Health Services Research Department, Institute of Psychiatry, Kings College London, UK
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Correspondence: Professor GrahamThornicroft, Health Service Research Department, Institute of Psychiatry, Kings College London, De Crespigny Park, London SE5 8AF, UK. Tel: +44 (0)207 848 0735; fax: +44 (0)207 277 1462; e-mail: g.thornicroft{at}iop.kcl.ac.uk
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ABSTRACT |
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Aims To provide an evidence base for this debate, and present a stepped care model.
Method Cochrane systematic reviews and other reviews were summarised.
Results The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation.
Conclusions Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.
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INTRODUCTION |
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Historically, the response of the mental health services can be seen in three periods: the rise of the asylum, the decline of the asylum and the reform of mental health services (Wing & Brown, 1970; Grob, 1991; Desjarlais et al, 1995; Thornicroft & Tansella, 1999). In the third period, community-based and hospital-based services commonly aim to provide treatment and care that are close to home, including acute hospital-care and long-term residential facilities in the community; respond to disabilities as well as to symptoms; are able to offer treatment and care specific to the diagnosis and needs of each individual; are consistent with international conventions on human rights; are related to the priorities of service users themselves; are coordinated between mental health professions and agencies; and are mobile rather than static. We have described this as the balanced care approach (Thornicroft & Tansella, 2002).
This paper summarises and extends a review prepared for the Health Evidence Network of the World Health Organization European Regional Office (WHOEURO) (Thornicroft & Tansella, 2003). The Health Evidence Network is an information service initiated and coordinated by WHOEURO which provides the best evidence available in the field of public health (http://www.who.dk/hen). Working with over 30 partner organisations, it aims to deliver timely information to health care decision-makers in the WHO European Region by providing summaries from a wide range of existing sources, including websites, databases, documents, national and international organisations and institutions. It comprises two services: answers to questions to support the decision-making process, and ready access to sources of evidence such as databases, documents and networks of experts.
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METHOD |
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The recent growth of mental health services research has provided substantial evidence in relation to these questions, but few attempts have been made to review these results as a whole and to put them in a resource context so that they are usable for the planning and provision of services at national and regional levels. The aim of this review is therefore to summarise such evidence, and to propose a stepped care model that contextualises the relevance of this evidence to areas at different stages of economic development. It refers to mental health services for adults of working age, and does not directly address other important groups, such as children, older people or those whose primary problem is drug or alcohol misuse. We appreciate, however, that for regions with fewer resources, where the majority of service provision is at the primary care level, these distinctions may be less relevant.
The procedure used was that first we searched Medline for the period 1980 to April 2003, using the search terms MENTAL and COMMUNITY and HOSPITAL (3177 records were extracted). Only English-language articles were examined to include those relevant journals with higher impact factors (1810 records); of these 141 were review articles, which were considered in preparing this paper. In addition, the authors searched the Cochrane Library and included other relevant systematic reviews. This procedure allowed us to summarise the evidence for distinct service components, and to recommend three particular blends of these components as suitable for areas with low, medium and high level of resources, as a contribution to the debate about resource-appropriate models of care.
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RESULTS |
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Differences in mental health services between low-resource and high-resource countries are vast. In Europe, for example, there are 5.520.0 psychiatrists per 100 000 population, whereas the figure is 0.05 per 100 000 in African countries (Njenga, 2002); the average number of psychiatric beds is 8.70 in the European region and 0.34 in Africa (Alem, 2002). About 510% of the total health budget is spent on mental health in Europe (Becker & Vázquez-Barquero, 2001), whereas in the African continent 80% of countries spend less than 1% of their limited total health budget on mental health. These and other relevant comparative data are available from the WHO Project Atlas website (World Health Organization, 2001b) and from the World Bank (2002). For example, although health spending represents some 7.9% of global gross domestic product, with an average expenditure expressed in international dollars (based on purchasing power parities) of I$523 on health services, this average varies significantly across countries and regions, ranging from I$82 per person in Africa to I$2078 in the Organization for Economic Cooperation and Development (OECD) countries (Poullier et al, 2002). Further, for both Europe and Africa there are also considerable and often growing variations both between countries and between regions within countries, not only in health expenditure but also in social care. As a consequence the forms of service provision relevant to low-resource areas will be very different from those relevant to medium- and high-resource areas.
