attached to them, to it. 22 00:02:12,480 --> 00:02:19,200 So, for instance, if you show an MRI scan of somebody's brain lighting up when they're depressed, 23 00:02:19,200 --> 00:02:21,420 it's only meaningful if you can say they're depressed. 24 00:02:21,420 --> 00:02:28,080 And that actually requires a judgement about their relationship to themselves and their relationship to the world around them. 25 00:02:28,080 --> 00:02:36,150 Now, our thinking behind that editorial was that for all sorts of historical reasons, 26 00:02:36,150 --> 00:02:44,460 we've the pendulum has swung to a very scientific and often a very episodic 27 00:02:44,460 --> 00:02:50,100 interventionist approach to psychiatry and shields and interesting findings. 28 00:02:50,100 --> 00:02:53,910 But it hasn't really advanced the subject as much as we often think it has. 29 00:02:53,910 --> 00:03:01,980 And I believe was that ignoring the interpersonal and psychiatry has two two major problems with it. 30 00:03:01,980 --> 00:03:07,860 First of all, it misrepresents the subject and therefore it slows down what we can do in research. 31 00:03:07,860 --> 00:03:14,380 We ignore it. Our research questions are going to be limited and perhaps a little bit oversimplistic. 32 00:03:14,380 --> 00:03:23,070 But secondly, I think it actually impacts on recruitment into our profession, because if you're going to work in psychiatry, 33 00:03:23,070 --> 00:03:28,560 you have to be interested in people, people's narratives, their lives, their relationships. 34 00:03:28,560 --> 00:03:33,690 If you're not interested in that, the job would disappoint you. And I think we've seen that, 35 00:03:33,690 --> 00:03:41,880 that people who go into psychiatry thinking it's going to be just the same as neurology very quickly become disaffected and leave. 36 00:03:41,880 --> 00:03:52,620 And similarly, if we don't make clear the people of psychiatry is embedded in this very rewarding interpersonal interaction, 37 00:03:52,620 --> 00:03:56,250 then we may fail to connect the people who would otherwise flourish in it. 38 00:03:56,250 --> 00:04:01,200 So that's what we were concerned to say in the editorial. That was more important to us, I think, 39 00:04:01,200 --> 00:04:11,910 than to say we need more money invested in family interventions or or looking at how resilience is developed by people in their social networks. 40 00:04:11,910 --> 00:04:14,280 Although we think that sort of research is important, 41 00:04:14,280 --> 00:04:20,610 we were more interested in in identifying the degree to which ignoring the interpersonal or social 42 00:04:20,610 --> 00:04:26,370 aspects of psychiatry was skewing our understanding of it and limiting all of our activity, 43 00:04:26,370 --> 00:04:32,070 both research and clinical. Thus fantastically interesting, actually, Tom, 44 00:04:32,070 --> 00:04:40,350 to hear a little bit about not only a social psychiatry perspective on our current position in psychiatry, 45 00:04:40,350 --> 00:04:44,760 but also to have the historical understanding of the development of our profession at large. 46 00:04:44,760 --> 00:04:49,950 Yes, that's very interesting and maybe gives us a good background into beginning 47 00:04:49,950 --> 00:04:55,200 to talk about your your recent research or recent randomised control trial, 48 00:04:55,200 --> 00:05:00,050 which is looking specifically into one recent developed. 49 00:05:00,050 --> 00:05:09,580 In mental health law, this happened recently, community treatment orders, so maybe we can get back to that topic and talk about that. 50 00:05:09,580 --> 00:05:16,510 So what you know, let's start with talking about what community treatment orders are, 51 00:05:16,510 --> 00:05:21,610 because I'm sure there are a lot of people who are listening to this who aren't quite familiar with that term. 52 00:05:21,610 --> 00:05:29,920 The country has always had the provision to compel treatment on patients against their wishes, but that has always been restricted inpatient care. 53 00:05:29,920 --> 00:05:36,100 Traditionally, as psychiatrists moved out of mental hospitals the last 30 or 40 years across the world, 54 00:05:36,100 --> 00:05:41,320 people have begun to recognise that if coercion and compulsion was sometimes necessary in hospital, 55 00:05:41,320 --> 00:05:46,090 it might be necessary to help people comply with treatment outside hospital. 