Psychiatric care for more than 100 years has been more of a public responsibility than has care in other areas of medicine. Mental illness, because of concerns about social control and economic dependency, continues to be a community responsibility at local, regional, and national levels. Direct treatment and related supportive services are paid for with tax dollars, and the political marketplace has been even more important than the economic marketplace in the opportunities available to individuals and families for care and support.
When one combines these policy issues with the complexities of mental illnesses and human behavior, it is a real challenge to try to conceptualize and understand where we’ve been, where we are, and where we are going and to make rational decisions on allocating resources. The Mental Health Matrix by Thornicroft and Tansella, English and Italian psychiatrists, respectively, is a remarkable effort to develop a model that brings together the public health and individual patient care issues for clinicians, patients, families, and policy makers.
The typology itself combines both space and time concepts; that is, it has a geographical and temporal dimension and, therefore, can describe clearly where we have been and why and where we need to go.
The book is divided into five sections. The first introduces the concept of the matrix model and then draws some lessons from the history of public mental health care, tracing the major changes from asylum to community-based treatment. In the next two sections, the authors elaborate on their matrix, which includes the spatial dimensions of regional, local, and patient levels and the temporal dimensions of the input process and outcome phases of care. This serves as the basis for the systems approach that is elaborated in the fourth section, which includes a clear exposition on the ethics of care from a distributive justice perspective. In addition to ethics, the issues of human resources and evidence-based care are taken up in this section. Then, in the fifth and most compelling section, the authors invite pieces from five different contributors using the model to describe mental health systems in Australia, Canada, central and eastern Europe, the Nordic European countries, and finally the United States. A conclusion provides an agenda for reform for the future, but the book, I think, is even more valuable as a description of the past and the present.
One final comment. As the authors acknowledge, the increasing scientific basis of psychiatric care and the growth of evidence-based treatment will transform our systems and policies. These changes, which we can only begin to anticipate, will increasingly become much more outcome-driven. The politics and economics of care will conform much more closely to what we know we can do to help people. This gives us hope for the future, as this optimistic book suggests.