Areas (countries or regions) with a medium level of resources may first establish the service components shown in column 2 of Table 1, and later, as resources allow, choose to add some of the wider range of more differentiated services indicated in column 3. The choice of which of these more specialised services to develop first depends upon local factors, including service traditions and specific circumstances; consumer, carer and staff preferences; existing service strengths and weaknesses; and the way in which evidence is interpreted and used. This stepped care model also indicates that the forms of care relevant and affordable in areas with a high level of resources will include elements from column 3, in addition to the components in columns 1 and 2 which will usually already be present. The model is therefore both additive and sequential, in that new resources allow extra levels of service to be provided over time, in terms of mixtures of the components within each step, when the provision of the components in the previous step is complete.
Decisions on the planning and investment of funds to improve mental health will need to include a wide range of stake-holders, often bringing divergent or even conflicting perspectives to this task. It is now increasingly common in many countries for service users and family members or carers to participate routinely in such decision-making.
Step A: Primary care mental health with specialist back-up
Well-defined psychological problems are common in general health care and
primary health care settings in every country, and cause disability which is
usually in proportion to the number of symptoms present
(Ormel et al, 1994).
In areas with a low level of resources
(Table 1, column 1), the large
majority of cases of mental disorder should be recognised and treated within
primary health care (Desjarlais et
al, 1995). The WHO has shown that the integration of
essential mental health treatments within primary health care in these
countries is feasible (World Health
Organization, 2001a).
Step B: Mainstream mental health care
Mainstream mental health care refers to a range of service components,
which may be necessary in areas that can afford more than a primary care-based
system with specialist back-up. However, the recognition and treatment of the
majority of people with mental illnesses, especially depression and
anxiety-related disorders, remains a task that falls mostly to primary care.
Von Korff & Goldberg
(2001) reviewed 12 different
randomised controlled trials of enhanced care for major depression in primary
care settings. They found that interventions directed solely towards training
and supporting general practitioners have not been shown to be effective. They
argued that interventions should focus on low-cost case management, coupled
with flexible and accessible working relationships between the case manager,
the primary care doctor and the mental health specialist. In other words, the
whole process of care needs to be enhanced and reorganised to include the
following key elements: active follow-up by the case manager, monitoring
treatment adherence and patient outcomes, adjustment of treatment plan if
patients do not improve, and referral to a specialist when necessary
(Von Korff & Goldberg,
2001). This could be seen as a major reversal of what is
considered by many to be the conventional approach: enhancing the training of
family doctors. Rather, the evidence now strongly suggests that improving
outcomes of chronic diseases such as depression does appear to require more
than changing the skills of one profession alone: namely, the combination of
several concurrent active ingredients.
Mainstream mental health care can be considered to be an amalgam of the core components described below.
Out-patient and ambulatory clinics
Out-patient and ambulatory clinics vary according to:
There is surprisingly little evidence on any of these key characteristics of out-patient care (Becker, 2001), but there is a strong clinical consensus in many countries that such clinics are a relatively efficient way of organising the provision of assessment and treatment, provided that the clinic sites are accessible to local populations. Nevertheless, these clinics are simply methods of arranging clinical contact between staff and patients, and so the key issue is the content of the clinical interventions: namely, to deliver treatments that are known to be evidence-based (Roth & Fonagy, 1996; Nathan & Gorman, 2002; BMJ Publishing Group, 2003).
Community mental health teams (CMHTs)
Community mental health teams are the basic building block for community
mental health services. The simplest model of provision of community care is
for generic (non-specialised) teams to provide the full range of interventions
(including the contributions of psychiatrists, community psychiatric nurses,
social workers, psychologists and occupational therapists), prioritising
adults with severe mental illness, for a local defined geographical catchment
area (Thornicroft et al,
1999; Department of Health,
2002). A series of studies and systematic reviews, comparing
community mental health teams with a variety of local usual services, suggests
that there are clear benefits to the introduction of generic, community-based
multidisciplinary teams: they can improve engagement with services, increase
user satisfaction, increase met needs and improve adherence to treatment,
although they do not improve symptoms or social function (Tyrer et
al, 1995,
1998,
2003;
Thornicroft et al,
1998; Burns, 2001;
Simmonds et al,
2001). In addition, continuity of care and service flexibility
have been shown to be more developed where a community mental health team
model is in place (Sytema et al,
1997).