56 00:05:46,090 --> 00:05:50,410 So there are many legislations, over 30 legislations. 57 00:05:50,410 --> 00:05:54,130 We've had the introduction of some form of community treatment order, 58 00:05:54,130 --> 00:06:04,120 and in the UK it was introduced by changing the 1983 Mental Health Act, an amendment in 2007 which became active in 2008. 59 00:06:04,120 --> 00:06:14,950 And what that said was that patients who were currently detained in hospital against their will for treatment and using Section three could, 60 00:06:14,950 --> 00:06:21,250 if their clinical team felt they were great risk of rapid relapse and could not comply with treatment, 61 00:06:21,250 --> 00:06:26,470 could put them on what was called a community treatment order and a community treatment order, 62 00:06:26,470 --> 00:06:32,440 which lasts for six months in the first instance, but can be renewed and indeed can be renewed indefinitely. 63 00:06:32,440 --> 00:06:37,540 And gave could allow you to insist on two things for the patient. 64 00:06:37,540 --> 00:06:44,860 One is that they should maintain contact with the team, and two, that they should agree to take their medication. 65 00:06:44,860 --> 00:06:52,390 And the power that lay behind the community treatment order was that if the patient failed to do either of these two things, 66 00:06:52,390 --> 00:07:00,910 they could be brought back to hospital for review of their condition without any further legalistic processes. 67 00:07:00,910 --> 00:07:12,520 No need to call social workers and do the U.S. forms out if in those 72 hours that they were called, they continued to refuse to take that treatment? 68 00:07:12,520 --> 00:07:16,270 You can make a decision either to accept that and let them go. 69 00:07:16,270 --> 00:07:21,190 Or if you thought they really needed compulsory treatment, you could reinstate their Section three. 70 00:07:21,190 --> 00:07:28,510 So it allowed you to oblige a patient to keep contact with you and to take a treatment. 71 00:07:28,510 --> 00:07:36,820 What it does not allow and in no in no jurisdiction in the world does it allow is for forcible treatment outside the hospital. 72 00:07:36,820 --> 00:07:39,940 Therefore, if a patient says, no, I won't take the medication, 73 00:07:39,940 --> 00:07:47,230 it usually depo medication long acting antipsychotics because this is almost exclusively restricted to psychotic patients. 74 00:07:47,230 --> 00:07:54,560 You can't grab hold of them in their own home and inject them, but you can have them go back to hospital. 75 00:07:54,560 --> 00:08:01,510 That may involve the police sometimes and then in hospital only if they go back on to Section three can force be used. 76 00:08:01,510 --> 00:08:08,350 So that was the legislation that got passed. It had been argued about for over 20 years. 77 00:08:08,350 --> 00:08:13,750 It's always controversial and rightly so, because I think that for most people, 78 00:08:13,750 --> 00:08:20,740 compulsion in somebody who's so unwell, they need 24 hour nursing, has a certain natural justice to it. 79 00:08:20,740 --> 00:08:28,760 But there's a real understandable concern that if somebody is well enough to survive outside hospital, why should they be compelled to do something? 80 00:08:28,760 --> 00:08:33,760 And why can't they just make a mess of their lives, just as you and I make a mess of our lives? 81 00:08:33,760 --> 00:08:43,780 Now, the argument against that has been twofold. One is that we know we have overwhelming evidence that if patients, particularly schizophrenia, 82 00:08:43,780 --> 00:08:48,160 stay on their maintenance medication, their lives are vastly better. 83 00:08:48,160 --> 00:08:58,720 Stay in a hospital. They have less stigmatising compulsive admissions, etc. So there's good reason to want to keep them on their medication. 84 00:08:58,720 --> 00:09:06,010 So that that was really and there was also perhaps we have psychiatrists would not take it seriously, but the government took it seriously. 85 00:09:06,010 --> 00:09:12,040 And I was the psychiatric adviser for the government's committee on this, and it was quite interesting to watch their thinking. 