2004 - Community Mental Health

Revijalni ilanci/Reviews

carein Europe communifyMentalHealth an ovefuew SrcrrrNPntngu UNtlFon Soctrrl.rrxoCovvunrlY ts1'ctttA'lRY

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'Ji"niiloo" bccn institutionsfor thc mcntally ill' such as psychiatry.Bvc' bcforc thc I 9'r'ccntury,thcrc had liuropc slrarcssomc histoilcal roots of.rodcm i. thc community for pcoplc witlr ncntal illcarc of forms rnoic than ?50 ycarsago.and orga.iscd thc Bcthlcm in London wliich was foundcd tlrroughthc spirit of cnlightcnmcntand in B.clgiurn.Modcnr psychiatry,howcvcr,was initiatcd ncss,snch as thc traditio, of lamily carc in Gccl i. Paris'thc first publicationo f thc paticnts ill mcntally of chai's thc ol .utting by bcganaround I g00.This rr"gi,r,ri,rl;L, rnarkcd -thciy.uori. risc of modcm psychiatryas a Thc England' Yoik' in .psychiarry, in l;03, a;d nrc cstabtistimcntof thc rctrcat tcrm 1.,nry"triutr,";;jii c"-.,uny carc a'd acadcmia ln thc I 9'r'ccntury'various thc devclopmcntof new institutionsin both hcalth spccialityof mcdicine *as "loscly li'kcd to thc mcntally ill wcrc built acrossEuropc Tbc for asylums dcpartmclts oipsychiatry, andlargc univcrsiticscstablishcdchairs a'd acadcmic familics could.ot fulfil that fu'ctron rn an fo, th. ni-ut'"tiuin."atoipu,icnti sinccmany asylumswcrc mcant to ..p,u." ih" family as "a.ricr. a thcrapcuticcnvironmcnt. provide and Iifc ofurban '',"'ou" th" mcntally ill from tlrc public scc,rcs industrialisingsocicty anymorc Key words: community menthal health care' historJ''

1. HISTORYOF MODE,RN PSYCHIATRY

and environment in modern hospitals is more humanc and asylums' rherapeuticallyoriented as compared to old on Staff the staff-patient-ratio has significantly improved doctors' wards ,tsually is multi-disciplinary with nurses'. as lnPut well as therapists psychologists and occupational hospitals in stay of length of socialworkers. The average is in has beeh dramatically reduced, and most frequently tendency ageneral the range between 15 and 60 days with

The dominance of institutions was rePeatedlychallenged' in the and since 1900 modeis of alternative forms of care published' community were increasingly conceivedand forms AIso, the development of psychoanalysisand further health of psychotherapy led to ideas to provide mental In to fall even furtherinstitutions' traditional outside clientele carefor a wider largewas in Europe care health mentai practice, however, provide more The aims of de-institutionalisationwere to iy institution baseduntil the 1950s and, in most countrles' the walls of outside care of and respectful forms lVorldwide, the number of psychiatric humane eu.n beyond that. in terms of care of asylums, to have more effective forms qualhospital beds reachedtheir peak in the 1910s' patients' ,"drr.irrg psychopathology and improving patients' ity of liie, ro reduce costs of care' to Promote 2. DE-INSTITUTIONALISATION of menautonomy, and, possibly,to Prevent exacerbations facthe identified clearly frequently Historical researchhas still not tal illness instead of treating them' The most de-inhave been tors that led to mental health care reforms and raised concerns about de-institutionaiisation is that without asylums stitutionalisation in different countries' The fact from that patients would be discharged occurred de-institutionalisation would 1990s and costs 1950s that between hauing alternative forms of care in place, It Union' European the of states that and member in all current euentu"lly not be mucll lower than for asylums' simishared countries all that criminal may therefore be assumed some patients with mentai illnessmight commit lar political, sociai, historical and cultural factors that offences and become a risk to public safety (2)' point maJe de-institutionalisation happen' Yet, the exact to var- TlTerehas been surprisingly little systematic research of time, fasl.rionand pace of de-inscitutionalisation some Yet' evaluate the effects of de-institutionalisation ied enormously as do the resulting forms of community do exist and clearly show that (a) the dismental health care which have been establishedacross good studies number .l-,urg" of former long-term hospitalised Patienrs into Europe (i). The common features are that tl.re asy- the community is feasible, (b) the outcome tn terms of beds have been reduced either by closing former are them' of patients' quality of life and sat;sfactionwith care lums more or less completely or by downsizing care provided mostly positive, i.e. paticnts C:, prefer communlty Psychiatric hospital care is nowadays mostly ar- to hospitalisation.(u) tlic costsfor care in the communtty in small units which are based in smaller catchment The have been rather loo",r tl-,anfor former irospital care, and eas and ofteq atr*'1,-J r'l 5c'rrf3l district i-rospitals'