Case management. Within community mental health teams, case management is a method of delivering care, rather than being a clinical intervention in its own right, and at this stage the evidence suggests that it can most usefully be implemented within the context of the community mental health team (Holloway & Carson, 2001). It is a style of working that has been described as the coordination, integration and allocation of individualised care within limited resources (Thornicroft, 1991). There is now a considerable literature to show that this style of working can be moderately effective in improving continuity of care, quality of life and patient satisfaction, but there is conflicting evidence as to whether it has any impact on the use of in-patient services (Saarento et al, 1996; Hansson et al, 1998; Mueser et al, 1998; Ziguras & Stuart, 2000; Ziguras et al, 2002). Case management needs to be carefully distinguished from the much more specific and more intensive assertive community treatment (see below).
Acute in-patient care
There is no evidence that a balanced system of mental health care can be
provided without acute beds. Some services (such as home treatment teams,
crisis houses and acute day hospital care, see below) may be able to offer
realistic alternative care for some voluntary patients. Nevertheless, people
who need urgent medical assessment, or those with severe and comorbid medical
and psychiatric conditions, or those experiencing severe psychiatric relapse
and behavioural disturbance, or those with high levels of suicidality or
assaultativeness, or with an acute neuropsychiatric condition, or elderly
patients with concomitant severe physical disorders, will usually require
high-intensity immediate support in acute in-patient hospital units.
There is a relatively weak evidence base on many aspects of in-patient care, and most studies are descriptive accounts (Szmukler & Holloway, 2001). There are few systematic reviews in this field, one of which found no difference in outcomes between routine admissions and planned short hospital stays (Johnstone & Zolese, 1999). More generally, although there is a consensus that acute in-patient services are necessary, the number of beds required is highly contingent upon what other services exist locally and upon local social and cultural characteristics (Thornicroft & Tansella, 1999). Acute in-patient care commonly absorbs most of the mental health budget (Knapp et al, 1997). Therefore, minimising the number of bed-days used, for example by reducing the average length of stay, may be an important goal, if the resources released in this way can be used for other service components. A related policy issue concerns how to provide acute beds in a humane and less institutionalised way that is acceptable to patients, for example in general hospital units (Quirk & Lelliott, 2001; Tomov, 2001).
Long-term community-based residential care
It is important to know whether patients with severe and long-term
disabilities should be cared for in larger, traditional institutions, or be
transferred to long-term community-based residential care. The evidence here,
for areas with medium and high resource levels, is clear. When
deinstitutionalisation is done carefully for those who had previously received
long-term in-patient care for many years, the outcomes are more favourable for
most patients who are discharged to community care
(Tansella, 1986;
Thornicroft & Bebbington,
1989; Shepherd & Murray,
2001). The Team for the Assessment of Psychiatric Services study
in London (Leff, 1997), for
example, completed a 5-year follow-up of over 95% of 670 people without
dementia discharged from long-stay residential care and found that:
However, there is less evidence available on the treatment and care needs of the never-institutionalised group of long-term patients (Holloway et al, 1999), and so careful local assessment of the needs of this population will be especially important. The range and capacity of community residential long-term care that will be needed in any particular area is also highly dependent upon which other services are available locally, and upon social and cultural factors, such as the amount of family care that is provided (van Wijngaarden et al, 2003).
Employment and occupation
Rates of unemployment among people with mental disorders are usually much
higher than in the general population
(Warr, 1987; Warner, 1994). Traditional
methods of occupation and day care have been provided by day centres or a
variety of psychiatric rehabilitation centres
(Shepherd, 1990;
Rosen & Barfoot, 2001). There has been little scientific research into these traditional forms of day
care, and a review of over 300 papers found no relevant randomised controlled
trial (Marshall et al,
2001). Non-randomised studies have given conflicting results, and
for areas with medium levels of resources it is reasonable at this stage to
make pragmatic decisions about the provision of rehabilitation and day care
services if the more differentiated and evidence-based options discussed below
are not affordable (Marshall et
al, 2001; Catty et
al, 2003).
Step C: Specialised and differentiated mental health services
The stepped care model suggests that areas with a high level of resources
may already provide all or most of the service components in steps A and B,
and are then able to offer additional components from the following options
(step C; Table 1).
Specialised out-patient and ambulatory clinics
Specialised out-patient facilities for specific disorders or patient groups
are common in many high-resource areas and may include services dedicated, for
example, to those with eating disorders; patients with dual diagnosis
(psychotic disorder and substance misuse); people with treatment-resistant
affective or psychotic disorders; those requiring specialised forms of
psychotherapy; mentally disordered offenders; mentally ill women with babies;
and those with other specific disorder groups (such as post-traumatic stress
disorder). Local decisions about whether to establish such specialist clinics
will depend upon several factors, including their relative priority in
relation to the other specialist services described below, identified services
gaps and the financial opportunities available.
