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This chapter uses Goffman’s concept of total institutions in a comparative case study approach to explore the role of psychotropic drugs in the process of transinstitutionalization.

This chapter interprets psychotropic drug use across four institutionalized contexts in the United States: the active-duty U.S. military, nursing homes and long-term care facilities, state and federal prisons, and the child welfare system.

This chapter documents a major unintended consequence of transinstitutionalization – the questionable distribution of psychotropics among vulnerable populations. The patterns of psychotropic use we synthesize suggest that total institutions are engaging in ethically and medically questionable practices and that psychotropics are being used to serve the bureaucratic imperatives for social control in the era of transinstitutionalization.

Psychotropic prescribing practices require close surveillance and increased scrutiny in institutional settings in the United States. The flows of mentally ill people through a vast network of total institutions raises questions about the wisdom and unintended consequences of psychotropic distribution to vulnerable populations, despite health policy makers’ efforts regulating their distribution. Medical sociologists must examine trans-institutional power arrangements that converge around the mental health of vulnerable groups.

This is the first synthesis and interpretive review of psychotropic use patterns across institutional systems in the United States. This chapter will be of value to medical sociologists, mental health professionals and administrators, pharmacologists, health system pharmacists, and sociological theorists.

Formal recognition of the human rights of people living with mental health problems has greatly progressed. We must ask ourselves, however, to what extent the formal recognition of these rights has transformed the culture of psychiatric care and improved their quality of life. Gaining Autonomy & Medication Management (GAM) is an approach that strives to empower service users and providers and promotes the exercise of users’ rights by transforming their relationship with the central component of psychiatric treatment in community services: psychopharmacology. The purpose of this paper is to show how GAM highlights the issues surrounding the establishment of a culture of rights.

For this analysis qualitative data were collected in Brazil and in Quebec, Canada, through over 100 interviews done with people living with mental health issues and practitioners who participated in the different GAM implementation projects.

Issues, challenges and obstacles facing the instauration of a human rights culture in mental health services are presented. The profound changes that the understanding and exercise of users’ rights bring to the lives of individuals are supported by excerpts illustrating recurring issues, situations and common experiences that appear in the various contexts of the two different countries.

This is not a parallel study taking place into two countries. The methodologies used were different, and as a consequence the comparative power can be limited. However, the results reveal striking similarities.

There is scant research on human rights in mental health services in the community, and the issues surrounding the prescribing and follow-up of pharmacological treatment. The joint analysis of the researches in Brazil and in Canada, identified common challenges which are intertwined with the dominant approach of biomedical psychiatry.

The purpose of this paper is to compare the pharmacy services provided to people taking psychotropic and cardiovascular medications and examine the association between pharmacists’ attitudes towards mental illness and provision of pharmacy services. The paper also considers pharmacists’ opinions of the pharmaceutical care needs of people with mental illness including their physical health.

A survey instrument was sent by facsimile to a random sample of community pharmacists in England and Wales.

Community pharmacists had generally positive attitudes towards mental illness but provided significantly fewer pharmacy services (and were less comfortable providing them) to patients taking psychotropic medications than to patients taking cardiovascular medications. Awareness of the higher prevalence of physical health conditions among people with severe mental illness was not high. Provision of pharmacy services was associated with pharmacists’ attitudes towards mental illness and comfort providing pharmaceutical care. Other factors that may contribute to these disparities in service provision are discussed.

The study findings indicate the need for enhanced mental health education for pharmacy students to improve attitudes, knowledge and confidence in mental health and the inclusion of mental health in pharmacy advanced services.

Few studies have examined the relationship between attitudes towards mental illness and provision of pharmacy services. This was the first study to examine the attitudes of British community pharmacists towards mental illness.

The purpose of this paper is to examine two competing pharmacological models that have been used to understand how psychiatric drugs work: the disease-centred model and the drug-centred model. In addition, it explores the implications of these two models for mental health service users and the degree to which they are meaningfully involved in decisions about the use of psychiatric drugs.

The approach is a conceptual review and critical comparison of two pharmacological models used to understand the mode of action of psychiatric drugs. On the basis of this analysis, the paper also provides a critical examination, supported by the available literature, of the implications of these two models for service user involvement in mental health care.

The disease-centred model is associated with a tendency to view the use of psychiatric drugs as a technical matter that is to be determined by mental health professionals. In contrast, the drug-centred model emphasises the centrality of the individual experience of taking a psychiatric drug and implies a more equitable relationship between practitioners and mental health service users.

Although infrequently articulated, assumptions about how psychiatric drugs work have important consequences for service user involvement in mental health care. Critical consideration of these assumptions is an important aspect of seeking to maximise service user involvement in decisions about the use of psychiatric drugs as a response to their experience of mental distress.

The combination of heightened emphasis on risk and its management in mental health, the precautionary principle, the idea of genetic susceptibility, advances in screening technology, and the promise of preventive pharmaceutical intervention is highly potent, especially in a world in which preventive prescription of psychiatric medication has become routine. Psychiatric professionals are given the obligation of governing, and being governed, in the name of risk, and in a political and public sphere suffused by the dread of insecurity. But there are risks in seeking to govern risk in a biological age. In this paper Nikolas Rose argues that the public, politicians and professionals alike might do better to refuse the demands of risk, and learn to live with uncertainty.