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MedArh200); J7(J-6supl.1) the state

has not led to a higher rate of same time, it runs a national health servicewhere (d) de-institutionalisation for the quality o[care and the homicidescommittedby mentallyill people.Studieshave cakesextreme responsibility more or less all European failedto identifr a consistenteffecton psychopathology,health of the people. \fhilst, health care, meaning thac i.e. the symptomsof patientsare, by and.large,not af- countries provide free mental people pay for health care through taxes or insurance Prefectedby their dischargeinto the communiry(3,4,5)'

3. CLIENTELE OF MENTAL HEALTH CARE

miums or both, but do not need pay a significant excra amount of money when using the service' Despite this general principle there are two asPectsthat vary considerably: one is the degree to which the systems focus on

Mental health care in the community facesthe challenge people with severe and chronic illnesses and makes sure co care for at least three discinct grouPs ofpatients. The that even those patients receiveadequate care who are not first group are rhe former long-term hospitalisedpatients' willing and able to actively seek help themselves.In a way, Most of them now live in various forms of sheltered acchis reflects the emphasis thac a nation and its healthcare commodation. The population is aging and the numbers system puts on the weakest people in the society who are are dwindling. Increasingly, care for this patient group not able to look after themselves. Another asPect that becomes a historical issue, and the experiencesmade in the countries vary in is the spectrum ofservices and support de-institutionalisation processwith this group cannoceasthat is available to those patients who can actively seek ily be transferred to other groups ofpatients. The second treatment and know how to make best use of all oPtions. and most difficulc part of the clientele are the so-called For instance, in the United Kingdom much focus is on new long-stay patients with severemental illness. They patients with severe iilnesses, and specific teams follow are younger and might have been long-term hospitalised those patients up in the community and make sure chat in che former asylum system. Nowadays, however, they co-ordinaced and continuous care is provided, whilsc ir either use inappropriately different servicesat the same may be difficult to arrange psychological treatment for time or avoid care altogether. In any case, it is difficult patients with anxiety disorders. In Germany, patients for servicesto engage with them and provide cul. th.t with anxiety disorders may be able to receive hundreds would be acceptableto che Patients and effective in terms of sessionsof different forms of psychotherapy within a of achieving satisfactory clinical and socialoutcomes. The few years, but nobody is really responsible for the treatillnessesare often complicared chrough substancemisuse, ment of mentally ill patients who are homelessor do not criminal behaviour, antisocial personality craicsand very seek treatment or boch. A third aspect rhat distingr-rishes unstable or non-existing social suPPort. In countries with the pracciceof healch care is the funding levels, which high rates of immigracion, sorne ethnic minority SrouPs show great variations. Using che United Kingdom and are over represented in this cliencele. Germany as examples again, the difference is significant: The third and by far largest group ofpatients are the ones whilsr around 65% of the GDP is spent on healthcare with lessseveredisorders who receivemainly outpatient care,often but not exclusivelyin the form ofpsychological

in the UK, ic is more than l0% in Germany. It is obvious chat more money buys better buildings, more staff or outside within treatment may seek treatments. They and more expensiveinterventions. Bosnia-Herzegovina is the conventional healthcare system.

4. DIFFERENCE BETWEEN

COUNTzuES

among the group of European countries with relatively low spending levels. This has implicacions for what can be provided and requires to set priorities. Finally, the

funding arrangement determines whac services aim to good at. Services that are paid for as a Alchough there are some forms of community mental achieve and are therealsoaresig- whole, such as in the nacional system of the UK, aim at

healthcarein most Europeancountries, (6).Thesedifferences areembeddedin nificantdifferences and culturalvaluesaswell aspractinationalphilosophies cal cradicions. Somedifferencesoftenseemat first glance to be due to mere technicalissuesof how to administer reveal and managecaresystems,whilst detailedanalyses that they in fact reflect very discinctvaluesand ways to think about health care.Differencesare also heavily and detailsof fundinfluencedby politicalcircumstances countriesshow between Comparisons ing arrangements. complexpacerns.For example,the United Kingdom has arguablea very capitaliscictradition throughout society emphasising commerceand forcesof freemarkets.At the

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effectiveness,but rarely care abouc how attractive they are to the patient. Services that receive money flor each patient and performance- e.g. as in Germany - make sure that they are attractive to customers, but do not necessarily put emphasis on effectiveness.There seems co be a balance becween attractiveness and effectivenessthar is differently struck in different countries. Despite these differences, there also are significant commonalities and central features thac are shared across countries.Some of these issueswill be briefly discussed.

