At home with psychiatric crisis

This is a timely publication. Rarely has there been such general public interest in the care of people with mental illness. But much of the debate has been ill informed. It is widely assumed that the only safe place to care for someone going through a psychiatric crisis is a hospital. Problems associated with institutional care are ignored and increasingly one hears the call for "more beds" to be provided. The contributors to this volume argue for an alternative.

This book arose from a study commissioned by the Department of Health. It is a multi-authored work and brings an international perspective to the debate. The first section covers principles and policies. The discussions herein are wide ranging. Liz Sayce and colleagues provide a useful summary of what users have asked for in terms of emergency psychiatry. They also provide a good discussion of the professional politics involved. Other contributions include reviews of existing services, legal aspects of emergency provision and the economics of community-based services. Kim Sutherby and George Szmukler provide an interesting discussion of how hospital-based assessments of need differ from those carried out in the community. The hospital environment lends authority to the medical perspective and so in this setting there is focus on subtle diagnostic considerations. When assessments are carried out in the client's own environment, assessments are often more "holistic" and practical.

In the second section contributors provide accounts of how they or their colleagues have established community-based emergency services. These contributions are testimony to the fact that it is possible to care for people in crisis out of hospital. The chapters relating to the provision of alternative accommodation in times of crisis are particularly impressive. Very often admission to hospital at these times is prompted by family tension rather than by psychiatric symptoms. Admission can be avoided if alternative places of care are available. Russell Bennet provides a fascinating description of a "family placement scheme" developed in conjunction with other services in Wisconsin.

The editors are to be congratulated for assembling such as comprehensive volume. It should be read by all involved in psychiatry. Its message is clear: there are safe and effective alternatives to hospital care for people with psychiatric problems.

Patrick Bracken is consultant psychiatrist, Bradford Community Health (NHS) Trust.