Community-based mental healthcare (CMH) has increasingly been advocated for as an alternative to standard, institutional-based approaches to treating mental health. A new study, published in BMJ Global Health, found that community-based care outperforms institutionalized treatment in addressing severe mental illness.
The researchers were individuals from universities across Europe and were led by Laura Shields-Zeeman of Utrecht University in the Netherlands. They describe the implications of their findings:
“Recovery-oriented CMH for people with severe mental illness was effective in improving functioning and quality of life for people with schizophrenia, bipolar disorder and severe depression in five South-Eastern European countries and could be implemented across different health systems.”
Traditional approaches to treating severe mental illness tend to rely on the biomedical model, which emphasizes biological and genetic understandings of psychopathology. In this view, “mental illness” is framed as a biological problem instead of a normal response to traumatic experiences or broader social conditions like poverty or racism. Treatment then takes an institutionalized approach that relies on psychiatric drugs and, in severe cases, hospitalization.
The harms associated with this model, including that it contributes to social rejection, stigma, and discrimination, alongside the dangers of psychiatric drugs and forced hospitalization, have led researchers to urge psychiatry to abandon it.
Community-based approaches to treating mental health have been identified as alternatives that help to improve the health, wellness, and recovery of people struggling with severe mental health issues. The current study adds to a growing body of research supporting community-based frameworks.
The RECOVER-E project set out to create, put into practice, and examine a recovery-focused model of CMH for individuals affected by schizophrenia, bipolar disorder, and severe depressive disorder in five locations across Southeast Europe—Bulgaria, Croatia, Montenegro, North Macedonia, and Romania. The goal was to facilitate the transition from institutionalized mental healthcare to CMH grounded in evidence and oriented towards recovery.
Researchers conducted two non-blinded randomized controlled trials in which participants were randomized to receive CMH or treatment as usual (TAU), which primarily consisted of medication-based treatment and limited psychological treatment. CMH was implemented by multidisciplinary teams, with hospital staff assigned to each team and including at least one nurse, psychiatrist, psychologist, social worker, and peer support (or someone with lived experience of severe mental health issues). All team members received training in the Flexible Assertive Community Treatment (F-ACT) model, which takes a strengths-based approach and emphasizes service users’ recovery goals.
The CMH team met with service users mainly through home visits or community-based outpatient appointments. They provided medication management, psychological support, and referrals to social services. Working from a shared caseload, the team met regularly to review each user’s needs and decide who required more intensive case management.
Four hundred sixty-four participants were included in the CMH sample, and 467 were included in the TAU sample. Participants ranged in age from 19 to 89 years, with an average of 47.5 years. Most participants were women (52%), unemployed, and had been in treatment longer than 5 years (70.8%). The most frequently occurring condition among participants was schizophrenia.
Shields-Zeeman found that across all five sites, participants who received CMH had significantly lower disability than those who had received TAU at an 18-month follow-up. The researchers also reported that CMH produced a 6.4% higher treatment response rate than standard institutional care. That edge became statistically stronger after adjusting for COVID-19. The improvement is especially striking given that 70% participants had been in treatment for conditions such as schizophrenia, bipolar disorder, or severe depression for more than five years.
Finally, the study found that people receiving CMH reported a measurable boost in quality of life, scoring 0.07 higher on the EQ-5D scale — an improvement equivalent to roughly 25 extra days of full health. Crucially, this result held up even after researchers adjusted the analysis to account for COVID-19 disruptions.
One limitation of the study includes the impact of COVID-19 spikes that occurred during the study, which may have affected treatment delivery and outcomes, although statistical analyses were used to account for these disturbances. Additionally, outcomes were based on self-report measures, which may have influenced findings. Other limitations include study dropout and the lack of evaluation of adherence to the treatment protocol, which may have led to the CMH program not being carried out as planned across all five sites.
The study’s findings align with other recent research on the effectiveness of CMH. A 2017 international meta-analysis found that CMH reduced symptom severity and improved functioning at 18 months after treatment. Three more recent RCTs also found that CMH leads to better overall health outcomes and fewer severe symptoms than institutional care.
The researchers conclude:
“In short, our study provides evidence of the benefits of CMH delivered by CMH teams with the mandate and practical means to provide recovery-oriented services in improving functioning, reducing disability and improving quality of life compared with traditional, institution-based care. Such evidence is needed in the region of SEE to continue driving reforms focused on deinstitutionalisation and aimed at personal and social recovery and improving health-related quality of life in those most in need of it.”
