Acute hospital care

Sir: We have read with interest the editorial by Dratcu (Psychiatric Bulletin, February 2002, 26, 81-82). In developing countries such as ours mental health has come into national focus, with policy makers and health administrators recognising the importance of improving mental health services following the publication of the World Health Report (World Health Organization, 2001).

This document places much emphasis on care in the community and deinstitutionalisation. In Sri Lanka an international conference on mental health and psychiatry, organised by ‘Sahanaya’ (National Council for Mental Health) in April 2002 addressed the issues and challenges in community mental health care. Many international participants with experience in community care, especially from the UK and USA, cautioned the proponents of community care from rushing into such a model with scarce resources. They raised the practical implications of closing down large mental hospitals overnight, such as homelessness, social deprivation and even patients ending up in prisons. They reiterated the importance of recognising the role of acute hospital care and ensuring adequate provision of hospital beds and services for those with mental illness.

In Sri Lanka, with a population of more than 18 million people, there are but less than 2000 beds for psychiatric patients, with more than 1500 beds being confined to two mental hospitals. This, by any standards, is far below expectation. Most patients in the developing world, however, are traditionally managed in the community by family and friends. It is the severely ill, who are not stable enough to live and survive in the community, that remain in the mental hospitals. Experience shows that the readmission of these patients on discharge is also high.

This is by no means an attempt to downplay the role of community care in the developing world. On the contrary, care in the community should be promoted, even championed, but not for the sake of aping models implemented in the developed world that may not be relevant to our setting. Community care will have to be seen in its context and developed accordingly. The hazards of discharging patients with mental illness without sufficient care facilities, such as increased rates of suicide, have been addressed before (Morgan, 1992). It would be pertinent to strike a balance between community care and deinstitutionalisation so that individual patients and their carers are not sacrificed on the altar of ill-planned but well-meaning programmes.