Who needs their head examined?

Whenever people with mental illess commit violent crimes, care in the community is seen to have failed. But psychiatric patients can be treated without locking them up and throwing away the key, says Dr Raj Persaud

The life sentence handed down last week to Peter Bryan, a paranoid schizophrenic and "self-confessed cannibal" who killed two people while under the supervision of the mental health services, is the kind of high-profile case that reinforces the assumption that "care in the community" simply isn't working.

The life sentence handed down last week to Peter Bryan, a paranoid schizophrenic and "self-confessed cannibal" who killed two people while under the supervision of the mental health services, is the kind of high-profile case that reinforces the assumption that "care in the community" simply isn't working.

Judging from its widely signalled intention to introduce a much more restrictive Mental Health Act, the Government privately agrees. Even while care in the community was being introduced, many experts were convinced that closing psychiatric hospitals was not the right policy to pursue. When the closure of Claybury Hospital in Chigwell was announced in 1983, consultants at first defied the proposal to shut this large Victorian asylum and attempted to sabotage the closure by refusing to allow their patients to be assessed for possible discharge. This "strike" lasted six months but eventually buckled. Claybury put up the shutters in 1997 as resistance to asylum closure from psychiatrists elsewhere in Britain also collapsed.

Claybury is now a development of prestigious flats, which is incongruous given that one of the problems besetting community care is that the closure of long-term beds may have made many mental illness sufferers homeless. Of the 130 large psychiatric hospitals functioning in England and Wales in 1975, only around 14 now remain open, with fewer than 200 patients in each. Asylums like Claybury would have held a couple of thousand patients at their peak.

Alongside the psychiatric hospital closure programme in the 1980s, the number of homeless people in England doubled and has since remained at about 400,000, according to the homelessness charity Shelter. Whether all, or even the majority, of these new homeless people came out of asylums is the subject of much debate within psychiatry, but what isn't controversial is that community psychiatrists today have to try to look after a patient group of whom, in inner cities, 50 per cent might be homeless.

This has produced what community psychiatrists Dr Trevor Turner and Dr Stefan Priebe, who work at the Homerton Hospital in East London, recently described in the British Journal of Psychiatry as "a Gormenghast-like labyrinth, with voluntary agencies, privately run hostels and forensic units carefully trying to ward off all difficult comers [while] in the case of the latter, usually being full". They point out that the proportion of time spent on interface issues (such as meetings, letters and telephone conversations) rather than patient care is rising remorselessly as a result.

Priebe and Turner make the point that we have entered a "post-community care phase" in the treatment of the seriously mentally ill, when in fact care in the community has long been covertly abandoned. After all, whether you call a building a continuing care unit, a 24-hour nursing-staffed hostel or a medium-secure rehabilitation unit does not matter, since essentially you are reproducing the asylum. It's just that the architecture is no longer Victorian.

Maybe the real problem is not so much that community care failed, but rather that it was never properly tried in the first place, because to do so requires the kind of resources and conviction with which the NHS has never really backed psychiatry.

Waiting lists for medicine and surgery continue to grab headlines, whereas the same problems affecting psychiatric patients do not merit any exposure at all. The fact that mental health gets virtually no mention in the media, except of course when cannibalism becomes involved, is that governments experience little pressure to find solutions to the longer-term issue of providing proper care, rather than focusing more narrowly on protecting the public. The forensic psychiatrists Professor John Gunn and Professor Pamela Taylor of the Institute of Psychiatry point out that while there are an average of 40 high-profile murders by the mentally ill every year, the police record a total of 6-700 homicides over the same period, another 300 people are killed by dangerous, drunken or drugged drivers, and a further 3,500-4,000 die as a result of road traffic accidents.

Another forensic psychiatrist, Professor Jeremy Coid of St Bartholomew's Hospital in London, suggests that, because Britain has a relatively low murder rate, those carried out by the mentally disordered stand out more than in other countries and thus receive more media attention. This certainly fits with the priority given in Britain to examining each case in depth, contrasting with the USA, which has a substantially higher murder rate and where homicides by the mentally disordered receive little official study.