86 00:09:12,040 --> 00:09:17,890 There were two other reasons they wanted to here. The most important was to keep patient on the on the medication, keep them, 87 00:09:17,890 --> 00:09:24,190 while the other was to restore some flagging faith in the public and mental health services. 88 00:09:24,190 --> 00:09:32,410 Because every high profile scandal of a patient who's known was known to be a risk no knew, 89 00:09:32,410 --> 00:09:38,860 but not taking their treatment makes us look really quite questionable in the public's eyes. 90 00:09:38,860 --> 00:09:44,470 And the other reason they wanted it, because it gave them sensible monitoring of what was going on, 91 00:09:44,470 --> 00:09:54,170 because the old system was allowing all sorts of tricks to to compel people which weren't legally registered. 92 00:09:54,170 --> 00:09:59,970 That's a really good comprehensive answer, actually, and it helps us understand what. 93 00:09:59,970 --> 00:10:06,510 The different while the different arguments for seats from different from different corners of our country, 94 00:10:06,510 --> 00:10:10,870 both in the psychiatric community and the government. 95 00:10:10,870 --> 00:10:16,440 So when do they come into effect? Well, they came into effect in November 2008. 96 00:10:16,440 --> 00:10:23,070 Interestingly, they came into effect earlier in Scotland when they were told by England and Wales they came into effect in November 2008. 97 00:10:23,070 --> 00:10:33,180 And we had obtained funding from our random control trial prior to them becoming active legislatively. 98 00:10:33,180 --> 00:10:36,690 And there's a reason for that, that I've been down to Australia and New Zealand. 99 00:10:36,690 --> 00:10:45,510 And it became clear to me that once Kyozo introduced, psychiatrists become extremely wedded to them very quickly. 100 00:10:45,510 --> 00:10:54,510 And to conduct a random drug trial, you have to have an acknowledged doubt about the effectiveness of the treatment. 101 00:10:54,510 --> 00:11:00,960 You have to have some degree of clinical equipoise. Otherwise people won't submit patients to the trial. 102 00:11:00,960 --> 00:11:06,390 And it seemed clear to me that if you leave it a year or two, we might lose that window of opportunity. 103 00:11:06,390 --> 00:11:12,930 So we decided to have our trial as soon as the law was passed as a possible. 104 00:11:12,930 --> 00:11:17,610 I'm just a sort of subquestion on onto your answer there. 105 00:11:17,610 --> 00:11:25,620 Have they indeed been taken up as expected by clinicians and been accepted in that way that they did in Victoria, in Australia? 106 00:11:25,620 --> 00:11:27,810 Well, there have undoubtedly been taken up by clinicians. 107 00:11:27,810 --> 00:11:36,690 And you've done some work with Andrew Linsky, which shows that clinicians attitudes to Kyoto are now much more positive than they were five years ago, 108 00:11:36,690 --> 00:11:40,890 not quite as positive as New Zealand's characters have been used in for 10 years. 109 00:11:40,890 --> 00:11:43,440 So attitudes change very quickly, 110 00:11:43,440 --> 00:11:52,470 and the uptake of them has been about the level that we would expect from within looking at international literature. 111 00:11:52,470 --> 00:11:59,910 The government came up with a very bizarre figure of 400 a year, but that was nothing to do with the clinically predicted level. 112 00:11:59,910 --> 00:12:04,690 And I think actually the uptake is about what we would expect not as high as Victoria. 113 00:12:04,690 --> 00:12:16,110 Victoria is the world leader on Kyoto, and it's a sobering fact that every 1000 individual in Victoria is on almost kto at every of patient, 114 00:12:16,110 --> 00:12:19,950 not even every thousands adult, every thousand person. 115 00:12:19,950 --> 00:12:26,400 I don't think we're anywhere near that. I hope we won't get that. Yes. Yes, that's interesting. 116 00:12:26,400 --> 00:12:30,840 So let's move on to talking about your particular trial. 