Components of a modern mental health service: a pragmatic balance of community and hospital care

BackgroundThere is controversy about whether mental health services should be provided in community or hospital settings. There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas.AimsTo provide an evidence base for this debate, and present a stepped care model.MethodCochrane systematic reviews and other reviews were summarised.ResultsThe evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation.ConclusionsBoth community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.