Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries
Stefan Priebe, Alli Badesconyi, Angelo Fioritti, Lars Hansson, Reinhold Kilian,Francisco Torres-Gonzales, Trevor Turner and Durk Wiersma
2005;330;123-126; originally published online 26 Nov 2004;
BMJdoi:10.1136/bmj.38296.611215.AE
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Group includes D W Paty, S A Hashimoto, V Devonshire, J
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MS Society of Canada Scientific Research Foundation. CJW and
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Western Ontario and the University of British Columbia, which
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sis in white South-African-born and in white immigrants to South Africa. BMJ 1967;ii:724-30. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries Stefan Priebe, Alli Badesconyi, Angelo Fioritti, Lars Hansson, Reinhold Kilian, Francisco Torres-Gonzales, Trevor Turner, Durk Wiersma Abstract
supported housing. The general prison population
has substantially increased in all countries. Objective To establish whether reinstitutionalisation Conclusions Reinstitutionalisation is taking place in
is occurring in mental health care and, if so, with what
European countries with different traditions of health
variations between western European countries.
care, although with significant variation between the
Design Comparison of data on changes in service
six countries studied. The precise reasons for the
phenomenon remain unclear. General attitudes to
Setting Six European countries with different
risk containment in a society, as indicated by the size
traditions of mental health care that have all
of the prison population, may be more important
experienced deinstitutionalisation since the
than changing morbidity and new methods of mental
1970s—England, Germany, Italy, the Netherlands,
Outcome measures Changes in the number of
forensic hospital beds, involuntary hospital
Introduction
admissions, places in supported housing, general
Since the 1950s, deinstitutionalisation has dominated
psychiatric hospital beds, and general prison
population between 1990-1 and 2002-3.
Europe. Large asylums have been closed or downsized,
Results Forensic beds and places in supported
and the total number of psychiatric hospital beds has
housing have increased in all countries, whereas
changes in involuntary hospital admissions have been
inconsistent. The number of psychiatric hospital beds
Data sources are listed on bmj.com
has been reduced in five countries, but only in two
countries does this reduction outweigh the number of
This article was posted on bmj.com on 26 November 2004:
additional places in forensic institutions and
http://bmj.com/cgi/doi/10.1136/bmj.38296.611215.AEBMJ VOLUME 330 15 JANUARY 2005
fallen dramatically. Mental health services have been
Mediterranean countries. We thus included England,
established in the community, albeit with significant
Germany, Italy, the Netherlands, Spain, and Sweden.
We collected data on forensic beds, involuntary
Community mental health care is being further
hospital admissions, places in residential care or
developed in the United Kingdom through substantial
supported housing, conventional psychiatric hospital
additional investment in specialised teams such as
beds, and the general prison population. For each of
assertive outreach and early intervention. It has been
these categories, we investigated how numbers have
argued, however, that the new era of reinstitutionalisa-
changed since 1990. We chose this period of time
tion has already begun and has occurred largely unno-
because 1990 has a historical significance as the end of
ticed by the public and with little professional debate.5
the post-war period in Europe and the beginning of a
Major characteristics of reinstitutionalisation are the
new political era.7 If reliable data for the period since
rising numbers of forensic beds, involuntary hospital
1990 or for the whole country could not be
established, we used shorter periods and regional data.
However, the argument has as yet not been based on
As healthcare systems and legislation in the six
countries vary considerably, the precise definitions of
This paper presents data from six European coun-
forensic beds, involuntary hospital admission, and sup-
tries representing different traditions of health care.
ported housing also differ between some countries but
We aimed to establish whether reinstitutionalisation is
have been consistent over time within each country.