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Shields-Zeeman, L., Smit, F., Wijnen, B., Roth, C., Wensing, M., Petrea, I., RECOVER-E consortium, Bolinski, F., Bajraktarov, S., Dedovic, J., Keet, R., Rojnic Kuzman, M., Nakov, V., Nica, R., Novotni, A., Tomcuk, A., Djurisic, T., Morales, G., Rotaru Anghelescu, T., & RECOVER-E study (2025). Community versus institutionalised care for people with severe mental illness in five countries in Southeast Europe: Pooled analysis of five randomised trials. BMJ Global Health, 10(10). doi:10.1136/ bmjgh-2024-018594 (Link)
Ashley, this is recycled information wrapped up in lightbulbs. The first community mental health centers that came out of the federal government were around President JFK’s time. Because of his sister’s Rosemary ‘s lobotomy he and other family members concerned. She then needed constant care ( she had developmental disabilities but her father was concerned about her becoming sexual active and resorted without consolation with his wife to this new tool). There was a big push for community federal funding and for de institualuzation.. The federal funding line for IDEA and ADA only part and parcel and it never really came to be – more state funded than anything else with some connections to Medicaid abd Medicare.
If one goes further back and MIA really needs a comprehensive timeline. I would be more than willing to work on this!
You need to go back to Bedlam and it’s tours and to Geel, Belgium and its old community village focus for people in crisis.
Then witch trails abd Inquisitions because many global Inquisitions not just in Spain.
Moral Treatmebt and then Eugenics also should be on the timeline. Cold Springs Harbor as well and the German researchers who came to study Jim Crow before the Holocaust.
We still don’t have a super great understand of why folks spiral into or out of crisis or altered states. All I can figure out is trauma, environmental issues and really so many grains of sands in this area, and also some sort of spiritual possible mystic type of experience. Could be all three or just one and hard to say. I do not know just guesses based on my life experience in all sort of ways.
We do not have a multimodal viewpoint and until we do any community or more institutional building approach is going to miss the points involved and many times harm and hurt rather than help.
Periods of time in history have seen improvements such as after WWI and WWII and a bit after the Vietnam War. But a bit here and there and many times voices talking not in unison but alone ( also the infighting and politics also censoring and suppression) and never ever in coordination.
Folks on this steamy have read the Mother Jones article on RFK JR concerns about gun violence. But oh my he has had trauma and I do t think has ever truly worked it all out. Some things yes so called called medication – not in anyway te be all and end all! But he has no other plan comprehensive or otherwise. So no.
We also have to deal with children. This world is hard and difficult. Violence and the powers that be just don’t care. Again many things out of joint and this we all are so to speak out of joint.
Please consider a timeline and target issues within that time line and slowly break it all down.
Summarizing a piece of research helpful for graduate school but doing something out of the box helpful for all and perhaps fior all the graduate students a new and out of the box way of dealing with our human species.
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If a “community mental health center” can solve your problem, then “mental illness” was not your problem. Psychiatry and psychology don’t know how to treat “mental illness,” and many practitioners are the most “ill.”
“Community clinics” are just a way for Medicine to extend its influence to more people. And that influence has largely been unhelpful if not actually damaging. Changes to the delivery structure are not what is needed. Changes to the personnel and their training is what’s needed, and a firm divorce of “mental health care” from Medicine.
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You have to have a community something. Community is essential and part of the loss of most community supports part of the problem of now. Robert Putnam wrote Bowling Alone in 2000 ish Mr. Cox. The writing on the wall was there. And how many people know where that phrase comes from? Ancient and in the the Hebrew Bible and the Book of Daniel. A great story for our times as is John Ruskin’s King of the Golden River and Robert Browning’s The Pied Piper and Mary Doria Russell’s The Sparrow. The community MH severely problematic but if one does not understand why the problems arose then an answer and solution will never be found. Plato’s Cave and his wonderful descriptive allegory of people seeing only what is front of them not behind,besides, below, above is so part of our current survivor of mental health treatment. Anyone can criticize the abuse was so rampant but it take a wise person with historical framework and deep understanding to say something important. Some folks can some folks never are able to move out of the box and look around with accurate information and historical perspective and with compassion.
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Most modern “community centers” are run by NGOs and manned by people who don’t even live in the neighborhood. “Community organization” is a part of the profession of Social Work (my dad taught it), but was used for political purposes instead of building real communities were none existed or were weakened. Community is basically a social skill that was damaged or lost during the Industrial Revolution.
Of course we need real communities. But psychologists are not going to make that happen. People have to re-learn the skills of community building and then go out and apply them. It’s being done in some places, and god bless the people doing it.
