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Rapid Responses: Rapid Responses published:
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Early intervention in psychosis
- Alasdair J Macdonald (19 September 2005)
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What evidence is needed for service reforms in mental health?
- Tom Burns (23 September 2005)
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Unrealistic standards for reform
- PATRICK MCGORRY (25 September 2005)
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Re: Unrealistic standards for reform
- tom burns (14 October 2005)
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Alasdair J Macdonald, consultant psychiatrist Forston Clinic, Dorchester DT2 9TB
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Early assessment and intervention in psychosis was practised commonly and often appropriately during the 1950’s and 1960’s in the United Kingdom. It declined as mental health resources were reduced to the present state in which even emergency care is hard to achieve. Early intervention in the community is a desirable idea but clients will also need access to adequate resources for continuing intervention thereafter, sometimes in hospital. Competing interests: None declared |
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Tom Burns, professor of social psychiatry university of oxford, warneford hospital, OX3 7JX
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Evidence based reform of mental health care In an issue of the BMJ with two large, well conducted trials of community mental health care McGorry (1) argues that innovation and development must precede a full evidence base. He also records the ‘loss of momentum and corresponding decay in services’ in his native Australia after their introduction. The studies cited illustrate two major challenges if improvements are to be sustained. First innovation and research do need to be distinguished with more realistic field testing before sophisticated trials. Not all change is improvement. Even if it is there needs to be evidence that it can be sustained to warrant the inevitable costs of reorganisation. Our work has demonstrated that evaluating new services may be misleading as they are often short-lived (2). Crisis intervention services (albeit different from current ones) were very much in vogue in the 1970s and 1980s but failed to convince clinicians (including those who ran them) and consequently faded. Few innovators publish retractions – they simply ‘move on’. Second research must go beyond simply proving that new demonstration services are better than their local controls. ‘Routine’ mental health services vary enormously. For instance the variation in outcomes in Assertive Outreach studies is almost entirely accounted for by variation in the control (not the experimental) services (3). Any extensive new service in an NHS which is resource capped and always short of skilled personnel must be able to demonstrate that its establishment did not adversly affect its control services. If studies of new services are to have an enduring influence on policy they must be able to meet these criticisms. They should also, preferably, provide some evidence of which specific aspects of the new intervention are responsible for patient improvements. Such approaches are beginning to be possible (2) but the head-to-head studies reported here , for all their elegance, are unlikely to confound the sceptics. A new generation of more focused studies with tighter characterisation of the differences between experimental and control conditions is now urgently needed. Reference List (1) McGorry, P. Evidence based reform of mental health care. Early, intensive, and home based treatments are the answer. BMJ, 2005; 331:586-587 (2) Wright C, Catty J, Watt H, Burns T. A systematic review of home treatment services. Classification and sustainability. Soc Psychiatry Psychiatr Epidemiol 2004;39:789-96. (3) Burns T, Catty J, Watt H, Wright C, Knapp M, Henderson J. International differences in home treatment for mental health problems. Results of a systematic review. British Journal of Psychiatry 2002 Nov;181:375-82. Competing interests: None declared |
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PATRICK MCGORRY, PROFESSOR ORYGEN YOUTH HEALTH Locked Bag 10 Parkville Victoria 3052 Australia
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Burns makes some reasonable points which should refine and enhance the process of reform. However I disagree with his analysis of the reasons for poor sustainability of reform in community psychiatry. The main drivers for this are financial, a lack of quality clinical leadership and the effects of reinsitutionalisation. As someone who has not "retracted" or "moved on", my experience tells me that, if the conditions are favorable, better outcomes are sustainable over a 15 year period, and can be built upon further. Furthermore, the studies reported recently in the BMJ cannot be dismissed as "demonstration models". They are examples of high quality health services research based around real world models of care. There is also a double standard inherent in Burns' argument. The variable existing treatment model is not required to be subject to research assessing its value for money. If the utopian standards proposed by Burns for system reform were rigidly imposed than we can expect variable and frequently unacceptable quality of care to remain in place for a very long time. Competing interests: None declared |
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tom burns, professor of social psychiatry, university of oxford, warneford hospital, oxford ox3
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Prof McGorry misunderstands the thrust of my concerns. It is precisely to serve as a bulwark against financially motivated 'backsliding' that community psychiatry research needs to be stronger and more rigorous. My point was that 'black-box' head-to-head RCTs are not the methodology to deliver this quality of evidence. Our review (1) of studies aimed to reduce inpatient care demonstrated that the main differences between successful and unsuccessful studies were due to the length of time patients in the control services spent in hospital. The time in hospital in the experimental arms of both ‘successful’ and ‘unsuccessful’ studies was the same. I certainly do not defend the unacceptable variation in current practice and I would agree with Prof McGorry about the sources of these. Indeed it is because of the evidence that routine variations are so important that I have my concerns. Conducting apparently rigorous RCTs which ignore them will fail to support the necessary change agenda. Researchers will only advance this subject by designing studies which carefully target the differences whose efficacy they aim to establish. Introducing wholesale changes and then interpreting any resultant benefits according to current preferences would not be accepted as strong evidence in other branchs of medical research. It is time we stopped accepting it as such in psychiatry. (1) Wright C, Catty J, Watt H, Burns T. A systematic review of home treatment services. Classification and sustainability. Soc Psychiatry Psychiatr Epidemiol 2004;39:789-96. Competing interests: None declared |
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