Commwnity Mental Health Care in Ewrope

5. FRA(;MI'NTATION VIJRSUS CON'IINUITY AND CO_ ORDINATION

try to cngagc first u;r in the community' Clinicians oftcn bcfclrcpaticrrts support' generaland non-mcdical ,l..r.or.rgl.t (7)' might accePtmedication

Relrabilitationtcamslookaftcrtlroscpaticntswlrrlprcof both health timc and receivc Mental l.realrhcare usually utiliscs resources dictably will stay in care for a vcrl' l6ng difficult and tl.resocialcxfunded to avoid and socialcare,which are differently a high degrce of input. Tcams airn s e r v i c e s acl.ricvc t n a k c thcm can hclp r o i n t c g r a t e .T h i s a n d o t l t e r f a c r o r s .lr-,rio.,of these chronic 1;aticntsand for problem thcir pcrsistcnt fragmenrcd. Fragmentation is a particular as high a quality oflife as possiblcdcspitc co-ordinatc cannot and ill rely scve are tl',os"p"tients who m c n r a l h e a l rh P r o b l c m s ' managementand availablcinterventtonsthemselves'Case provide an alternativc to lnPatlcnt of various Homc treatment teams related proccdures may ensure co-ordination and situattons They visit paticnts at ]-romc over timc' whicl.r care in acute interventions and continuity of care ntions in tl-repatient's cnvironmcnt for effectivelong-term deliver all interve seemsto be of central importance for of time. ill-ress'Ideally' a limited period rreatment of people with severemental for all service Day hospitalscan also be an alternative to convcntional one agency should have full responsibility Paticnts catchmenr given a in target for a defined ElrouP inpatieni care for patients with acute disordcrs' orouirion 'zrea at go home and interventions of hospital day ..c"iue treatment in the and ensure both the co-ordination appropriate the and weekend' night and, often, during rhe on the level of individual patients investment of resourccs'

a comPrcEarly intervention teams are meant to deliver carly witl.r paticnts to interventions h.nriu. package of 6. SPECIAI-ISATIONVS GENEzuL n e g ativc a v o i d t o a i m T h e y o n s e to f p s y c h o t i cd i s o r d e r s ' APPROACHES thc on based are and careersof puri.n,, with psychoses aforementioned the earlier the countries, In the UK, as in other idea tl'rat interventions may be morc effective mental overall responsibility can be with community they are delivered. teams with health care teams, i.e. multi-discipiinary and There is some researchevidence showing that all these psycl.riatrists,nurses, psychologists,social workers catchment reams can be feasible and are often positively valued by oth., prof.rsions that take responsibility for Such the patients. In the case of day hospitals there also is ^r.^, of between J0 to 80 thousand population. '07hether establisl.rsecond- sound guidencefor their effectiveness' teams may oPerateas a single point of entry into arises ing specialisedservicesis or is not a good idea' probably ary healtfr caresystems.Nevercheless,the question and dependson the sPecificcontext' patients all with deal should team the as to whether necof range full cire provide and problems themselves that 7. DE-INSTITUTIONALISATION VS irr^ry "*p"r,ise or refer to other servicesand teams difprouid" more specific expertise and input' It is very RE-INSTITUTIONALISATION service quality a high provide to impossible hcult if not investedin comin In some European countries the money for the full spectrum of patients with mental disorders in others cared munity mental health care is being reduced' only one ,"^-, ,o that sub-grouPs may be better Tl-rus' to teams' there are plans for a further increaseof funding' for in specific teams. The existence of too many it is on the some extent de-institutionalisationis still going on if ho*.u.r, increases fragmentation, compromises comthc in services of and understood as the establishmenc principle of full responsibility for a catchment area However' may It effectiveness' than munity other than old or new types of asyiums' rather costs often increases re-incailed be the best there also is a new tendency which may depend on national and local factors as co what is a this balance between a generic approach and specialisation stitutionalisation (8)' Like de-institutionalisation' countrles is. This balance also affects the way mental health care phenomenon that occurs acrossmany European There care' understood' primary fully to yet linked not be are can it for teams and the reasons (a) number the are severalsigns of re-institutionalisation: The current debate on specialisedteams centres on some there is no offorensic beds has been increasingalthough specific approaches,i.e. assertiveoutreach, rehabilitation' ill have mentally tl-re evidence that tl.rehomicide rates of home creatment, day hospitalsand early intervention' (b) risen since the beginning of de-institutionalisation; are who patients those for most' care rn Assertive outreach teams involuntary admissionshave been on the iucrease "difficult to engage wich", i.e' for patients that conven- although not all, European countries reflecting a tendency tional services have failed to engage in proper care but tc force patients to treatment more often; (c) the sanre are thought to need such care. Assertive outreach works tenCcncy is reflected in initiatives to widen legislarion to with a low staff-patient-ratio allowing high level of time facilitate compulsorl' tr'-:Lrnent' This now also applies to and commitment of staff and proactively follows patients treatment outsidc hosn!tals,and there are variousplans to

