Community models of mental care warrant more governmental support
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《英国医生杂志》
1 Flinders Human Behaviour and Health Research Unit, Flinders University, Bedford Park, 5042, SA, Australia malcolm.battersby@flinders.edu.au
Although developed countries are relatively well resourced there is an unmet demand for mental health services, particularly for anxiety disorders and depression. A similar and escalating demand exists for services for other forms of chronic illness too, such as diabetes secondary to obesity. In both, the potential of community care is increasingly recognised.
The core elements that emerge from the models McKenzie et al describe are community involvement in the planning and delivery of services, harnessing social support, and providers with a diversity of skill levels in stepped services.1 Replicating these models in wealthy countries would require overcoming considerable barriers in the form of system inertia, multiple funders, funding that creates disincentives to provide alternative services, professional vested interests and boundaries, stigma, loss of the sense of community, breakdown of the family, and lack of resources for the treatment and prevention of mental disorders compared with medical conditions.
But there are examples of services in developed countries that have overcome some of these barriers. The use of collaboratives as a large scale method of bringing about change in the delivery of services for chronic illness have been widely used in the United States, United Kingdom, and Canada and, more, recently Australia.2 w1 These collaboratives base their programme for change on the six elements of the chronic care model,3 one of which is support for self management. Although these programmes have improved health outcomes, they have focused on diabetes and heart failure rather than on mental illness.w2-w4
The UK collaborative on falls prevention, which relies almost entirely on teams of community members, takes this model a step further.4 It uses principles of social inclusion, social support, and team working in a "plan do study act" cycle as a way of delivering change at the community level. It suggests that empowered communities in deprived areas can achieve what health professionals alone are unlikely to achieve.
A model that shows that a health professional qualification is not necessary at all levels of service delivery is the peer led six week generic group programme for chronic illness self management developed at Stanford University.5 This programme has been adopted for widespread dissemination by the NHS as the expert patient programme.w5 Recent use of this model in a pilot programme for people with chronic severe mental illness in South Australia has shown positive outcomes.w6
Stepped care for depression has been more efficacious than standard care in randomised trials in the United States, with primary care nurses supervised by a specialist providing case management by telephone. Similarly, a UK model for the provision of brief interventions in primary care has been developed.w7 w8 Elements of this approach have been transferred to South Africa in a mental health volunteer training programme.w9
Adoption of programmes developed in a different setting requires a rigorous evaluation of their efficacy, effectiveness, and transferability. A more systematic evaluation might discern the key successful elements of these overseas programmes, something that is missing from McKenzie et al's article. Nevertheless, there is certainly no conceptual obstacle to the use of collaborative models for psychiatric disorders, and the models described should direct attention to determine what is transferable. They should also stimulate a look closer to home for examples in other areas of chronic illness care and a demand for the adoption of similar initiatives and resources from governments to address the crisis in prevention and management of mental disorders in developed countries.
References w1-w9 are on bmj.com
Competing interests: None declared.
References
McKenzie K, Patel V, Araya R. Learning from low income countries: mental health. BMJ 2004;329: 1138-40.
Institute for Health Improvement. The breakthrough series: IHI's collaborative model for achieving breakthrough improvement. Boston: IHI, 2003.
Wagner EH, Austin BT, Davis C, Hindmarsh M. Improving chronic illness care: translating evidence into action. Health Affairs 2001;20: 64-78.
National Primary Care Development Team. Healthy communities collaborative—wave II www.npdt.org/scripts/default.asp?site_id=4 (accessed 28 Oct 2004).
Lorig K, Ritter P, Stewart A, Sobel D, William Brown B, Bandura A, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care 2201;39: 1217-23.(Malcolm W Battersby, seni)
Although developed countries are relatively well resourced there is an unmet demand for mental health services, particularly for anxiety disorders and depression. A similar and escalating demand exists for services for other forms of chronic illness too, such as diabetes secondary to obesity. In both, the potential of community care is increasingly recognised.
The core elements that emerge from the models McKenzie et al describe are community involvement in the planning and delivery of services, harnessing social support, and providers with a diversity of skill levels in stepped services.1 Replicating these models in wealthy countries would require overcoming considerable barriers in the form of system inertia, multiple funders, funding that creates disincentives to provide alternative services, professional vested interests and boundaries, stigma, loss of the sense of community, breakdown of the family, and lack of resources for the treatment and prevention of mental disorders compared with medical conditions.
But there are examples of services in developed countries that have overcome some of these barriers. The use of collaboratives as a large scale method of bringing about change in the delivery of services for chronic illness have been widely used in the United States, United Kingdom, and Canada and, more, recently Australia.2 w1 These collaboratives base their programme for change on the six elements of the chronic care model,3 one of which is support for self management. Although these programmes have improved health outcomes, they have focused on diabetes and heart failure rather than on mental illness.w2-w4
The UK collaborative on falls prevention, which relies almost entirely on teams of community members, takes this model a step further.4 It uses principles of social inclusion, social support, and team working in a "plan do study act" cycle as a way of delivering change at the community level. It suggests that empowered communities in deprived areas can achieve what health professionals alone are unlikely to achieve.
A model that shows that a health professional qualification is not necessary at all levels of service delivery is the peer led six week generic group programme for chronic illness self management developed at Stanford University.5 This programme has been adopted for widespread dissemination by the NHS as the expert patient programme.w5 Recent use of this model in a pilot programme for people with chronic severe mental illness in South Australia has shown positive outcomes.w6
Stepped care for depression has been more efficacious than standard care in randomised trials in the United States, with primary care nurses supervised by a specialist providing case management by telephone. Similarly, a UK model for the provision of brief interventions in primary care has been developed.w7 w8 Elements of this approach have been transferred to South Africa in a mental health volunteer training programme.w9
Adoption of programmes developed in a different setting requires a rigorous evaluation of their efficacy, effectiveness, and transferability. A more systematic evaluation might discern the key successful elements of these overseas programmes, something that is missing from McKenzie et al's article. Nevertheless, there is certainly no conceptual obstacle to the use of collaborative models for psychiatric disorders, and the models described should direct attention to determine what is transferable. They should also stimulate a look closer to home for examples in other areas of chronic illness care and a demand for the adoption of similar initiatives and resources from governments to address the crisis in prevention and management of mental disorders in developed countries.
References w1-w9 are on bmj.com
Competing interests: None declared.
References
McKenzie K, Patel V, Araya R. Learning from low income countries: mental health. BMJ 2004;329: 1138-40.
Institute for Health Improvement. The breakthrough series: IHI's collaborative model for achieving breakthrough improvement. Boston: IHI, 2003.
Wagner EH, Austin BT, Davis C, Hindmarsh M. Improving chronic illness care: translating evidence into action. Health Affairs 2001;20: 64-78.
National Primary Care Development Team. Healthy communities collaborative—wave II www.npdt.org/scripts/default.asp?site_id=4 (accessed 28 Oct 2004).
Lorig K, Ritter P, Stewart A, Sobel D, William Brown B, Bandura A, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care 2201;39: 1217-23.(Malcolm W Battersby, seni)