117 00:12:30,840 --> 00:12:42,030 So maybe you could just outline what what the the the time course was and the methods and and how you went about the trial octet is a very standard, 118 00:12:42,030 --> 00:12:51,900 rigorous, randomised controlled trial. Patients were randomly allocated between either going on to CTO or not going on to sit here. 119 00:12:51,900 --> 00:12:58,800 And they were followed up for a year. And before we start the trial, we submitted our protocols, The Lancet, 120 00:12:58,800 --> 00:13:08,270 and we had a clear decision that the primary outcome would be the proportion of patients readmitted to hospital over those 12 months of follow up. 121 00:13:08,270 --> 00:13:13,440 So that's a good outcome measure because it reflects relapse and we were hoping to reduce relapse. 122 00:13:13,440 --> 00:13:17,900 And that's the explicit purpose of KIOS in nearly every jurisdiction. 123 00:13:17,900 --> 00:13:24,480 And so it was one to one randomised controlled trial, bit of stratification for age, 124 00:13:24,480 --> 00:13:32,040 gender and duration of illness, but basically had to be randomly allocated to either care or not for care. 125 00:13:32,040 --> 00:13:42,650 Now, because of legal and ethical reasons, we had to construe that randomisation as between CTO and Section 17 leave. 126 00:13:42,650 --> 00:13:47,970 But in practise, Section 17 was what was being done anyway. 127 00:13:47,970 --> 00:13:54,330 And actually many of the people who were being considered for CTO already on Section 17, and that's confused a few people. 128 00:13:54,330 --> 00:13:59,460 Essentially, this is a trial of CTO that is not clear. 129 00:13:59,460 --> 00:14:04,590 And now we say our primary outcome was proportionally admitted. 130 00:14:04,590 --> 00:14:09,780 And that's because the only two previous trials also have that was their outcome measure. 131 00:14:09,780 --> 00:14:18,420 And also it was executed for and we wanted the patients to arms as much as possible 132 00:14:18,420 --> 00:14:24,180 to be treated similarly so we could test and isolate the effect of the KTO itself. 133 00:14:24,180 --> 00:14:29,430 So we encouraged him to try and offer the same level of clinical support to both arms. 134 00:14:29,430 --> 00:14:36,720 And we encourage them to aim for contact about once a week and at least once a fortnight over randomisation took place. 135 00:14:36,720 --> 00:14:44,730 It was across 32 trusts south of England, and it wasn't every consultant in any given trust. 136 00:14:44,730 --> 00:14:49,650 It was consultants who were prepared to convince their teams to take part because that 137 00:14:49,650 --> 00:14:56,910 was a major hurdle and could accept that there is a legitimate area of uncertainty here. 138 00:14:56,910 --> 00:15:00,930 So, no, every consultative part, these are essentially, I would think, 139 00:15:00,930 --> 00:15:09,810 a slightly better educated consultant were aware of the state of the evidence and know that we don't know, randomly allocated. 140 00:15:09,810 --> 00:15:13,080 And after that, we had no information whatsoever. 141 00:15:13,080 --> 00:15:20,070 So it was a very nail-biting time, frankly, because we didn't know, first of all, whether people would do what they said they would do. 142 00:15:20,070 --> 00:15:25,440 We didn't know whether some of them were keep on Section 17, leave for months, which they're not supposed to do. 143 00:15:25,440 --> 00:15:27,390 But you don't know. 144 00:15:27,390 --> 00:15:35,670 We didn't know whether the randomisation worked perfectly and we didn't know whether the treatments offered were going to be very different. 145 00:15:35,670 --> 00:15:40,200 And all of those could have made interpreting the results very complex. 146 00:15:40,200 --> 00:15:47,700 When we got the results. It seems simpler. First of all, the randomisation did work to groups exactly the same. 147 00:15:47,700 --> 00:15:52,740 Secondly, people did not abuse Section 17, leave a median of eight days. 148 00:15:52,740 --> 00:16:02,910 So as opposed to six months on a CTO. And thirdly, the treatment offered to be fairly comparable, about two and a half to three contacts a month. 149 00:16:02,910 --> 00:16:05,010 So they were both all about the same. 150 00:16:05,010 --> 00:16:12,190 So we knew that when we actually looked at our outcome measures, which was readmission rates and time to readmission. 151 00:16:12,190 --> 00:16:21,880 We could rule fairly confident conclusions are any differences were due to the Q because everything else was about say, shall I tell you the results? 