What are the arguments for community-based mental health care?

Summary

The issue

Mental disorders are responsible for about 12-15% of the world’s total disability – more than cardiovascular diseases, and twice as much as cancer. Their impact on daily life is even more extensive, accounting for more than 30% of all years lived with disability

Findings

There are no persuasive arguments or data to support a hospital-only approach. Nor is there any scientific evidence that community services alone can provide satisfactory comprehensive care. Instead, the weight of professional opinion and results from available studies support balanced care.

Balanced care is essentially community-based, but hospitals play an important backup role. This means that mental health services are provided in normal community settings close to the population served, and hospital stays are as brief as possible, arranged promptly and employed only when necessary.

It is important to coordinate the efforts of various mental health services, whether governmental, nongovernmental or private, and to ensure that the interfaces between them function properly.

Cost–effectiveness studies on deinstitutionalization and of community mental health teams have demonstrated that quality of care is closely related to expenditure. Community-based mental health services generally cost the same as the hospital-based services they replace.

Policy considerations

The priorities and policy goals for a particular country depend largely on the financial resources available.

• Low-resource countries should focus on establishing and improving mental health services within primary care settings, using specialist services as a backup.
• Medium-resource countries should also seek to provide related components such as outpatient clinics, community mental health teams, acute inpatient care, long-term community-based residential care and occupational care.
• In addition to such measures, high-resource countries should provide forms of more differentiated care such as specialized ambulatory clinics and community mental health teams, assertive community treatment, and alternatives to acute inpatient care, long-term community residential care and vocational rehabilitation.