The rise of community care

As hospitals closed, psychiatric services had to perform three functions. The first was to treat, in the community, patients with chronic psychiatric disorder who would previously have remained in hospital for many years. The second was to assist primary health services with the detection, prevention, and early treatment of the less severe psychiatric disorders. The third was to treat severe acute psychiatric disorder as far as possible without lengthy admission to hospital and as near as possible to the patient's home. These functions were to be carried out for a defined population. Services were to be comprehensive and deliver continuity of care, and be provided by multidisciplinary teams.

These general principles were applied rather differently in the UK and in the USA .

In the UK , emphasis was placed initially on the long-term care of patients with serious psychiatric disorders. In the USA , more emphasis was given to the prevention and early treatment of mental disorder as a way of avoiding admission to hospital. In the USA , the Joint Commission on Mental Illness and Health issued a report in 1961 recommending community treatment, delivered from community mental health centers (CMHCs) staffed from several disciplines. The centers offered psychological and social care and generally placed more emphasis on early intervention with acute problems (crisis intervention) than on the care of patients with chronic psychiatric disorders. This emphasis led to dissatisfaction with the centers as patients discharged from long-term hospital care found their way into private hospitals or prisons, or joined the homeless population of large cities.

In the UK and elsewhere, some commonly agreed principles about community services developed from these early experiences:

• Hospital care - Hospital admissions were to be brief, and as far as possible to psychiatric units in general hospitals rather than to psychiatric hospitals. Whenever practicable, patients were to be treated as out-patients or day patients.
• Rehabilitation - This was to be provided, originally with the hope that most patients would progress to independent living, but subsequently with the more modest aim of preventing further deterioration.
• Out-reach - Since some of the most vulnerable patients were unwilling to make use of the available care, staff had to take services to patients, and follow them actively.
• Multidisciplinary teams - Care was to be provided by teams which usually included psychiatrists, community nurses, clinical psychologists, and social workers, all of whom worked in collaboration with members of voluntary groups.
• Legal reform - In many countries new laws were introduced to limit the uses of compulsory treatment and to encourage alternatives to inpatient care. These reforms also reflected a greater public concern for the rights of the individual.
• User involvement - Users are increasingly involved in planning their own treatment and the services for populations.

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