152 00:16:21,880 --> 00:16:28,150 Well, just for those people who don't know what Section 17 leave is, OK, given that it's sort of the comparative arm, 153 00:16:28,150 --> 00:16:33,220 even though maybe the median duration was only eight days and Section 17 leave it such to 17, 154 00:16:33,220 --> 00:16:44,950 leave is a condition that the clinicians can give people leave if they are under detention and the Mental Health Act for a given period of time. 155 00:16:44,950 --> 00:16:54,040 And it's usually used when patients are getting to the end of their inpatient stay to allow them a bit of time in the community to see how it goes. 156 00:16:54,040 --> 00:17:03,760 And that usually ends pretty briefly, pretty quickly. And they go to being not under detention under the Mental Health Act, Section 17 leave it. 157 00:17:03,760 --> 00:17:07,570 Is that it's a comparative arm. Yes. Can you tell us about the results? 158 00:17:07,570 --> 00:17:12,490 That would be great. Well, the results were a bit of a shock, frankly. 159 00:17:12,490 --> 00:17:19,260 Her real worry was that either that, you know, that we haven't seen the results. 160 00:17:19,260 --> 00:17:24,360 A bit of shock with the other anxiety we had was that we get a massive result 161 00:17:24,360 --> 00:17:28,150 from the difference between statistical significance and clinical significance. 162 00:17:28,150 --> 00:17:34,090 Might be quite a tricky question, but actually, in the end, there is no tricky question. 163 00:17:34,090 --> 00:17:38,710 Our results are that there's not a flicker of difference between the two groups. 164 00:17:38,710 --> 00:17:46,660 Over the course of a year, 36 percent of patients were readmitted in both groups, not only with the same proportion readmitted. 165 00:17:46,660 --> 00:17:52,750 When we looked at trying to make sure we did a survival curve, there's no distinction whatsoever between that. 166 00:17:52,750 --> 00:17:56,920 So the rate of readmission hasn't changed. 167 00:17:56,920 --> 00:18:06,010 So the number of readmitted, the proportion and the time to readmissions, exactly the same two groups despite six months of extra caution. 168 00:18:06,010 --> 00:18:15,160 Now, although it isn't statistically significant, the duration of hospitalisation is a bit lower in patients. 169 00:18:15,160 --> 00:18:23,340 And that reflects all the international findings that usually people on KIOS stay in hospital a bit shorter. 170 00:18:23,340 --> 00:18:31,240 Of course, that's a measure of clinical clinician behaviour, not a patient wellbeing, but presumably that the same illnesses, the same relapse. 171 00:18:31,240 --> 00:18:37,840 But clearly people feel more confident in discharge early on if you're in the queue. 172 00:18:37,840 --> 00:18:40,750 But in terms of the patient outcomes, 173 00:18:40,750 --> 00:18:51,340 the number who relapsed have the time to relapse and indeed the clinical and social measures he used beepers and gaf not a flicker of difference. 174 00:18:51,340 --> 00:18:57,190 Now, the trial isn't perfect. No concrete is ever perfect. 175 00:18:57,190 --> 00:19:05,560 Let me tell you what the limitations of our time are, although I don't think they detract from such so overwhelmingly clear result. 176 00:19:05,560 --> 00:19:09,910 The first is we don't know what the potential denominator was. 177 00:19:09,910 --> 00:19:13,920 We don't know how many patients were being considered in different trusts who could have gone in. 178 00:19:13,920 --> 00:19:16,180 We can't say anything about that. 179 00:19:16,180 --> 00:19:30,640 Secondly, a lot of people didn't follow the the the proposed randomisation practises about 20 to 25 per cent, didn't get what they should have got. 180 00:19:30,640 --> 00:19:39,280 About 20 percent of people randomised to CTO didn't get onto see, perhaps because their condition improved when that was being considered. 181 00:19:39,280 --> 00:19:50,410 But more more upset. Disturbingly, about 20 percent of people allocated to Section 17, they were put on a queue despite the agreement. 182 00:19:50,410 --> 00:19:54,970 And there was a small number of patients, 13 overall, who never got out of hospital at all. 183 00:19:54,970 --> 00:20:01,090 And they always find that if you're looking at such a new group, luckily that was equally distributed. 184 00:20:01,090 --> 00:20:04,520 So we did what's called a per protocol analysis. 