Views And Reviews

Community Mental Health Care: International Perspectives on Making it Happen

BMJ 1994; 308 doi: (Published 19 February 1994) Cite this as: BMJ 1994;308:544
  1. S Sussman

    Ed Christine Dean, Hugh Freeman Gaskell (Royal College of Psychiatrists), £10, pp 140 ISBN 0-902241-58-3

    The 1975 white paper Better Services for the Mentally Ill established a target of 47 900 inpatient beds at the end of its planned programme of hospital closures. Between 1981 and 1991, 35 000 psychiatric beds were closed in England and Wales, with 50 000 remaining.

    This trend, which was duplicated in many Western countries, was due largely to advances in psychopharmacology; but government parsimony in allocating resources to the most severely mentally ill patients, more liberal mental health acts in Western countries, the concept of “normalisation,” and the growing vocal and influential civil liberties movement also played a part. Getting patients out of hospitals led in many places to mentally ill people inhabiting prisons, lying on street gratings for warmth, and sleeping in overcrowded temporary shelters, with correspondingly profound levels of squalor and misery. This so called “community care” had two particular features - no care and no treatment.

    In Community Mental Health Care: International Perspectives on Making it Happen Dean and Freeman provide, with empirical examples, a guide to comprehensive, humane, and effective psychiatric care in the community. Hugh Freeman's scholarly portrayal of the history of community psychiatry in Britain complements the depictions by Leonard I Stein (United States), John Hoult (Australia), Peter McGeorge (New Zealand), and Christine Dean (Britain) of accessible, responsive, multidisciplinary, comprehensive systems of delivering mental health services. These contrast with mere two and three page chapters on the people who use the services, carers, and the measurement of outcomes. There are also some “implants” - descriptions of services in Tuscany and in the Czech Republic. Nevertheless, the book captures the mosaic of successful community mental health care.

    Unemployment, homelessness, family breakdown, and social problems are probably stronger indicators of psychiatric admissions to mental hospitals than psychiatric diagnoses. A mental health care service works properly when it recognises that patients need both social and physiological care in varying amounts. Psychiatry is currently emphasising genetics, biochemical disorders, and complex physiological processes in the treatment of mental illness. This, however, must not be to the exclusion of social factors. Partnership in provision is essential.

    Stein and Hoult accentuate the social and human dimensions of effective psychiatric care convincingly and concisely, with emphasis on the importance of the family and adequate community support such as housing, income maintenance, and social, recreational, and vocational opportunities. In this change of focus from institutional to community care the book is both visionary and pragmatic. In addition it is a good read.


    Scanning electron micrograph of a microfracture of a bony trabeculum in a woman with osteoporosis. From An Atlas of the Menopause (Parthenon, £38, ISBN 1-85070-329-9). The scope for photography in this subject is limited and most of the illustrations consist of prettily coloured graphs.

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