Innovations in mental health care delivery.

In serious mental illness (SMI) even good community care does not usually make a major impact on clinical or social function, but patients and relatives prefer community to hospital care, and it tends to be cheaper. Any gains are lost if the required community services are not resourced, coordinated, and maintained indefinitely. A few SMI patients continue to need asylum under one roof. CPNs see more anxiety/depression than SMI. Their patients come increasingly from GPs, and they tend to work in practices with less need. Their cost-effectiveness is uncertain, although nurse behaviour therapists are cost-effective in anxiety disorders in primary care. Such research is also needed into the work of other mental health professionals. Despite their effectiveness, there is a dearth of behaviour therapists among nurses and psychiatrists. Problem-orientated training is lacking for most professionals with most patients. Behavioural self-treatments have improved phobic disorders and non-severe depression in controlled studies. Gains were as great when self-treatment was guided by a computer or by a manual as by a clinician. Self-help can extend care delivery, with therapists acting as consultants. Computers can also aid clinical audit.