185 00:20:04,520 --> 00:20:11,440 You take out those who aren't treated in the way that they should be and that still doesn't find a difference. 186 00:20:11,440 --> 00:20:15,850 But it is an important limitation to the study, frankly. 187 00:20:15,850 --> 00:20:21,430 So that's quite surprising result perhaps, that they were so the two groups were so, 188 00:20:21,430 --> 00:20:27,910 so similar, given the addition of the CTO or the community treatment order. 189 00:20:27,910 --> 00:20:33,460 You've told us a little bit. Well, you told us that you were shocked actually at the results initially. 190 00:20:33,460 --> 00:20:37,810 How have your thoughts developed about community treatment orders in light of these results? 191 00:20:37,810 --> 00:20:44,260 What do you what do you think about the intervention now, having been the government advisor in that in that creation? 192 00:20:44,260 --> 00:20:49,330 Well, I've been an advocate of community. In the early 1990s. 193 00:20:49,330 --> 00:20:56,300 I was on the college's first committee on it. And so I'm very guilty party here, as I've always been very keen on them. 194 00:20:56,300 --> 00:21:01,090 They seem to make sense to me for the reasons we discussed earlier. 195 00:21:01,090 --> 00:21:05,440 And of course, if you do a trial like this for three or four years, you become identified with them. 196 00:21:05,440 --> 00:21:11,790 And I think that of unconsciously we drifted to being from being scientists, being an. 197 00:21:11,790 --> 00:21:15,240 Spoke to some extent. So what a shock. There's no question about that. 198 00:21:15,240 --> 00:21:23,520 It was a real shock and they had to take a deep breath and sit back and hope that I've given some thought that the 199 00:21:23,520 --> 00:21:30,510 first thing to to remind ourselves is it shouldn't have been shelved the beento previous randomised controlled trials. 200 00:21:30,510 --> 00:21:36,000 And they found exactly the same. OK, I thought it might be different here, but it wasn't. 201 00:21:36,000 --> 00:21:45,330 So it's actually not completely out of the blue. I've given a lot and I think it brings us back to what we discussed at the beginning. 202 00:21:45,330 --> 00:21:53,020 My conclusion from it really are that it's reaffirmed my faith in the central aspect of what we do in mental health practise. 203 00:21:53,020 --> 00:22:00,960 Our job is developing skills in understanding and working with very disturbed and troubled individuals. 204 00:22:00,960 --> 00:22:09,870 And the quality of our work is based on that ability to engage with persuade, encourage, 205 00:22:09,870 --> 00:22:14,880 support very ill people to comply with treatment which have some real downsides for them. 206 00:22:14,880 --> 00:22:18,390 We think in the long term it will help them. 207 00:22:18,390 --> 00:22:26,760 So essentially, I think I've had my belief that the carrot is better than the stick reaffirmed. 208 00:22:26,760 --> 00:22:39,150 I think in mental health we really ought to be putting more and more of our energy into building sustainable and durable therapeutic relationships. 209 00:22:39,150 --> 00:22:48,090 Do you think that the about the community treatment order could be improved by a review of the legislation? 210 00:22:48,090 --> 00:22:51,210 In truth, I don't think changing the legislation will make a difference. 211 00:22:51,210 --> 00:22:57,000 We didn't see any suggestion of any subgroup or any particular practise that made active work. 212 00:22:57,000 --> 00:23:01,050 So I just just genuinely think they don't work. 213 00:23:01,050 --> 00:23:06,690 Now, comments on our study have come from forensic psychiatrist who say that their 214 00:23:06,690 --> 00:23:11,580 patient may respond better to KIOS because they're used to being told what to do. 215 00:23:11,580 --> 00:23:17,730 They're used to restrictions. They're used to the legal consequences of not doing what they're asked. 216 00:23:17,730 --> 00:23:22,770 And simply some old age psychiatrists have commented that the the older generation 217 00:23:22,770 --> 00:23:27,870 a bit more law abiding and take take for the majesty of the law more seriously. 218 00:23:27,870 --> 00:23:32,970 And I think we have to take that seriously. Wiedner, we didn't test either of those groups in our study. 