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MedArh2003;11(j-6 supl.1)

strengthen the options for compulsory creatment in the community; (d) there has been an increasing number of various forms of residential care and supported housing'

appointmencsof senior decideabout funding for services, managersand clinicians,and prioritiesfor research' A seriousproblem for the developmentand delivery of

These projeccsmay be costly and can often be seenas new mental health care in che community is an increasing forms of asylum type institutions where standards of care shortageof qualifiedprofessional staffin many European can be low and many patients stay for decadeswithout a alsoco other

countries.This appliesto psychiatrists,buc

realistic chance to move on to a more independent form professions suchasnursesandsocialworker.Therealready of accommodation (9); (e) some new aPProachessuch is an incernational competitionfor qualifiedstaffland new as assertive outreach and early intervention teams, also in community constitute inscitutions although these inscitutions are not defined by walls (10). Both approaches aim to turn people into psychiatric patients, who otherwise would not have sought treatment. This is being done without a legal basis to enforce treatment (11). The issuesof reinstitutionalisation has so far received little debate and even less systemaric research.

8. THERAPEUTIC ASPIRATION VS SOCIAL CONTROL Psychiacry has aiways lived in tension between therapeutic ambition and the function of social control. There might be a prospect that chese functions will splic further resulting in two distinct areas of mencal health care, i.e. a statutory care for severeiy mentally ill patients who are seen as a danger or annoyance to the public, and d more

ways have to be found to make working mentalhealthcarean attraccivecareeroPtionso chatstaff can be recruitedand retained.

10 CONCLUSIONS This paper has focussedon the situation in current mernber scatesof the European Commission. For various reasons,it is not the same in other European countries. Countries which started the process of de-institutionalisation much later may have the advantage thac they can buiit on the experiencesmade elsewhere.Considering community mental health care in current member states,there are - as briefly described - aspectsof mental health care that are different between and common to various countries. Of course, there also are other important asPectssuch as the political structures that decide on funding and configuration of mental health care, which could not be discussed here. One may conclude that, despite all differences,chere

privately organised health care system with a rich range ofinterventions for those patients who can actively seek are now a few standards for good communicy mental treatment and - directly or indirectly - pay for it. The health care that have found wide accepcance,although statutory system might easiiy develop into a second rate they might not be tocally undispuced: system o[inferior quality, whilst servicesfor lessseverely "sold" ill patients may be driven by market forces and be to customers ignoring empirical evidence and effectiveness. In some European countries, che scatutory mental care has already become part of che social care system, whilsc other patiencs - usually with non-psychoric and less severedisorders - can seek tteatment of private psy-

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operate in the community. '

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for patients with severe mental illness must have a limiced caseloadand a clinical expertise,i.e. they should not iusc organise, but actually deliver care interventions.

More or less all European countries face the challenge to develop appropriate ways co involve users as well as '

tients' and carers'views are often inconsistentand they

Mencal health teams in the community shouid do home visits wich chosepatiencswho are noc able to actend outpacient appointments (12).

