The structural reform of mental health services.

During past decades many countries have initiated extensive mental health care system reforms, and the main goal of these reforms has been the transfer of treatment of the mentally ill from psychiatric hospitals to the community. For example, assessment of the results of these reforms in Italy and Austria demonstrates considerable reduction in the number of psychiatric beds, higher quality and more available community services, and increased total expenditure for mental health services. However, because sufficient data is not yet available, many questions regarding how these reforms impact improvement in patient clinical parameters remain unanswered. Some of the answers to these questions can be gleaned from the results of research carried out in the United States and Canada in the 1980s. This research evaluated transfer of psychiatric treatment from a hospital setting to a community service setting. The results demonstrated that community treatment models were more effective than a hospital treatment model in reducing the number of hospitalizations and shortening length of stay. Patient monitoring also demonstrated good integration into the community. However, alongside the research supporting these reforms, there is some research that demonstrates a number of possible disadvantages: an increase in the number of homeless and in the mortality rate among psychiatric patients, and an increase in rehospitalization rates of chronically ill patients," referred to as the "Revolving Door Syndrome." To avoid the disadvantages that could possibly accompany the reform, particular attention needs to be given to planning and funding, so that development of community services and reduction in psychiatric hospital system correspond. Care must be taken to ensure that the number and the geographic location of these services meets the need of the population at risk, and that staff is available and well trained. A monitoring system should be set in place to monitor the patients according to the clinical standards agreed upon, and at the same time guidelines should be set up to evaluate the functioning of community services. The structural reform is progressing and should be completed at the end of 2005. However, development of community services is not progressing at the desired rate. In January 2003, the Israeli government made a decision to transfer the responsibility for medical insurance for the mentally ill from the government to the Sick Funds. However, an agreement between the Ministry of Health, the Ministry of the Treasury and the Sick Funds has yet to be signed and the government's decision has yet to be realized. This has caused development of community services to come to a halt, and neither the government nor the Sick Funds are investing in community development. We can only hope that the transfer of responsibility for health insurance for the mentally ill from the State to the Sick Funds will be completed soon and that development of community service for the mentally ill will then move forward quickly.