taking place and, if so, to what extent and with what
Although supported housing is often regarded as an
variation between European countries. We also wished
alternative to asylums and therefore a sign of deinstitu-
to investigate whether reinstitutionalisation compen-
tionalisation, it still represents a form of institutional-
sates for the loss of conventional psychiatric hospital
beds and how it compares against changes in thegeneral prison population. This rate can be seen as a
non-healthcare indicator of societal tendencies to riskcontainment, and data suggest that psychiatric
The number of forensic beds and places in supported
housing have increased in all countries (table). Involuntary admissions have risen in England, the
Netherlands, and, especially, Germany, but have fallenslightly in Italy, Spain, and Sweden. The number of
The study included data from six European countries
psychiatric beds has been reduced in all countries. In
that fulfilled the following criteria: experience of major
England, Spain, and Sweden, the number of psychiatric
mental health reforms involving deinstitutionalisation
beds that have been closed is greater than the total
within the second half of the 20th century; availability
number of additional forensic beds and places in sup-
of reliable and reasonably complete data; and
ported housing that have been established in the same
representation of different traditions of mental health
period of time. In Italy and the Netherlands, the
care, including Scandinavian, central European, and
increase in forensic beds and supported housing has
Number of forensic beds, involuntary hospital admissions, places in residential care or supported housing, psychiatric hospital beds,and prison population in six countries in 1990-1 and 2002-3. Values are numbers per 100 000 population unless stated otherwise
Service provision Netherlands
See bmj.com for data sources. *Data refer to restricted patients admitted to all (high security and other) hospitals. †Data for Emilia-Romagna, a region in northern Italy with a population of 4 million. ‡Data for Drenthe, a rural area with 450 000 inhabitants. §Data for Andalucia, the second largest region in Spain, with a population of 7 million. ¶Discharges from treatment under the Compulsory Care Act during a six month period. BMJ VOLUME 330 15 JANUARY 2005
been much greater than any decrease in conventional
What is already known on this topic
psychiatric bed numbers, whereas in Germany the bal-ance is approximately equal. The general prison popu-
lation has grown in all countries by between 16% and
deinstitutionalisation in mental health care remain
104%, and the two countries with the highest
imprisonment rate (England and Spain) have the low-est rate of forensic beds. We found no clear sign of a
Isolated aspects of reinstitutionalisation have been
harmonisation of provision between countries.
It has been argued that reinstitutionalisation
Discussion
reflects a new international pattern, but this is not
Limitations of methods
Comparing the absolute numbers of institutionalised
What this study adds
patients between countries is difficult because of inter-nationally varying definitions of the reported forms of
Reinstitutionalisation in the form of newly
care. The differences in definitions, legislation, and
established forms of institutionalised mental
healthcare systems cannot be overcome by a
health care has occurred in different European
descriptive study. Consistent definitions were used
within each country, however, and no major changes inmental health legislation have occurred that substan-
tially altered the threshold for involuntary care. This
psychiatric hospital beds and new provision of
paper thus focuses only on changes over time, and
institutionalised care varies between countries
these processes can be synoptically interpreted.
The general prison population has increased in all
Changes over time
the countries, and this may be linked to the
Involuntary hospital admissions have not increased in
all investigated countries, and no clear link exists
between changes in involuntary admission rates andchanges in numbers of hospital beds. Institutions asdefined by bricks and mortar—that is, forensic hospital
a mere shifting of placements from one structure to
beds and places in supported housing—have shown
another) remains debatable. It might depend on the
national balance between further reduction of hospital
The extent of the new process varies, with no clear
beds on the one hand, and newly established institution-
pattern of differences between northern and southern
alised care on the other. To clarify this, research is
Europe. We could speculate as to whether the increase
needed on the type of patients using each of the current
in institutionalised care since 1990 has compensated
designations (forensic, supported housing, psychiatric
for the loss of psychiatric beds in the three decades of
hospital, prison) and how many patients with severe
deinstitutionalisation before that. However, within the
mental illness are cared for outside of these defined
same period of time more or less comprehensive serv-
ices for community care have also been established to
Potential explanations
treat in the community patients with severe mental ill-
Several potentially testable hypotheses exist as to why
ness who, without these services, may well have been
former deinstitutionalisation now tends to be compen-
admitted to hospital.3 4 Research suggests that these
sated, or even over-compensated, for by reinstitution-
developments have indeed embraced care for a
alisation. The need for institutionalised care may have
number of patients with severe mental illness.9 Why
risen because of a greater frequency of illness, severity
health commissioners in six different countries have
of illness, or both, possibly influenced by increasing use
still decided to invest heavily in additional institutional-
of illegal drugs. Another reason may be the loss of
ised care is therefore unclear. This is particularly strik-
social support for mentally ill people in traditional
ing with respect to expensive forensic beds, as no
families—for example, because of women taking
evidence exists to show that the number of homicides
professional roles instead of being domestic carers.
committed by mentally ill people in the community
Mental health care may have widened its remit and
has risen in the process of deinstitutionalisation.10–13
taken patients that it would not have considered as its
Reinstitutionalisation or trans-institutionalisation?
clientele 20 years ago, such as patients with personality
Most of the data are consistent with the assumption that
disorders, but no evidence exists that substantial num-
deinstitutionalisation, the defining process of mental
bers of these new patients have ended in supported
healthcare reforms since the 1950s, has come to an end.
housing and forensic beds. Furthermore, private
Although the number of psychiatric hospital beds has
providers may have successfully widened their share of
further decreased in five of the six studied countries
the market and secured profitable funding for an
since 1990, this was partly or more than compensated
increased supply of institutionalised care.8
for by additional places in other forms of institutional-
The substantial increase in the general prison popu-
ised care. This evidence indicates, therefore, that a
lation, however, suggests that reinstitutionalisation in
degree of new institutionalisation does exist as an inter-
mental health care might not be due to specific factors
national phenomenon, despite wide differences in
of morbidity or healthcare delivery, but might rather be
healthcare systems between the countries studied here.
