Background Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings, underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT). Objectives To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management. Search methods We searched The Cochrane Schizophrenia Group Trials Register (March 2006). We manually searched the Journal of Personality Disorders, and contacted colleagues at ENMESH, ISSPD and in forensic psychiatry. Selection criteria We included all randomised controlled trials of CMHT management versus non-team standard care. Data collection and analysis We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model. Main results CMHT management did not reveal any statistically significant difference in death by suicide and in suspicious circumstances (n=587, 3 RCTs, RR 0.49 CI 0.1 to 2.2) although overall, fewer deaths occurred in the CMHT group. We found no significant differences in the number of people leaving the studies early (n=253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). Significantly fewer people in the CMHT group were not satisfied with services compared with those receiving standard care (n=87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11). Also, hospital admission rates were significantly lower in the CMHT group (n=587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to accident and emergency services, contact with primary care, and contact with social services did not reveal any statistical difference between comparison groups. Authors’ conclusions Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide. The evidence for CMHT based care is insubstantial considering the massive impact the drive toward community care has on patients, carers, clinicians and the community at large.

Community mental health team management is superior to standard care in promoting greater acceptance of treatment, and may also reduce hospital admission and avoid deaths by suicide. This model of care is effective and deserves encouragement.

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Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favor of providing care in a variety of nonhospital settings, underpins the rationale behind care in the community. A major thrust toward community care has been the development of community mental health teams.

National clinical guidelines can provide a way for health professionals, patients and users of services to work together to make decisions about care. For guidelines to have a positive impact on the quality of care, however, it is important that they are valid. The validity of a guideline is determined by its evidence base. Patients and users of services can contribute evidence about the quality of care and its outcomes which can be used to enhance a guideline's validity. Patient evidence can be accessed from existing research studies, from studies designed expressly to examine patient views or from the direct contribution of patients and users of services to guideline development. A seminar was held to debate the timing and ways in which patients and users of services are most effectively, and to the satisfaction of all, involved in developing clinical guidelines. They key factors influencing the success of health care professionals, patients and users of services collaborating to develop guidelines were identified. These include: deciding who should represent an identified patient community, supporting patient representatives by ensuring that more than one representative joins a group, ensuring there are links with patient representative groups, and that all participants feel prepared and so on. The seminar also identified questions about collaborative working requiring further research.

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The first 590 patients referred to a community mental health service (the Early Intervention Service) in an inner-city district were separated into groups based on their referral source. The service has an open referral system allowing any agency (including patients) to contact the service by letter or by telephone, and priority is given to patients with serious mental illness. The results of open referral showed that the number of referrals was adequate for the service to process, the proportion of inappropriate referrals was similar in all referral agencies, and milder cases of mental illness were referred more often from doctors than from other agencies. It is concluded that an open referral system is likely to be more sensitive to need and has some advantage over closed referral arrangements in inner-city areas.