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Actually Mr Cox and I have twenty years post graduate Social Work experience and yes a parent was also a MSW! So originally the community mental health center approach was non medical. Some as in Lancaster, Ohio were peer run. Slowly over time the medical folks became the medical directors which may or may not have been total directors. Many directors just MSW with experience either through themselves, family members, or previous work.Not psychologists. Some MAs in clinical psychology , some clinical phds but only for consultation.In the early eighties especially in New York then is the rest of the USA the case management approach. That was a reworking recycling of the old case management approach of Ida Cannon and others with Out Patient Medicine or as the old term used Amblatory medicine. That in fact was taken by Jane Addams and others settle house creators in England and in the United States which was previously used in New England as with Abby Lowell Alcott who was the first paid social worker in Massachusetts. Note welll more elite folks and mainly white so the racism and elitism baked in but the smart ones like Jane Addams would say yes of course and the way society is at least we can play the game thus fighting the game by the white male capitalists gilded age merchant groups. She was good in that she actually followed sanitation workers in her ward because she felt corruption in the city at all levels and proved at least with sanitation services what was going on.She also had a long term same sex relationship which was not all the unusual hence the term Boston marriages.
Most folks involved in this type of struggle Nelly Bly, Jacob Riis, Lillian Wald, Edna Jane Hunter, were aware of the multimodality issues and tried with what they had available. The rise and fall of this type of social efforts is a continuous pattern and one needs to know a lot before one can really speak on and it’s complicated and I just have stumbled on a lot. I was not taught in my graduate experience about settlement houses or Robert Owen’s or the Moral Treatment movement of the Quakers and how it stopped because some folk didn’t get better And that the concept of some folks can only do so much with the life they have been given and our jobs a neighbors ,friends, relatives is to try to help them achieve a modicum of better. And many many times we fail and we failed badly. Community Mental Health Centers started again in the early eighties every person had to have goals and a treatment plan. The push became just bigger and better and this was with the developmentally disabled .So if one was doing great in as in a so called sheltered workshop this can’t be have them go to regular work even if that regular work was just too much People were never allowed just be be and I blame the MBAs and the surge of neoconservative stuff with Reagan. I still remember a man dying who had severe COPD and was so afraid the Reagan Social Security Department review would strip his payments. His parents were lovely Eastern European WWII immigrants and he was their only son. I still weep for that family. The son was killed by government induced fear. Sound familiar?
One needs a global timeline and a global highlighting of all the people involved in helping and yes also hurting. Then we all can look and try to se how to stop the patterns that hinder and do harm and create new patterns of hope and support.
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Obviously, Mary, you know a lot more about this than I do!
And rebuilding a sense of community in the “post industrial” age, when people move around so much and no longer feel connected to geographical location is a big challenge, maybe impossible.
But it is ultimately the way people should be organized. We start with individuals, who then form couples who create families (though that is breaking down), who participate in neighborhoods, and communities and towns, cities, states, nations. And we need all levels of the system operating for people to feel comfortable and not too oppressed.
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Yes, indeed! The medicalisation of mental health is the problem in my opinion. It can and does happen in hospitals and in the community – surely this was the original idea when the large asylums were emptied during the last century. Care in the Community was seen as the new idea – all with the assistance of the new medications available via Big Pharma. So, the Chemical Cosh is still alive and well within the community, causing all sorts of problems for people who find it hard to function because they are over-medicated. People are unable to deal with the usual issues of money management, housing issues, social issues, etc, which today is essential if you don’t want to end up homeless and living on the streets. The quality of people’s lives is sadly being made worse and, in some cases, destroyed. There needs to be a complete paradigm change with regard to mental health and emotional distress. The current system is not working because it relies almost totally on the view that the problems reside in the individual rather than looking at their social, psychological and environmental issues. It is necessary to ask the question “what happened to you” not “what is wrong with you?” The current system does more harm than good for many, many people and the medication/drugs used causes many people to become dependent on them – with no support or advice provided to reduce or withdraw from them. The evidence is all out there, so what are we waiting for? We don’t need more research which repeats the same questions and answers – be more curious and look at the alternatives to medicalisation, please. Be critical and sceptical – speak to service users and family members who know from experience what the difficulties are and what needs to be changed, please!!
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We must find a way to translate this excellent work to pediatric populations. The need is urgent because child-specific psychiatric hospitals are being built around the country to handle the rise in psychiatric crises and violence among children – most of whom have already been prescribed a book of psychiatric meds.
