Introduction

Two sources of ambiguity

The subject of this book is the functioning of community care and is mainly concerned with acute psychiatric illness. Ambiguities in this frame of reference require examination to understand the Daily Living Programme (DLP) study discussed below. Such ambiguities reflect universal difficulties in the classification of psychiatric illnesses and their treatments.

The first type of ambiguity concerns the term ‘acute’. Does ‘acute’ mean sudden onset, recent onset, marked severity or all three? Does it include sudden recent onset of severe obsessive-compulsive disorder which can cripple the patient and family as much and for as long as do psychotic disorders? Are we only considering schizophrenia and affective psychosis? Does ‘acute’ mean a first-ever crisis? Can it mean a new crisis in a chronic illness? Does it include the same patients when they are no longer in crisis? Similar ambiguities also appear if we use the term ‘severe mental illness’ (SMI) instead of ‘acute’ mental illness.

Meaningful comparisons across treatment studies require reasonable similarities across their patient samples. Creed's valuable contrast (Chapter 1) showed that in none of the DLP and four other studies presented in this volume did every patient have a diagnosis of schizophrenia or affective psychosis. Following entry to the study only 12% of the DLP patients turned out to have a non-psychotic diagnosis on the Present State Examination (PSE), in contrast to the far higher proportion in the other studies described in this volume. The DLP had a higher proportion of patients with schizophrenia (49%) than did any of the other studies.