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The balanced care model: the case for both hospital- and community-based mental healthcare

  • Graham Thornicroft (a1) and Michele Tansella (a2)
Summary

The balanced care model proposes that a comprehensive mental health system needs to include both community-and hospital-based care. The model is based on a structured review of scientific evidence, and is also informed by the experience of experts active in mental health system change in many countries worldwide.

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Copyright
Corresponding author
Graham Thornicroft, Professor of Community Psychiatry, Health Service and Population Research Department, King's College London, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email: graham.thornicroft@kcl.ac.uk
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Declaration of interest

None.

Footnotes
References
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1 Thornicroft, G, Semrau, M, Alem, A, Drake, RE, Ito, H, Mari, J, et al. Global Mental Health: Putting Community Care into Practice. Wiley-Blackwell, 2011.
2 EUROSTAT. Psychiatric Care Bed Hospitals in Europe: TPS00047. EUROSTAT, 2011 (http://epp.eurostat.ec.europa.eu/tgm/table.do?tab=table&init=1&plugin=1&language=en&pcode=tps00047).
3 Watts, BV, Shiner, B, Klauss, G, Weeks, WB. Supplier-induced demand for psychiatric admissions in Northern New England. BMC Psychiatry 2011; 11: 146.
4 Thornicroft, G, Tansella, M. Components of a modern mental health service: a pragmatic balance of community and hospital care. Overview of systematic evidence. Br J Psychiatry 2004; 185: 283–90.
5 Thornicroft, G, Szmukler, G, Mueser, K, Drake, R. Oxford Textbook of Community Mental Health. Oxford University Press, 2011.
6 Thornicroft, G, Tansella, M. Better Mental Health Care. Cambridge University Press, 2009.
7 Eaton, J, McCay, L, Semrau, M, Chatterjee, S, Baingana, F, Araya, R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet 2011; 378: 1592–603.
8 Dua, T, Barbui, C, Clark, N, Fleischmann, A, van Ommeren, M, Poznyak, V, et al. Evidence based guidelines for mental, neurological and substance use disorders in low- and middle-income countries: summary of WHO recommendations. PLoS Med 2011; 8: 111.
9 Patel, V, Thornicroft, G. Packages of care for mental, neurological, and substance use disorders in low- and middle-income countries: PLoS Medicine Series. PLoS Med 2009; 6: e1000160.
10 Tansella, M, Thornicroft, G. Implementation science: understanding the translation of evidence into practice. Br J Psychiatry 2009; 195: 283–5.
11 Whiteford, H, Buckingham, B, Manderscheid, R. Australia's National Mental Health Strategy. Br J Psychiatry 2002; 180: 210–5.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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The balanced care model: the case for both hospital- and community-based mental healthcare

  • Graham Thornicroft (a1) and Michele Tansella (a2)
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eLetters

Problems with clinical staging of mental illness

Andrew A. Amos, Associate Lecturer
10 April 2013

Scott and colleagues (1) continue recent efforts to construct a viable model of clinical staging for mental illness, most notably for psychotic illness (2). The only respect in which clinical staging can be distinguished from the universally applicable model of matching care to the individual presentation is the implicit assumption of the staging model that action at an earlier stage can prevent progression to later stages.

Unfortunately, the evidence to date suggests that early intervention in psychosis does not modify disease progression. Despite early promise, intervention in the ultra-high risk period may delay but does not prevent progression to psychotic illness (3). Reducing the duration of untreated psychosis does not lead to sustainable differences in symptomatic, functional, or remission measures (4). Finally, intensive intervention in the early stages of psychotic illness appears to be beneficial while the intervention continues, but does not alter long-term outcomes (5).

The danger of constructing a clinical staging model in defiance of the evidence is that it matches the implicit assumption of progression with an implicit promise of prevention. Our current knowledge does not allow us to advise policy-makers, or patients with subthreshold psychotic symptoms, confirmed first-episode psychosis, or later stages of psychotic illness, that earlier or more intense treatment will prevent progression, only that there are treatments that can reduce symptoms and improve function.

References

1. Scott J, Leboyer M, Hickie I, et al. Clinical staging in psychiatry: a cross-cutting model of diagnosis with heuristic and practical value. Br J Psychiatry 2013 202(4):243-5.2. Fusar-Poli P, Yung AR, McGorry P, van Os J. Lessons learned from the psychosis high-risk state: towards a general staging model of prodromal intervention. Psychological Medicine, Available on CJO doi:10.1017/S00332917130001843. Stafford MR, Jackson H, Mayo-Wilson E, Morrison AP, Kendall T. Early interventions to prevent psychosis: systematic review and meta-analysis. British Medical Journal 2013; 346:f185.4. Hegelstad WvV, Larsen TK, Auestad B, et al. Long-term follow-up of the TIPS early detection in psychosis study: Effects on 10-Year outcome. Am J Psychiatry 2012; 169(4):374-380.5. Bertelsen M, Jeppesen P, Petersen L, et al. Five-year follow-up of a randomized multi-center trial of intensive early intervention vs standard treatment for patients with a first-episode of psychotic illness The OPUS trial. Archives of General Psychiatry 2008; 65(7):762-771.

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Conflict of interest: None declared

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