Specialised community mental health teams
Specialised community mental health teams are by far the most researched of
all the components of balanced care, and most recent randomised controlled
trials and systematic reviews in this field refer to such teams
(Mueser et al, 1998).
Two types of specialised community mental health team have been particularly
well developed as adjuncts to generic teams: assertive community treatment
teams and early intervention teams.
Assertive community treatment teams. Assertive community treatment teams provide a form of specialised mobile outreach treatment for people with more disabling mental disorders, and have been clearly characterised (Deci et al, 1995; Teague et al, 1998; Scott & Lehman, 2001). There is now strong evidence that assertive community treatment can produce the following advantages in areas with high levels of resources:
Assertive community treatment has not been shown to produce improvements in mental state or social behaviour. It can reduce the cost of in-patient services, but does not change the overall costs of care (Latimer, 1999; Phillips et al, 2001; Marshall & Lockwood, 2003). Nevertheless, it is not known how far this approach is cross-culturally relevant and indeed there is evidence that it may be less effective where usual services already offer high levels of continuity of care, for example in the UK, than in settings where the treatment as usual control condition may offer little to patients with severe mental illness (Burns et al, 1999, 2001; Fiander et al, 2003).
Early intervention teams. There has been considerable interest in recent years in the prompt identification and treatment of first- or early-episode cases of psychosis. Much of this research has focused upon the time between the first clear onset of symptoms and the beginning of treatment, referred to as the duration of untreated psychosis; other studies have placed more emphasis upon providing family interventions when a young persons psychosis is first identified (Addington et al, 2003; Raune et al, 2004). There is now emerging evidence that longer duration of untreated psychosis is a predictor of worse outcome for the disorder; in other words, if patients wait a long time after developing a psychotic condition before they receive treatment, then they may take longer to recover and have a less favourable long-term prognosis. Few controlled trials of such interventions have been published, and a recent Cochrane systematic review (Marshall & Lockwood, 2004) has concluded that there are insufficient trials to draw any definitive conclusions,... the substantial international interest in early intervention offers an opportunity to make major positive changes in psychiatric practice, but this opportunity may be missed without a concerted international programme of research to address key unanswered questions. It is therefore currently premature to judge whether specialised early intervention teams should be seen as a priority (Larsen et al, 2001; McGorry & Killackey, 2002; McGorry et al, 2002; Warner & McGorry, 2002; Friis et al, 2003; Harrigan et al, 2003).
Alternatives to acute in-patient care
In recent years three main alternatives to acute in-patient care have been
developed: acute day hospitals, crisis houses and home treatment/crisis
resolution teams.
Acute day hospitals. Acute day hospitals offer programmes of day treatment for those with acute and severe psychiatric problems, as an alternative to admission to in-patient units. A recent systematic review of nine randomised controlled trials has established that acute day hospital care is suitable for about 30% of people who would otherwise be admitted to hospital, and offers advantages in terms of faster improvement and lower cost. It is reasonable to conclude that acute day hospital care is an effective option when demand for in-patient beds is high (Wiersma et al, 1995; Marshall et al, 2001).
Crisis houses. Crisis houses are houses in community settings which are staffed by trained mental health professionals and offer admission for some patients who would otherwise be admitted to hospital. A wide variety of respite houses, havens and refuges have been developed, but the term crisis house is used here to mean facilities that are alternatives to non-compulsory hospital admission. The little available research evidence suggests that they are very acceptable to their residents (Davies et al, 1994; Sledge et al, 1996a,b; Szmukler & Holloway, 2001), may be able to offer an alternative to hospital admission for about a quarter of those who would otherwise be admitted, and may be more cost-effective than hospital admission (Sledge et al, 1996a,b; Mosher, 1999). Nevertheless, there is emerging evidence that female patients in particular prefer non-hospital alternatives (such as crisis houses) to acute in-patient treatment, and this may reflect the lack of perceived safety in hospital (Killaspy et al, 2000).
Home treatment and crisis resolution teams. Home treatment and crisis resolution teams are mobile community mental health teams offering assessment for patients in psychiatric crises and providing intensive treatment and care at home. A Cochrane systematic review (Catty et al, 2002) found that most of the research evidence comes from the USA and the UK, and concluded that home treatment teams reduce days spent in hospital, especially if the teams make regular home visits and have responsibility for both health and social care (Joy et al, 2002).
