Inpatient Care in the 21st Century: Who Needs It?—In Reply

We appreciate Dr. Heath's feedback on our proposed model of inpatient care. In his book, he has championed “home treatment” as an alternative to hospitalization (1). Such proposals have been frequent over the past four decades, but they have gained little traction because anecdotally most clinicians in most countries have found them not to work for their patients over time or they turn out to be impractical or not financially viable.

To settle this issue, we look forward to a controlled study that compares our model of acute inpatient care with the three outpatient alternatives mentioned by Dr. Heath. The primary outcome measure should assess changes in the trajectory of the patient's life course over six to 12 months after discharge. The study should, of course, include measures of patient satisfaction and cost-effectiveness. We're all for “international research,” but we're not clear on which predictors can identify the 40% of patients for whom clinicians can “dispense with inpatient care” and the 60% who need inpatient care not only to prevent their illness from worsening but also to help them toward recovery.

We disagree with Dr. Heath's last paragraph. The issue is not where you treat patients who clinicians believe need inpatient care or how quickly you discharge them—or not admit them at all. Rather the objective is to provide controlled data on what is the most cost-effective treatment model in which mental health system to improve postdischarge outcomes for patients and their families, regardless of country.