Vigorous, well designed trials are needed

EDITOR—Smyth and Hoult ask why the implementation of home treatment has been “delayed” in the United Kingdom and call for more “sophisticated evaluations” while continuing the same tired (and tiresome) polemic masquerading as science that holds up such progress.1 They present a categorical view of home treatment versus “the rest,” where only one of “the 12 features of an effective home treatment team” (several visits daily) is not available in some form in routine British mental health practice. How do Smyth and Hoult know that each of these 12 features is necessary or makes a difference? They do not. The series of studies they quote are all “black box” trials of complex and often poorly defined experimental services against even more poorly defined control services (often simply called standard care). To prove effectiveness, carefully controlled trials that vary only one component are needed. Smyth and Hoult did not quote our study (of which they were aware), which is one of the first community care studies to do this.2

Crisis intervention makes intuitive sense to physicians and surgeons used to myocardial infarcts and obstructed hernias. It does not sustain close scrutiny in mental health—breakdowns take days and weeks, not hours. Mental health services that are well linked to primary care and that offer reasonable access soon find that “crises” become a small part of their work. (The exception is in inner cities with many homeless mentally ill patients.) As Pelosi and Graham remark, crisis intervention services soon evaporate.3 These services are either …