Alternative types of long-stay community residential care
These are usually replacements for long-stay wards in psychiatric
institutions (Shepherd et al,
1996; Trieman et al,
1998; Shepherd & Murray,
2001). Three categories of such residential care can be
identified:
There is limited evidence as to the cost-effectiveness of these types of residential care, and no completed systematic review (Chilvers et al, 2003). It is therefore reasonable for policy makers to decide upon the need for such services with local stake-holders (Hafner, 1987; Nordentoft et al, 1992; Rosen & Barfoot, 2001; Thornicroft, 2001).
Alternative forms of employment and occupation
Although vocational rehabilitation has been offered in various forms to
people with severe mental illness for over a century, its role has weakened
because of discouraging results, financial disincentives to work and pessimism
about outcomes for these patients (Lehman
et al, 1995; Polak
& Warner, 1996; Wiersma
et al, 1997). However, recent alternative forms of
occupation and vocational rehabilitation have again raised employment as an
outcome priority. Consumer and carer advocacy groups have set work and
occupation as one of their highest priorities, to enhance both functional
status and quality of life (Becker et
al, 1996; Thornicroft
et al, 2002). There are recent indications that it is
possible to improve vocational and psychosocial outcomes with supported
employment models, which emphasise rapid placement in competitive jobs and
support from employment specialists (Drake
et al, 1999). This individual placement and support model
emphasises competitive employment in integrated work settings with follow-up
support (Priebe et al,
1998); studies of such programmes have been encouraging in terms
of increased rates of competitive employment
(Marshall et al,
2001; Lehman et al,
2002).
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DISCUSSION |
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The material resources available will severely constrain how this approach is applied in practice. In low-resource areas it may be unrealistic to invest in any of the components described here as mainstream mental health care (step B), and the focus will need to be upon primary mental health care, where the main role for the relatively few specialist mental health staff is to support primary care staff (step A, column 1, Table 1). Areas that can afford a more differentiated model of care may first consolidate their mainstream mental health care (step B), with the capacity of each service component decided as a balance between the known local needs (Thornicroft, 2001), the resources available and the priorities of local stakeholders. In general, as mental health systems develop away from an asylum-based model, the proportion of the total budget spent on the large asylums gradually decreases. In other words, new services outside hospital can only be provided by using extra resources (which is uncommon) or by using the resources that are transferred from the hospital sites and staff (which is the more usual case). Interestingly, the evidence from cost-effectiveness studies of deinstitutionalisation and the provision of community mental health teams is that the quality of care is closely related to the expenditure upon services, and overall community-based models of care are largely equivalent in cost to the services that they replace.
Over time, and as resources allow, each of the components of the mainstream model can be complemented by additional and differentiated options, described here as specialised differentiated mental health services (step C). Notably, the evidence base for these more recent and innovative forms of care is stronger than for any of the service components in steps A or B, described above in relation to lower resource countries. Indeed, few high-quality scientific studies have been carried out in low-income countries (Patel & Sumathipala, 2001; Isaakidis et al, 2002). Consequently, the relevance of most published research in this field to less economically developed countries may be low. This schema therefore places the evidence of effective services within the appropriate resource context; resource here refers not only to the monetary investments made, but also to the available numbers of staff, their levels of experience and expertise, their therapeutic orientation and the contributions available from the wider social and family networks (Desjarlais et al, 1995).
Two important implications arise from this approach. First, the stepped care model suggests that there should be a degree of coordination between service components, in particular between the provision of primary and specialist care. We recognise that such planning mechanisms may be weak in some areas. Second, this model implies that the training of mental health staff should be fit for purpose according to the service stage reached (A, B or C) and the level of resources in the area of practice (high, medium or low). In practice it is likely that in any particular area some but not all of the service components described here will be present, and that such identified gaps may inform local planning for service developments.
In recent years there has been a debate between those who are in favour of the provision of mental health treatment and care in hospitals, and those who prefer to use primarily or even exclusively community settings, in which the two forms of care are often seen as incompatible. This false dichotomy can now be replaced by an approach that balances both community services and modern hospital care. However, since this framework cannot be applied in the same way in settings with different resources, the stepped care model presented in this paper suggests a sequential view of how to develop a balance of services in any specific context, moving over time from the left column to the right column in Table 1. In this way, implementing the components of a modern mental health service can be seen as a pragmatic exercise undertaken by all those with an interest in improving care.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication October 7, 2003. Revision received May 21, 2004. Accepted for publication May 24, 2004.
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