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other problem is chat such involvement naturally favours

There should be alternacivesto conventional inpatient care florpeople with acute problems.

the vociferous and skilled users and carers, who can well representtheir interestsin public and commitcees,whilst

Co-ordination and continuity of care has co be ensured particularly for patients with severe and chronic disorders, which may be achieved through case management or key working. Key workers

9. USERAND CARER INVOLVEMENT AND STAFFRECRUITMENT

can have different and even contradiccory interests. An-

These teams should have responsibility for both healch and social care for their patients.

chiatrists. Depending on values, this may or may not be seen as a chreat to good mental heaith care.

the patients' relacivesinto service development and care delivery. This is complicaced by the experience that pa-

A modern community healthcare system can be expected to provide multi-disciplinary teams thac

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Incegration into

"normal"

socialcontexcsis prefera-

the interesrsofless skilled patients may remain relatively

ble to carein institutionalisedsectings.For example,

ignored. It is increasinglycommon to have representa-

support in regular employment seemsto be a better

tives of user and carer organisationson committees thac

option than supervision of sheltered employment

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CommunityMentalHealth Carein Europe

facilities, and the same applies to accommodation

(13). '

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shouldfind a wayto involveusers providers Service

(). Becker T. & Vazquez-BirqueroJL The European persPectiveof psychiatricreform' Acta Psychiatrica 2001: 410' 8-I4' S.".rdlrr"ui."(Supplementum),

. and relativesin servicedevelopmentand caredeii- 1 very. Finally, a modern community mental health care systemcanbe expectedto havesometyPeofregular evaluation,ideallysupportedby data on outcomes such as Patients'symptoms'disabilities'quality of 8. life and creatmentsatisfaction'

PriebeS, Fakhoury\( \7atts J, BebbingtonI Burns \WhiteI' & \Wright ! JohnsonS, Muiien M, Ryrie I, C. Assertiveoutreach teams in London: patient and outcomes'Pan-LondonAssertive characteristics OutreachStudy,Part l. BritishJournalof Psychiatry' 2003: 183, 148-154.

- new PriebeS. & TurnerT. Reinstitutionalisation a era in mental health care' British MedicalJournal' effecThus, community mental health careshouldapply 2 0 0 3 :3 2 6 , I 7 t - 7 7 6 . tive rreatment basedon researchevidenceand facilitate & Priebe S' 9. Fakhoury $ Murrey A, ShepherdG' measuresfor the socialinclusionof Patients' and Psychiatry Social in supportedhousing' Research 2002: 37, 301-1t' RTFERENCES Epidemiology, Psychiatric 'J( 1. Fakhoury a PriebeS' The processof deinstitution- 10. rVarner R. The prevention of schizophrenia:what alization:an internationaloverview'CurrentOpinion interventionsare safe and effective'Schizophrenia in PsychiatrY,2002: 15, L87-92' Bulletin,2001: 24, 55I-62' gone ' of 2. Munk-JorgensenP Has deinstitutionalization 1 1. N7attsJ. & PriebeS' A phenomenologicalaccount Clinical Psychiatry of treatment' Archives community of assertive too far? European users'experiences Neuroscience , 1999: 249, 136-43. Bioethics,2002: 16, 439-454. from 3. LeffJ, Tiieman N. Long-staypatientsdischarged 12. CartyJ,BurnsT, Knapp M, \Vatt H, \Tright C' Henafoutcomes pry.hi.tri. hospitals.Socialand clinical dersonJ, Healey A. Home Treatment For Mental i., firr. y.urc in the community' The TAPS Proiect46' Health Problems:A SystematicReview'Psychological -23' 217 6, 7 2000: Psychiatry, of British Journal Medicine,2002: 32, 383-401. A Project' TAPS The M' Knapp N, 4. LeffJ, Tiieman 13. Drake RE, McHugo GJ, Bebout RR, Becker DR' Psychiatric 1985-L998' research, years report on 13 Harris M, Bond GR. & Quimby E' A Randomized Bulletin, 2000; 24, 165-8' ClinicalTiial of SupportedEmployment for Inner-city Do Patients\(ith SevereMental Disorders Archivesof 5. PriebeS, Hoffmann K, IsermanM' & Kaiser\il -3)' GeneralPsychiatry1999: 56, 627 Iong-term hospitalisedpatients benefit from dis.h"ig. into the community? SocialPsychiatryand PsychiatricEpidemiology,2002: )7 ,381-92'

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