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Gretchen, I don’t know your background, but I don’t know why you are suggesting that children need ANY psychiatric “care.” Don’t you expect psychiatric community clinics to prescribe drugs, just like psychiatrists have been doing to everyone for several decades now? Psychiatric drugs commonly cause akathisia, which then leads to suicide attempts and violent behaviors in many people, especially younger people. Who is going to help children “recover” from psychiatry? That’s what I want to know.
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The idea of community mental health has been talked about for many years and seems, at least at first glance, like a good idea. Why then hasn’t it eventuated?
For what they may be worth, I would like to share some of my thoughts and experiences here.
For a start, mental health is a huge trillion dollar a year international business driven by multinational pharmaceutical companies and the psychiatric fraternity. These people have infiltrated related areas like text book and journal publishing, university research departments, public and social media and more. We refer to this powerful collective simply as Conservative Vested Interests (CVI’s).
The tentacles of the CVI’s reach far and wide into bureaucracies and government through powerful lobby groups and political cronyism. In my country, Australia, many of these people, particularly the ones advising government on mental health policy are in the top 1% of income earners. Obviously they are not going to readily relinquish control of that situation. The situation is probably not that different in others parts of the western world.
Taking on the CVI’s is a formidable undertaking. They are well funded and organized. They repeatedly show little respect for human well being, rights or laws and have openly attacked and destroyed a number of alternative efforts over the years. MIA’s own Robert Whitaker said in a blog not that long ago that it was a David vs Goliath scenario.
In Australia, there are now a number of organizations providing what looks at least something like alternative community oriented mental health services. These are typically not for profit Non Government Organizations (NGO’s) who derive most or all of their funding from government sources.
When you look at their websites and glossy brochures, many appear to be doing good things. A closer look behind the smoke and mirrors typically reveals that it is just the same old show, heavily oriented towards main stream biomedical psychiatry, with different window dressing.
To find out the truth about these organizations we talk to clients and where possible staff including lived experience (peer) workers whose insights can be very revealing.
A look at financial reports that few people bother to read can shed further light on their activities. Many of the CEO’s of these supposedly not for profit organizations draw similar salaries to people at the top of large public companies. Below them are inevitably large numbers of competitive underlings scrambling to try and climb the slippery slopes to the top. This inevitably establishes a competitive hierarchal environment oriented towards money, perks, power and empire building. The needs of their mental health clients are often little more than a means to their own self interested ends.
Not all these organizations rank equally. Some appear to be doing a half reasonable job but some are atrocious to the point of just being scandalous rorts of public funding. It takes quite a lot of time and effort to investigate these organizations so we make no claim to having looked at all of them. The ones that come most readily to our attention are the really bad ones with frequent reports of mistreatment.
Todate we have only found one organization in Australia that we would consider to be a true community based mental health service. They are located in Western Australia, the most remote state in the country in the remote South West corner of that state. Their name is Lamp Inc (https://www.lampinc.org.au/). You won’t find an over hyped glossy website.
They have been around for about 30 years. Nobody except the locals know much about them. They don’t spend time and money thumping their chest telling the world how great they are or that they are a “peak body” for something or other. They are too busy doing what they are supposed to be doing which is providing mental health services to their local community as well surviving financially.
There may well be other true community based organizations in Australia like Lamp Inc. We just haven’t come across them as yet.
Despite the formidable challenges, Lamp Inc shows that community based mental health services are possible.
Our own initiative has been to promote the idea of community based co-operatives owned and operated by peer workers. While many people have offered moral support and encouragement for this idea, interest from lived experience/peer workers, who actually have a lot to gain from such an endeavour, has so far been disappointing.
As soon as it is suggested to someone that they roll up their sleeves and engage in helping set up a community mental health co-op they inevitably mutter that they have other interests, obligations or commitments in their life and wander off into the sunset.
Anyone interested in more information about this community mental health coop effort may want to check out some of the information on our web site (https://PinkPantherActivists.au)
Community based mental health services are a viable, cost effective alternative to main stream and pseudo alternative mental health services but for it to happen, ultimately a group of like minded people have to somehow come together, get off their butts and do something.
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They are not “psychiatric hospitals,” they are psych wards. And they are designed to damage you beyond repair so that you will forever be reliant on the system either as someone who is placed in and out of involuntary and “voluntary” (which often becomes involuntary) and subscribed endless medications.
I was placed in an unjust involuntary psychiatric hold last year after trying to board a legitimate flight to Iceland as a double hurricane evacuee. The conditions and zero “treatment” that happened over my 7 day hold (when I was downgraded to voluntary 70 hours in) and the less than 30 minutes with actual doctors opened my eyes that we are still Cuckoo’s Nesting people, and this is part of the Psychiatric Industrial Complex and a modern day witch hunt.
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