The way to protect the public is simply to provide better psychiatric care. This is the conclusion of Dr Eileen Munro and Dr Judith Rumgay from the Department of Social Policy at the London School of Economics, who recently published an in-depth study looking at all the recent inquiries into murders committed by the mentally ill in Britain. They point out that the defects in current NHS psychiatric care are often framed by the 40 homicides committed by the mentally disordered each year, while the 1,000 suicides among those recently in contact with mental health services over the same period are largely ignored by the media and NHS planners. It is this basic issue of poor care that might explain why inquiry inexorably follows inquiry, often with depressingly similar recommendations. A total of 40 inquiries figure in Munro and Rumgay's survey, with no apparent positive impact in the number of homicides by the mentally ill.

Perhaps this is because the violence itself is often not predictable. But often the relapse could have been forseen, and, with a reasonable standard of care, should have been. Only by providing such care can we prevent patients being released back into the community in such a disordered state.

The Norman Dunn inquiry provides a classic example of this. Dunn killed his mother in 1995 after being discharged into the community while under the care of the Newcastle and North Tyneside Health Authority, and the inquiry report states: "Two questions arise. The first is - could anyone have foreseen that Norman would have been so violent that he caused his mother to die? The answer, the inquiry is quite certain, must be no. The second, however, is - could this tragedy have been prevented? The answer, the inquiry is equally certain, must be yes, most definitely. Those who were professionally responsible and directly concerned in the care of Norman in the community had not noticed the deterioration observed by others. Had they done so, there is little doubt that he would have been admitted to hospital and the symptoms of his illness corrected. Norman would have been spared the further deterioration that occurred, his symptoms would have been more easily resolved, his family would have been spared the burden of coping with him in his ill state, and the attack on Mrs M would never have occurred."

The LSE study found that Dunn's mother and sister had attempted to raise their concerns about him at a case review meeting, but felt that they were not taken seriously. They became so upset that they left abruptly. "After a surprised silence," the reports says, "discussion resumed as if nothing had happened." It was decided that Dunn was coping with minimal support and should be discharged from supervision.

Munro and Rumgay conclude that more murders could be prevented by improving the response to patients who start to relapse, regardless of their assessed potential for violence. They claim that this is more effective than trying to identify high-risk patients and targeting resources on them.

According to the survey, improved risk assessment would have identified 11 of the 40 cases, and murders could have been prevented in nine of them. But it also states that 17 other deaths could have been avoided if professionals had responded more readily to signs that patients were relapsing, despite the fact that, on the occasion in question, they gave no clear signs that their illness would include violence.

Munro and Rumgay's findings reveal that those showing signs that they may be dangerous over a long period are only a subsection of those who are eventually violent. Even those fitting this category do not always show imminent signs that they are about to be aggressive; and there are a substantial group of people who display none of the accepted indicators of violence before committing homicide.

Concern for public safety has been taking political precedence over concern for the general welfare of those suffering from mental disorders. As a result, the relatively meagre resources available are focused on those patients that pose the greatest threat to the public. Munro and Rumgay's results suggest that if we want to see fewer headlines linking mental illness to extreme violence, the media has to put pressure on the Government to provide better general psychiatric care. This in turn can only happen when the press devotes more space to the perennial scandal of the generally poor quality of treatment available to the mentally ill, rather than displaying an interest in psychiatry only when lurid headlines involving cannibalism are involved.

The World Health Organisation recently calculated that mental disorders represent 11.6 per cent of disabilities worldwide. By contrast, cardiovascular disease causes 10.3 per cent of all disabilities, and cancer just 5.3 per cent. These figures fly in the face of the current preoccupations of Government and the press, which in turn raises the question of which of the players involved in these scandals really needs their head examined.

Dr Raj Persaud is Gresham professor for public understanding of psychiatry and a consultant psychiatrist at the Institute of Psychiatry in London. His best-selling book, 'The Motivated Mind', is now available from Bantam (£12.99)