Book Review
General Psychiatry
The Mental Health Matrix: A Manual to Improve
Services. Graham Thornicroft, Michele Tansella. Cambridge (UK):
Cambridge University Press; 1999. 291 p. CAN$125.05.
Reviewer
rating*: Excellent
Review by Jean-François Trudel, MD, FRCP
Sherbrooke, Quebec
In an epoch of information overload and tedious repetitions, books
of all kinds clamour for our attention. Once in a while, however,
a book stands out: readable, clear, succinct, timely, and pertinent,
it deserves to be widely read and quoted. This is such a book. Its
lackluster title obscure, its subtitle more eloquent, it is a manual
to improve services.
As clinicians, we aim to provide the best possible care to our
individual patients. Yet, in a public system, this essential individual
outlook is insufficient. Broader, more collective questions must
be asked: Are we providing care to those in our communities who
most need it? Are our services accessible, comprehensive, and well-coordinated?
Are resources fairly distributed? Are we spending available funds
on those services most likely to benefit patients? These concerns
are seldom voiced in our usual departmental meetings, where planning
decisions are often haphazard political affairs. Yet more and more,
we are held accountable to those who pay for these services: each
and every citizen-taxpayer.
These ethical concerns—a strong public health perspective,
a belief in the value of evidence-based practice, an explicitly
patient-centred approach, and a plea for better integration of research
and clinical practice—form the ideological backbone of this
book.
The authors are 2 psychiatrists well known in the fields of epidemiological
psychiatry and mental health service evaluation. They wrote this
volume because they
believe that a conceptual model is necessary to help formulate
service aims and the steps necessary for their implementation
Our aim is that this model will help people to diagnose the relative
strengths and weaknesses of services in their local area, and
to formulate a clear course of action for their improvement (p
4).
The conceptual model they offer explains the title of the book:
their “mental health matrix” is a simple 3 x 3 matrix.
The horizontal axis represents the temporal dimension divided in
3 sections: input, process, and outcome. Inputs are the resources
put into the mental health care system. Process is defined as the
activities that take place to deliver mental health services. Outcomes
are, of course, results—visible effects of our programs and
interventions. The vertical axis is the geographical dimension,
again divided in 3: the country or regional level, the local level,
and the patient level. The resulting 9 boxes serve as “organizers”
of the available data about services. For example, local budget
figures or the number of acute care beds available in your area
would fit in the local-level input box. The national suicide rate
would be an outcome indicator at the country-regional level. Improvement
in symptoms or level of functioning in a given patient would be
an example of outcome at the patient level. This last box, located
at the lower right-hand corner of the matrix, is of course the one
toward which all others converge—the ultimate aim and test
of our mental health services.
Part I of this book introduces the model and the public health
perspective of the work and reviews the historical evolution of
mental health services. Parts II and III elaborate on the model’s
geographic and temporal dimensions. This provides us with an overview
of the growing field of evaluative research. The available tools
to monitor and measure various aspects of the mental health care
system are described and often organized in clear lists.
Part IV is boldly called “Reforming Community-Based Mental
Health Services.” Here, the authors first review the evidence
base for mental health services. They provide us with methods to
assess local services and outline what they consider to be the essential
elements in any system of care. They describe the ethical values
upon which planning and reforming efforts should be based. A chapter
is devoted to issues of staff training and morale, a fundamental
and often overlooked aspect of mental health service systems.
Part V offers an international perspective. Authors from Australia,
Canada, the US, and Eastern and Nordic Europe assess the state of
services in their parts of the world. For Canada, this task has
been delegated to Montreal’s Alain Lesage—a prolific contributor
to the psychiatric epidemiology and service evaluation literature
and a member of the recent Best Practices in Reforming Mental Health
Services project commissioned by Health and Welfare Canada. His
description of the Canadian scene is spare and lucid.
Who should read this book? It is an excellent “crash course”
in administrative psychiatry. As such, it is a “must”
for chiefs of departments or others in local or provincial planning
roles. I recommend it highly for hospital or regional health board
administrators involved in mental health. Those planning psychiatry
residency training programs should consider using it as the text
for seminars on the planning, organization, and assessment of services.
Novice students of evaluation research methodology will find it
essential first reading. Busy clinicians who wish to understand
more fully and participate more meaningfullly in the health care
system in which their practices are embedded will be happy to find
it free of cant, highly informative, and brief. They will, I hope,
be convinced that evaluative research can potentially enlighten,
focus, and direct our everyday clinical efforts.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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