219 00:23:32,970 --> 00:23:39,330 And I guess the a contention and ethical contention to community treatment orders is that given the overwhelming 220 00:23:39,330 --> 00:23:45,600 evidence that they don't necessarily make any improvements in admission rates or time to admission, 221 00:23:45,600 --> 00:23:53,100 there has to be held against the the fact that they're being patients being held under detention for longer periods of time. 222 00:23:53,100 --> 00:23:59,790 Yeah, I think our study bear in mind, I studied only four people up for 12 months and the average time, 223 00:23:59,790 --> 00:24:08,070 the median time on a street year was six months. And that means that half the patients had their queue renewed. 224 00:24:08,070 --> 00:24:15,150 My guess is that if we followed these patients up in three years time, which we're doing, by the way, we'll find that those six years, 225 00:24:15,150 --> 00:24:24,240 the average time of which duration, the average duration of coercion, losing their freedom will be perhaps even years. 226 00:24:24,240 --> 00:24:30,120 So so we've underestimated the loss of individual liberty and freedom. 227 00:24:30,120 --> 00:24:34,980 That's very that's very helpful to talk through the the pros and cons and the 228 00:24:34,980 --> 00:24:40,320 different opinions that continue despite the outcomes of your your trial, 229 00:24:40,320 --> 00:24:44,850 at least the the the primary outcome data from your trial. 230 00:24:44,850 --> 00:24:52,080 Let me tell you, one of the most dismaying things about presenting this evidence is the number of psychiatrists who said to me, 231 00:24:52,080 --> 00:24:58,350 very interesting results. But, you know, I've seen with my own eyes close work. 232 00:24:58,350 --> 00:25:04,020 Now you can't see with your own eyes that are probabilistic outcome, 233 00:25:04,020 --> 00:25:08,860 i.e. the difference being 40 percent admission and 60 percent admission over one two years. 234 00:25:08,860 --> 00:25:20,130 You cannot see that with your own eyes. And psychiatry has a really quite a bad record in continuing with treatment because we hope they work. 235 00:25:20,130 --> 00:25:26,070 And I've been disappointed at the reluctance to accept disappointing that these results may be to some of us. 236 00:25:26,070 --> 00:25:32,340 They were, to me, a reluctance to accept that the facts are fairly clear cut. 237 00:25:32,340 --> 00:25:37,820 They do not appear to achieve what they were meant to achieve. Thank you. 238 00:25:37,820 --> 00:25:43,140 So a real argument for evidence based practise in psychiatry given given these results, 239 00:25:43,140 --> 00:25:48,780 which incidentally, are published in The Lancet in March of this year. 240 00:25:48,780 --> 00:25:54,300 So thank you, Tom. It's been a really interesting talk, not only about community treatment orders, 241 00:25:54,300 --> 00:26:03,240 but maybe some more in-depth sort of analysis of our profession and and and how we should operate as clinicians. 242 00:26:03,240 --> 00:26:11,680 I just want to finish with maybe a slightly lighter note. I'm very aware that you have published a book. 243 00:26:11,680 --> 00:26:17,640 Unnecessary châteaux recently, and I wonder whether you could just tell us about this briefly. 244 00:26:17,640 --> 00:26:25,770 Delighted to tell you about the book, Rush out and buy it. This is a book describing psychiatry for non psychiatrists, if you want. 245 00:26:25,770 --> 00:26:28,800 And that's what got me to write this book, 246 00:26:28,800 --> 00:26:38,580 was that I became impatient and I really got tired of many of the books which were written about psychiatry in which straw men were put up. 247 00:26:38,580 --> 00:26:46,200 So suddenly, Rich and Bentall would say, all psychiatrists believe that all disorders are genetic. 248 00:26:46,200 --> 00:26:52,590 Now, you and I know no psychiatrist believe that nobody believes anorexia nervosa is genetic. 249 00:26:52,590 --> 00:26:59,540 Right. Nor do we believe that you can't have a diagnosis that's meaningful unless you can find a physical marker for it. 250 00:26:59,540 --> 00:27:04,890 It was absolute nonsense. It was surrounded by misrepresentation of our profession. 