sábado, 10 de marzo de 2018

Towards WAPR Madrid 2018. Validity of Community Model.

    Today we know that the importance of the environment in the prognosis and evolution of people with mental illness is of the utmost importance. We know that whatever mental illness is, it is not a closed entity in itself that evolves according to internal rules, but a dynamic entity in whose evolution the environment plays a very important role.
EUCompass Meeting, Luxembourg, February 9th. 2018.
    One of the most curious findings of the early days of psychiatric epidemiology was that the prognosis of people with mental illness was better in developing countries than in developed countries (1). The interpretation of this finding suggests that, given that the diagnostic criteria were common, the differential factors (cultural, religious, or social) operated as more protective in countries with lower incomes in relation to the higher income countries.
    Another example of the importance of the environment as a factor in evolution was Leff and Vaughn's finding  (2), who showed through their Expressed Emotion construct the importance of the relational style of the family in the prognosis of the disease.
    Many indications such as these have emphasized the importance of the environment and the notion of "community", basic in the "community" approach to mental health, in opposition to the conceptually obsolete "institutional model" - although still in force in many countries of the world .
    However, the notion of "community", so that it is not an abstraction, needs to be specified in a network of services. It has been in that direction as the model has been developing and how numerous experiences and community care attention programs have appeared for more than 40 years.
    Examples of these services can be very numerous: community mental health services, Community Outreach Treatment, early intervention services for incipient psychosis, community rehabilitation services, special services as an alternative to hospitalization, crisis or home support teams, day hospitals, residential services and residential alternatives to long-stay hospitals, or employment support programs.
    At the recent meeting in Luxembourg of the EUCompass group, a report was presented (3) that included detailed analysis and an assessment of effectiveness and cost effectiveness of multiple different models and practices of community care in mental health in countries of the European region, whose conclusions are interesting to review.

    Although conceptually clearly obsolete, the institutional model - psychiatric hospitals that consume most of the resources in the care of a limited segment of the people in need - this model still remains in practice in many countries.
    In general, the reforms of many countries towards the community model have produced enormous advances, especially in the improvement of the living conditions of long-stay hospitals, in the development of accessible community services, in the integration of specialized services with services primary, in the protection of the human rights of people with mental disorders, and in the incorporation of users and family members in the improvement of services and policies.
    The community model proposes the transfer of resources from psychiatric hospitals to community programs. To date, the transfer of services has been only partial in most countries and regions.
    In general, the most important progress has been made in the placement of psychiatric services in general hospitals, followed by the creation of outpatient services in hospitals and in the community.
   Progress has been less in the implementation of primary health care services in mental health, in the exploitation of the possibilities of home treatment, implementation of sufficient rehabilitation resources, mobile teams of assertive treatment, implementation of self-help groups in the community, and in the development of the new possibilities of e-technology.
     The main barriers to the full implementation of the possibilities of the community model identified in the report remain the insufficient political priority that mental health receives in relation to the data that inform the real needs of the population and the effectiveness and cost indicators effectiveness of services. This is followed by the lack of consensus among the different interlocutors and cooperation between the social and health services, the difficulties to take advantage of the possibilities of integration of primary services in the mental health network, the absence of clear leadership in the sector and the resistance to change.
   As facilitating factors, situations of clear political support, adequate leadership and governance and alliance with user and family organizations are identified.

The WAPR Madrid 2018 congress will feature José Miguel Caldas de Almeida, one of the speakers of this report, in a special Symposium on mental health policies in Europe.

1-     Sartorius, N., Jablensky, A., & Shapiro, R. (1977). Two-year follow-up of the patients included in the WHO International Pilot Study of schizophrenia. Psychological Medicine, 7(3), 529-541.
2-     Vaughn  CE, Leff  JP: The measurement of expressed emotion in the families of psychiatric patients.  Br J Soc Clin Psychol. 1976;15157- 165.

3-   Killaspy, H., McPherson, P., Samele, C., Keet R., Caldas, JM: EU Compass for action, providing community-based mental health services, Position Paper. Funded by European Union, 3rd. EU Health Programme (2014-2020)