Book Reviews |
Olson RP. Mental health systems compared.
Graham ThornicroftInstitute of Psychiatry, King's College, London
graham.thornicroft{at}iop.kcl.ac.uk
Olson RP. Mental health systems compared. Springfield, Illinois: Charles C. Thomas, 2006.
This compendious volume sets itself an ambitious goal: to fairly compare the mental health systems in Great Britain, Norway, Canada and the United States and to draw out lessons of how they can be improved. Dr Olson carefully sets the writers of each national review a framework for the task, namely to describe each system under five headings (overview, needs for mental health services, policies and programs, delivery systems and financing systems, and to evaluate them in key domains (access and equity, quality and efficacy, cost and efficiency, financing and fairness, protection and participation, and population relevance).
The chapter authors then set about their task with admirable dedication to detail. One clear use of these aggregated data is as an historical snapshot. Most scientific literature examines one particular aspect of a service in great detail, but rarely can we read an overview of the whole mental health landscape, as a point of reference with the past, and for future comparisons. At a set piece this book is therefore a tour de force in terms of its fine-grained characterization of mental health provision in four particular countries, especially as each system is in continuous flux.
A second benefit of this four horse race is to clarify for policy makers the relative benefits and disadvantages of each system as assessed under the 11 key domains chosen. Revealingly the US system rates relatively poorly for most of these criteria, even though its per capital total health expenditure (mental health spend is not given) is over half as much again as that in Canada and Norway, and over double that in the UK.
What these chapters do highlight quite clearly, however, is that almost all of the information which is available to be summarized reflects either system inputs or processes. Input data most often detail expenditure, numbers of facilities or beds, or types and numbers of staff. Process descriptors include a range of service activity measures, such as admission or discharge rates. However, the most important information we could have to judge an individual episode of care, or the success of a treatment programme, or the effectiveness of the system as a whole, depends upon the outcomes of care. It is precisely outcome data which are least often collected (and collated), and so this book necessarily presents us with a picture of vast and expensive human services operating largely blind to their effects upon patients. To their credit the authors acknowledge the limitations of the information they need to work with.
A further vital constraint, which is discussed well in the two concluding chapters of this book, is the fact that, even in these very well-resourced countries, most people with mental illness receive no treatment. This is the case in every country, and has not yet attracted policy attention as a scandalous degree of public health neglect, Acknowledging this, the authors do document the degree of unmet mental health need in the four countries considered, without necessarily going further to draw out the full policy implications to scale up mental health service coverage to an extent never yet seen in any part of the world.
Of course there are some quibbles: why were these particular countries chosen, how far are they representative of any others, are the data used compatible with the new WHO ATLAS and AIMS systems, why are local and regional variations within countries not given more prominence, why do the prevalence data reported exclude several anxiety and personality disorders, are the indicators used useful for future international comparisons?
Yet this book, both by what it reports and by what it cannot summarizes because of missing data, brings into clear profile important tasks which are necessary in future to allow informed decisions on whether mental health care is improving or not, within the post-deinstitutional era. The authors, correctly in my view, come to the conclusion that consumer ratings of outcome need to be central in rating service quality. They hint that the wider public context, going well beyond the formal mental health system, is a largely pernicious environment offering few sanctions against stigmatising and socially excluding reaction towards people with mental illness. The authors of Mental Health Systems Compared are therefore to be congratulated for providing us with such a wealth of data to mine, and for providing such a sharp profile of mental health care early in the new millennium.
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