Mental health systems: proposals beyond evidence-based mental health?

The paper by Thornicroft and Tansella comprehensively covers the historical transition from the rigid hospital care system to the open community model, with all considerations for cultural, economic and ethnic differences. The 'balanced' model it puts forward can be adapted to many countries and communities that vary in economic and other resources.

The balanced system discussed in the paper excludes child and adolescent psychiatry, drug and alcohol abuse and old age psychiatry. This is probably at least in part due to the following reasons.

In the case of drug abuse and alcoholism, there is a tremendous amount of stigma, legislation conflicts and concern by the community about the possible threats to the security and stability of the society at large. The medical and psychiatric complications vary a great deal, each requiring specialized care. The systems of such care are experimental, deficient in many instances, lacking in resources. Moreover, the comorbidity with other conditions is quite frequent, necessitating different levels of care. The dilemma between short or long inpatient care and community based care, which leads to less stigmatization, still remains unresolved, with no guidelines that can be, at least in part, applied to different cultures and countries.

In child and early adolescent mental health, the problems of subnormality, special education, school health, parental abuse, delinquency and conduct disorders require a complex and unified system of care. Needless to say, in many countries such a system does not exist or is in disarray.

According to the WHO Mental Health Report 2001, the world population is becoming older and most elderly people are in a good mental and physical condition. However, if we consider the psychiatrically afflicted elderly, of whom the majority suffer from dementia, planning a strategy to combine inpatient acute and chronic care and community-based care is highly needed.

In the above three categories of patients, we could apply the constructs outlined in Tables 2, 4 and 6 of Thornicroft and Tansella's paper, with the adaptations required to address their specific needs.

It is imperative to develop a national training system for psychiatrists, psychologists, nurses, social workers and educators. This national system should incorporate local, ethnic and cultural values in the training schemes, which are usually derived from the Western core curriculum.

In all mental health circles, in the last few years, the two main themes of mental health administration and planning have been: a) the incorporation of mental health into primary care, by designing curricula for 'primary care psychiatry', due to the shortage of psychiatrists worldwide and the need for the specialists to devote more time to care for the difficult cases, as well as to teaching and administration; b) community mental health, with the purpose of destigmatization and integration of the patient into society, where he/she can be productive or at least socially capable of managing his/her affairs. Such a scheme is quite costly, as it also involves day-care centers, sheltered homes and hostels, but can never replace completely the inpatient care unit, which nowadays is part of the general medical complex generating less stigma. Affordability of the community system, however, is not within the reach of many countries.

The open community care system has been wrongly assumed to have led to increased homelessness (1), which was later found to be largely due to failure in planning resettlement hostels. The same misconception is now occurring about violence and mental illness (2). The new generations of psychiatrists are now being trained in a balanced system of acute hospital care and integration of the patient into society with outpatient follow-up. Of the 130 psychiatric hospitals present in England and Wales in 1995, only 14 remain open (3). Such a trend is taking place all over the world and the 'matrix' system presented in the Thornicroft and Tansella's paper is a good framework to model or remodel a system, with the flexibility it has to suit the needs and resources of any society.