The Czech Republic suffers many of the problems reported in other Central European and Eastern European countries with respect to the care, treatment and prevention of mental ill health. Most psychiatric care is provided in long‐stay hospitals and the transition to a community‐based service has yet to be made. Mental health services suffer from chronic under‐investment and there is a lack of mental health legislation protecting patients' rights and autonomy. The pressures of transition to a capitalist economy have brought their own problems, in the form of increased rates of addicitions, suicide, and other mental health problems related to social, policitical and economic instability, and there is a pressing need to address the position of mental health within public health services.

Although the sexuality of people with mental health problems raises important clinical, social and legal concerns, there is relatively little written about the subject, and it is clear that staff often feel confused and embarrassed when discussing these issues with colleagues, carers and service users. Staff are often unsure about how to balance service users' rights to live a full life (including the right to express themselves sexually) with the need to protect people considered to be vulnerable. Here, Richard Pacitti and Graham Thornicroft describe how Mind in Croydon made a film about sex, relationships and mental health to help explore these issues further.‘Those of us who have been diagnosed with major mental illness do not cease to be human beings by virtue of that diagnosis. Like all people we experience the need for love, companionship, solitude, and intimacy. Like all people we want to feel loved, valued, and desired by others.’ (Patricia E Deegan, 1999).‘Not having a relationship if you want one can be like that constant feeling of being hungry and not being fed.’ (Bill, contributor to Unspoken)

The purpose of this paper is to increase awareness of shared decision making, the initial aim of the study was to understand how psychiatrists-in-training defined themselves as unique among physicians with an eye on how professional identity might shape approach to care. The second aim was to use those definitions and descriptions related to professional identity and tailor a brief training module to promote awareness of the shared decision making model.

The authors do this by first conducting focus groups to ascertain how psychiatric residents characterize their professional identity and unique disciplinary characteristics. The authors then designed a brief training session that exploits the relationship between how they define themselves as physicians and how they approach clinical decision making with patients.

Three major themes that emerged from the focus group data: the central role of societal and treatment contexts in shaping their professional identity and approaches to care, a professional identity characterized by a great sense of pride, and a strong commitment to systematic decision-making processes in practice. While the assessment of the training module is preliminary and lacks rigor for any generalizability or statements of causality, responses likely affirm the training tailored around professional identity as a possible vehicle for effective exposure to the concept of shared decision making and served as a useful avenue for self-reflection about needed changes to more fully embrace the practice.

More inquiry may be needed into the association between trust, relationship longevity and power and paternalism, as a way to bring greater insight into the adoption of shared decision making. Future research will have to investigate whether or not including identity-related content is empirically connected to successful training on shared decision making. Likewise, future research should also look at the reciprocal impact of effectively using shared decision making on the affirmation of professional identity among psychiatrists, and indeed all who embrace patient-centered care.

This is the one of the first papers to investigate issues of professional identity among psychiatry residents, and also among the first papers to consider the relationship between professional identity and use of shared decision making.

The purpose of this paper is: first, to consider the reported problems in sexual function caused by psychotropic medication. Second, the complex undertaking of completing an assessment of sexual functioning. Third, the role of the pharmaceutical industry is explored. Finally, implications for future research and practice are suggested.

As a commentary this paper draws on the available literature to synthesise what is already known about the relationship between psychoactive substances and sexual functioning.

The limited literature and lack of research attention given to psychotropic induced sexual dysfunction limits our collective understanding of how many people are affected and in what way.

A greater focus on psychotropic induced sexual dysfunction is needed for people with a dual diagnosis. There has been an over reliance on single case studies and self-reporting. Large scale epidemiological investigation would help understand the extent and nature of the problem more fully. The demographic shift particularly in relation to an ageing population should be considered as psychotropic substances effect individuals in different ways as they grow older.

There is scope for workers to engage more fully in a conversation with clients about their experience of using psychotropic substances and how this has impacted their sexual functioning. The literature suggests that clients want to talk about this issue but staff are unwilling or unable to discuss the topic.

To the authors’ knowledge this is the first paper that draws on the available literature to explore the known and likely implications of psychotropic induced sexual dysfunction for this client group.

This review paper will look at internationally existing publications in the English language on mental health shared decision making (SDM) implementation of a variety of interventions, including different methodologies and research methods, age groups and countries. The purpose of this paper is to provide an overview of: process, degree and outcomes of implementation; barriers and facilitators; perspectives on implementation by different stakeholders; analysis of the process of implementation in mental health services through the lenses of the normalisation process theory (NPT).

Following a targeted literature search the data were analysed in order to provide an overview of methodologies and methods applied in the articles, as well as of the variables listed above. Three different types of information were included: a content analysis of key issues, reflective understanding coming out of participating in implementation of an SDM project in the form of two narratives written by two key participants in an SDM pilot project and an NPT analysis of the process of implementation.

Only a minority of mental health SDM research focuses on implementation in everyday practice. It is possible and often desirable to achieve SDM in mental health services; it requires a low level of technology, it can save time once routinized, and it is based on enhancing therapeutic alliance, as well as service users’ motivation. Implementation requires an explicit policy decision, a clear procedure, and regular adherence to the aims and methods of implementation by all participants. These necessary and sufficient conditions are rarely met, due to the different levels of commitment to SDM and its process by the different key stakeholders, as well as due to competing providers’ objectives and the time allocated to achieving them.

The review indicates both the need to take into account the complexity of SDM, as well as future strategies for enhancing its implementation in everyday mental health practice. Perhaps because applying SDM reflects a major cultural change in mental health practice, current value attached to SDM among clinicians and service managers would need to be more positive, prominent and enduring to enable a greater degree of implementation.