Why are psychiatric services getting better but looking worse

Thornicroft et al have provided a service to the mental health community worldwide by summarising their combined experiences in developing community orientated mental health services in England and Italy over the past 30 years. The challenges they identify go a long way to explaining why mental health reform is often piecemeal and incomplete, sometimes leaving the system more fragmented than it was before reform was embarked upon. This has certainly been the case in Australia, where mental health reforms, whilst occurring in the context of a well articulated and universally agreed national mental health policy 1, have been differentially implemented in the various state and territory jurisdictions. Even within such jurisdictions there is inconsistency with respect to how community care is provided.

Within Australia, the state of Victoria has arguably undertaken the most comprehensive and rapid restructuring of mental health services, closing all its psychiatric hospitals within the decade of the 1990s. This rapid deinstitutionalisation was hugely successful in shifting the locus of mental health care into the community, along with a shift of resources. For example, between 1993 and 2003, expenditure on mental inpatient facilities in Victoria was reduced by AU$ 184 million, with a growth in spending on community based care of some AU$ 323 million 2. Each of the urban area mental health services provides services to around 250,000 people. Each has a small number of acute inpatient beds (around 20; average length of stay 10–14 days) co-located with general hospitals, but also has access to 20 bed continuing care units for longer-stay rehabilitation (length of stay from 3 months to 2 years) and various other facilities provided either solely by, or in partnership with, non-government organizations. Community health services are configured uniformly, with acute crisis work being performed by a crisis and assessment team, longer-term care by a continuing care team, and intensive case management by a multidisciplinary mobile support and treatment team.

Thus, both in terms of emphasis of dollar allocation, as well as staffing and overall service provision, Victoria has delivered on the imperative to shift mental health care into the community. However, we have been struck by the dissonance that has arisen between many mental health professionals who are convinced that services are much better than they were, and many in the community (including consumers and particularly carers) who are convinced they are worse.

One explanation for this phenomenon is the changing expectation of the community in response to the benefits of community psychiatry having been oversold by its vigorous and sometimes zealot proponents. These advocates (perhaps more in the past than at present) appear to be working on certain assumptions about the nature of mental health and its amenability to treatment. We 3 have recently published a summary of these premises and the reality that decades of experiences with deinstitutionalisation has subsequently generated about them. They are as follows: — Psychotropic drugs, particularly the newer atypical antipsychotics, will deal effectively with most psychotic symptoms and reduce markedly consequent disability.

– Insight into the need for treatment will be enhanced, so that adherence to treatment will improve.

– Intensive case management (or assertive community treatment) will only be required for brief periods, and have lasting gains for individuals.

– Substance abuse will not increase in the psychiatrically ill population.

– Stigma against the mentally ill in the community at large will decrease.

– The justice system will be more tolerant of mentally ill people who run foul of the law.

– Mentally ill patients will be adequately serviced by available accommodation options as well as adequately dealt with by the general health system in regard to their physical health.

– Effective community services will substantially reduce if not eliminate the need for acute and (more specifically) chronic beds.

– Demand for psychiatric service will remain stable over time.

– The costs of community services can be constrained by limiting services to the low prevalence disorders (or those with “severe mental illness”).

Anyone who has lived through the full implementation of a comprehensive mental health reform program will recognise that many of these premises are substantially misguided. This does not mean that community care for the vast majority of psychiatric patients is impossible, or that we should reverse the process of deinstitutionalisation. But we would argue that further reforms need to be more cognisant of the reality and tragedy of mental illness, and that there is no panacea. We need to keep on trying new ways of enhancing community care to the betterment of the health of our patients, rather than continually restructuring service delivery models. Much more needs to be done to reduce community stigma against people with illnesses such as schizophrenia, and concerted approaches adopted more effectively to reintegrate these individuals into mainstream living. Lack of suitable accommodation and very low work participation rates are particular barriers in this regard.

It is true that mental health systems, perhaps more obviously than general health systems, are under-funded for what they are expected to achieve. This is certainly the case even in an affluent country such as ours. But significant gains have been made, and our profession should expend energy on building on those gains rather than seeking to dismantle them.

Thus, we would contend that any approach to improving the mental health of the population needs to take particular heed of the strength of the challenges articulated by Thornicroft et al, namely to acknowledge that there is no right way but that each community society and nation needs to put the necessary elements for care together in a package that makes sense for them. We would add the imperative to ensure ongoing evaluation of the effectiveness of service interventions, and continuing to listen to all the main stakeholders, not least staff within services, and patients and carers themselves.