Green and Gowans are right to worry about what has happened to the seriously mentally ill when the number of psychiatric beds has been mercilessly cut.1 However, it may be misleading when they talk of ‘a lack of evidence for community teams’ and then talk about crisis teams (CTs). The fact that CTs — often heralded as ‘the’ alternative to admission — perform poorly under scrutiny2 does not mean that community care is by necessity poor.
The rise of the so-called functional teams — CT, assertive outreach (AO), early intervention for psychosis — has not led to great (or at least greatly demonstrable) advantages for patients. A particularly salutary tale comes from the work of Killaspy et al.3 They used the community mental health team (CMHT) as treatment-as-usual comparator for an intensive case management model, the AO team. But be careful what the placebo is. While briefer follow-up looked promising,4 this longer follow-up eventually found AO to do scarcely better than the CMHT for a lot more clinical effort and presumably, cost.3 Early intervention for psychosis services, too, have had questionable benefits.5
All of this could, and should, be seen as evidence of the value of generic boring-but-important community mental health care on the district psychiatry model.6 The CMHT suffers from having come into the world essentially before the era of the randomised controlled trial, but some other research also indicates its usefulness among even the most severely ill long-stay patients.7
The authors here hint at a problem at the other side of the hospitals, acute presentation, which may explain their focus on CTs.1 When justly lamenting the increasingly poor provision of inpatient care for the most mentally ill in our society, though, it is as well to talk of the tangible relative success of the CMHT rather than the straw man of the CT.
- © British Journal of General Practice 2015