Evidence based reform of mental health care

Two big ideas have dominated reform in mental health care in recent years and underpin the widespread enhancement of services that is being attempted in England. These are that people with mental disorders should have treatment in the community, and that young people with early psychosis should receive timely and comprehensive intervention during the critical years following onset. Two large, high quality studies in this issue report much needed evidence on the impact and feasibility of these drivers for reform.¹,² Both studies are large and well designed and report positive results in support of the present reforms.

Johnson and colleagues (p 599) show elegantly that providing, in a disadvantaged inner city community, intensive treatment at home for acutely ill people with severe mental disorder substantially reduces the use of inpatient care.¹ The number needed to treat attests to the potency of this effect, which seems to be sustained for at least six months. Furthermore, although treatment at home did not increase risk, patients were less exposed to the disruption and the often harmful effects of inpatient care. This study also indicates that home treatment could be highly cost effective.

Petersen and colleagues (p 602) show that more intensive, assertive community treatment in early psychosis produces better outcomes at two years than does standard care,² reinforcing the message from a similar UK trial.³ Similarly, the OPUS study assessed intensive care during the critical period in early psychosis,⁴ but the content in the Petersen trial was less specific for that phase of illness than in the intervention used in other programmes for treating early psychosis.⁵ More phase specific forms of psycho-social intervention,⁶ preventive programmes to help people back to work,⁷ and earlier detection of psychosis⁸ may further improve outcomes.

These two concepts of reform are related but have evolved sequentially. The model of community psychiatry was spawned within the wider process of deinstitutionalisation and was ignited sociologically, not scientifically. Science came later. And where the community model has struggled, it has been for economic rather than scientific reasons. The reforms towards early intervention in psychosis, catalysed by the rise of community psychiatry, have developed along with evidence based medicine, which emerged at the same time. Representing the overdue introduction of early diagnosis into psychiatry, this process has woven science, clinical care, consumerism, values, and sociology into a potent blend. This disturbs some people, who defend treatment as usual.⁹ Are they defending the indefensible?

The criticism that each reform process has attracted deserves deeper analysis. Both reform and resistance to it are complex phenomena influenced by values, evidence, and opinion. The resistance to early intervention in psychosis is based on an overly narrow interpretation of the evidence based model.¹⁰ Evidence based medicine refers to individual interventions and diagnoses while evidence based health care focuses on systems and models of care. ¹¹ Evidence based practice is an even more pragmatic and mature concept which integrates the best research evidence with clinical expertise and patients' values. Studies of new approaches to evidence based practice are difficult to carry out, and high quality studies, such as the two in this issue are rare.¹,²

Critics argue that reforms to health care should not begin until the evidence base for them is virtually complete. Yet we cannot remain paralysed, waiting for perfect studies to be conducted and published before we respond to the needs of patients with serious health problems. To create the evidence for evidence based practice we should develop “best bets” in a stepwise manner and use well conducted evaluations to initiate, guide, and sustain effective models of care while weeding out ineffective, harmful, or wasteful ones.

In Australia, where the building blocks of both community treatment and early intervention were constructed and the first wave of reforms was rolled out,¹² there has lately been a loss of momentum and a corresponding decay in services.¹³ Many of the crisis resolution teams in big cities have lost funding, retreated into hospital emergency departments, or lost the key skills and sense of purpose required for this challenging role. Early intervention for psychosis is still supported by rhetoric but is struggling in practice.¹⁴ One main reason for this is the failure to grasp that reform is a continuing task requiring sustainability as well as innovation.