251 00:27:04,890 --> 00:27:13,440 So I really wanted to write a book that described our profession, warts and all, and so that people, 252 00:27:13,440 --> 00:27:19,950 when they read these critiques of our profession, could actually put it in perspective and perhaps understand why, 253 00:27:19,950 --> 00:27:26,670 because we operate in this very rapidly shifting area of social consensus, 254 00:27:26,670 --> 00:27:31,890 we are perhaps more vulnerable than other branches of medicine to make mistakes and we will make mistakes. 255 00:27:31,890 --> 00:27:37,560 But there are often honourable mistakes and we should not be too ashamed of it. 256 00:27:37,560 --> 00:27:39,660 But we need to explain to people what we do. 257 00:27:39,660 --> 00:27:46,380 And there hasn't been a book that simply set out to explain psychiatry rather than to defend one arm from the other, 258 00:27:46,380 --> 00:27:51,000 as it were, for a decade or know for a generation at random. 259 00:27:51,000 --> 00:27:57,030 To get a proper understanding of psychiatry, I think you have to understand its history. It has a short, easily definable history. 260 00:27:57,030 --> 00:28:01,290 200 years ago it started and it has two aspects of history. 261 00:28:01,290 --> 00:28:04,560 One is the medical model. One is well, well known, 262 00:28:04,560 --> 00:28:12,720 which is the development of asylums and the classification of psychosis which has given rise to what we often think of as the medical model. 263 00:28:12,720 --> 00:28:18,990 But the other equally important started around the same time was the whole issue of depth 264 00:28:18,990 --> 00:28:24,300 psychology and how we understood troubled individuals and what that got them there, 265 00:28:24,300 --> 00:28:33,570 the experiences meant to them and to those around them. Both those strands have continued to play a part in psychiatry up into our present time. 266 00:28:33,570 --> 00:28:36,690 So what I did in the book really was outline that history, 267 00:28:36,690 --> 00:28:44,280 outlined how it continues to invent all the controversies that we struggle with in psychiatry at the moment. 268 00:28:44,280 --> 00:28:53,670 And I hope that it will give people who read it. I respect the difficulty of our job without tending to gloss over the things that we have got wrong. 269 00:28:53,670 --> 00:28:57,150 And we certainly have got something quite seriously wrong. 270 00:28:57,150 --> 00:29:04,100 So an honest account of psychiatry, both historically and this and how we see it operating today. 271 00:29:04,100 --> 00:29:10,350 There is a lot of psychiatry around it, particularly with the of coming out of DSM five. 272 00:29:10,350 --> 00:29:19,140 And it's it's I mean, I find it personally very interesting how developments in psychiatric practise bring forth this wave of psychiatry. 273 00:29:19,140 --> 00:29:25,880 And it'll be very helpful to have your book there as a as a proponent of psychiatry and it's in its current form. 274 00:29:25,880 --> 00:29:30,060 And so having said that, I am not defending DSM five at all. 275 00:29:30,060 --> 00:29:34,260 I think it is a disaster for our profession, as was DSM three and four. 276 00:29:34,260 --> 00:29:41,850 And I think it was precisely a failure to respect and grasp the process of making diagnoses, 277 00:29:41,850 --> 00:29:52,260 because the process of making diagnosis in psychiatry always requires a degree of entering into a patient's subjective life and death. 278 00:29:52,260 --> 00:29:57,750 And three onwards ignored that. Now the reality is that most of us still do it, thank God. 279 00:29:57,750 --> 00:30:07,470 But this this attempt to suggest that it's simply like taking a picture is misleading and nothing long term, potentially destructive. 280 00:30:07,470 --> 00:30:11,250 And I think we will reject it and move back to a more commonsensical position. 281 00:30:11,250 --> 00:30:15,300 Eventually we could go on and talk about this. Very interesting. 282 00:30:15,300 --> 00:30:20,280 But, Tom, thank you very much for actually very enlightening discussion. 283 00:30:20,280 --> 00:30:28,530 And we look forward to hearing the new about the other outcomes from OCTETS and its extension as well. 284 00:30:28,530 --> 00:30:37,130 So thank you, Tom. And I hope you tune into other podcasts found on the Oxford University Psychiatry podcast series page. 285 00:30:37,130 --> 00:30:38,616 Thank you.