Just as American mental hospitals have downsized or closed since the
mid-20th century, the same trend has occurred throughout Europe. Europeans
with severe mental illnesses have had an advantage during these decades,
however, that Americans with severe mental illnesses have not had—the
establishment of comprehensive community mental health services to compensate
for the loss of institutionalized care.
Nonetheless, a new era of reinstitutionalization of the seriously mentally
ill may have begun in Europe, a study reported in the November 26, 2004,
British Medical Journal suggests. Reinstitutionalization in the study
is defined as placement in residential care or supported housing or in
prison.
The investigation was headed by Stefan Priebe, M.D., Ph.D., a professor of
social and community psychiatry at Queen Mary University of London. The study
team also included Durk Wiersma, M.D., a professor of clinical epidemiology of
psychiatric disorders at the University of Groningen in the Netherlands, and
other researchers.
Priebe and his coworkers had reason to believe that a new era of
reinstitutionalization for gravely mentally ill individuals might be beginning
in Europe because of isolated reports on the subject. They decided to
investigate the issue in England, Germany, Italy, the Netherlands, Spain, and
Sweden because these countries had experienced major mental health reforms
involving deinstitutionalization since the second half of the 20th century;
had fairly reliable data on mental health care; and represented different
traditions of mental health care, including Scandinavian, central European,
and Mediterranean.
They collected data from the six countries on conventional psychiatric
hospital beds (beds provided by psychiatric departments in public or private
hospitals; only a tiny minority of these beds are still long term for patients
with chronic disorders); involuntary hospital admissions; the number of places
in residential care or supported housing (which, while often regarded as an
alternative to psychiatric hospitals and a form of deinstitutionalization,
still constitute a form of institutionalization as defined by bricks and
mortar); forensic beds, and the general prison population. For each of these
categories, they investigated how numbers have changed since 1990.
They found that the number of conventional psychiatric hospital beds has
been reduced in five of the six countries—Italy is the
exception—and that changes in involuntary hospital admissions have been
inconsistent (they have risen in England, the Netherlands, and especially
Germany, but have fallen slightly in Italy, Spain, and Sweden). In contrast,
places in residential care or supported housing have increased in all six
countries (from 15 percent in Sweden to 259 percent in Italy). The number of
forensic beds has also increased (from 10 percent in Italy to 143 percent in
the Netherlands), and so has the size of the general prison population (from
16 percent in Sweden to 104 percent in the
Netherlands).FIG1
Thus, "reinstitutionalization [as defined by placement in residential
care or supported housing or in prison] is taking place in European countries
with different traditions of health care," they concluded,"
although with significant variation between the six countries
studied." In the Netherlands, for example, the number of conventional
psychiatric hospital beds has not changed much during the past few years,
Wiersma told Psychiatric News. "The increase of forensic
psychiatric beds is real, but concerns a rather small number of
patients," he added. "I doubt whether this will last."
Reasons for the apparent trend in reinstitutionalization remain to be
documented. However, Wiersma doubts whether it is due to an increase in cases
of severe mental illness. "Personally, I think that the most important
factor is a changed societal tendency toward risk containment and security as
indicated by the rising general prison population," Priebe said in an
interview. "In the history of psychiatry, there have repeatedly been
major shifts that had little to do with scientific evidence or new
developments within psychiatry, but were rather due to overall societal
processes."
In the event that such a reinstitutionalization trend is really occurring,
it shows "the need for a professional and public debate about the
ethical principles and, more importantly, specific values that underpin our
work in mental health care," Priebe asserted. "If nothing happens,
more and more funding will go into new institutions.... Also, it may lead to a
stronger split between mental health care for those who can actively seek
treatment and pay for it and mental health care for severely mentally ill
patients who would be subjected to a second class of institutionalized
care."
While Priebe is not aware of any study to explore the phenomenon of
reinstitutionalization in the United States, he believes that it might be a
worthwhile undertaking. "However, one should keep in mind that in the
United States, there are seven times as many people in general prisons as in
the average European country, and many of them suffer from mental illness.
Thus, an American study would probably have to pay particular attention to the
proportion of mentally ill people who are kept in prisons."
The study was funded by the East London and the City Mental Health
Trust.
An abstract of the study report, "Reinstitutionalization in
Mental Health Care: Comparison of Data on Service Provision From Six European
Countries," is posted online at<http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38296.611215.AEv1?maxtoshow=&....>▪