From efficacy to effectiveness in community mental health services

BACKGROUND: The PRiSM Psychosis Study investigated the outcomes of community mental health services for epidemiologically representative cases of psychosis in London. METHOD: The results presented in the preceding nine papers are interpreted. RESULTS: (a) The health and social gains reported in experimental studies of community health services are replicable in ordinary clinical settings, and are more effective than hospital-oriented services which they replace. (b) Dilution does occur--these gains are less pronounced than in experimental (efficacy) studies. (c) Both models of community services produced a range of improved outcomes. (d) Some limited extra advantages (in terms of met needs, improved quality of life, and social networks) were found in the intensive sector. (e) There is no consistent evidence that community-oriented services (which include in-patient beds) fail service users, their families or the wider public. On balance the results weigh slightly in favour of the two-team model (for acute and continuing care) in terms of clinical effectiveness, but the general model is almost as effective and is less expensive. CONCLUSIONS: The evidence supports a community-oriented rather than a hospital-oriented approach and there is little difference between the community mental health team models.