driven by a “zeitgeist” towards risk containment in 21st
Whether this process should be described as reinstitu-
century European society. This pertains even though we
tionalisation or only as trans-institutionalisation (that is,
do not know how the proportion of mentally ill prison-
BMJ VOLUME 330 15 JANUARY 2005
ers among the prison population has changed over
Becker T, Vazquez-Baquero JL. The European perspective of psychiatricreform. Acta Psychiatr Scand 2001;410(suppl 1):8-14.
time. Whatever the case, the data provided here
Fakhoury W, Priebe S. The process of de-institutionalisation: an interna-
underline the need for more specific research into the
tional overview. Curr Opin Psychiatry 2002;15:187-92.
Freeman H. Community psychiatry. In: Freeman H, ed.
phenomenon and causation of reinstitutionalisation. In
psychiatry. London: Mosby-Wolf, 1999:213-8.
addition, a professional and public debate is needed on
Jones K. Asylums and after. London: Athlone Press, 1993.
the ethical basis for detaining and “institutionalising”
Priebe S, Turner T. Reinstitutionalisation in mental health care. BMJ2003;326:175-6.
patients with severe mental illness.
Fazel S, Danesh J. Serious mental disorder in 23,000 prisoners: a system-atic review of 62 surveys. Lancet 2002;359:545-50.
Levy C. Three post-war eras in comparison: western Europe 1918-1945-1989.
Contributors: The study idea originated from SP and was further
developed in discussions with TT and specified in communication
Priebe S. Institutionalisation revisited—with and without walls. Acta
with all authors. All authors agreed on the study design and are
Psychiatr Scand 2004;110:81-2.
guarantors for data from their country: AF for data from Italy, LH
Leff J, Trieman N, Knapp M. The TAPS project: a report on 13 yearsresearch, 1985-1998.
for Sweden, RK for Germany, FT-G for Spain, DW for the Nether-
Psychiatr Bull 2004;24:165-8.
10 Munro E, Rumgay J. Role of risk assessment in reducing homicides by
lands, and SP for the United Kingdom. AB coordinated the data
people with mental illness. Br J Psychol 2000;176:116-20.
collection. Data interpretation was agreed among all authors. SP is
11 Taylor PJ, Gunn J. Homicides by people with mental illness: myth and
the overall guarantor for the paper.
reality. Br J Psychol 1999;174:9-14.
12 Safety first: five year report of the National Confidential Inquiry into Suicide and
Funding: East London and the City Mental Health Trust. The
Homicide by People with Mental Illness. London: Department of Health,
funding was through the R&D budget of the trust. East London
and the City Mental Health Trust did not influence the design of
13 Shaw J, Amos T, Hunt IM, Flynn S, Turnbull P, Kapur N, et al. Mental ill-
the study, data collection, or presentation of the findings in any
ness in people who kill strangers: longitudinal study and national clinicalsurvey. BMJ 2004;328:734-7.
way. Competing interests: None declared. Use of clomifene during early pregnancy and risk of hypospadias: population based case-control study Henrik Toft Sørensen, Lars Pedersen, Mette Vinther Skriver, Mette Nørgaard, Bente Nørgård, Elizabeth E Hatch
Clomifene is widely used for inducing ovulation.1 It is
diseases, eighth revision) until the end of 1993 and
structurally related to diethylstilbestrol, which has been
ICD-10 after 1993. The codes for hypospadias in
linked to vaginal and cervical clear cell adenocarci-
ICD-8 are 752.20, 752.21, 752.22, 752.28, and 752.29;
noma in women exposed in utero. The adverse effect is
in ICD-10, the codes are Q54.0, Q54.1, Q54.2, Q54.3,
less severe in sons, although links to testicular cancer
and urogenital anomalies, such as epididymal cysts,
We found a total of 319 cases of hypospadias (any
have been reported.2 3 A recent study also found an
time post partum) in the four counties. From the Dan-
increased risk of hypospadias in the sons of women
ish birth registry, which contains information on all
exposed to diethylstilbestrol in utero.4 Clomifene has a
births in Denmark since 1 January 1973, we selected a
half life of about five days, but its metabolites have been
control group of 10 records of male births without a
found in blood samples on day 22 of the menstrual
diagnosis of hypospadias and with a full prescription
cycle and in faeces up to six weeks after administra-
history during the same period. We matched cases and
tion.5 The occurrence of hypospadias may be
controls for birth month, birth year, and county of resi-
Bente Nørgårdassociate professor
increasing. Little is known about the risk of
hypospadias in boys born to women who have used
The Danish national health service reimburses part
of patients’ expenditure on many prescribed drugs,
including clomifene. The four counties have pharma-
Methods and results
cies equipped with electronic systems that record
information on the drug, dose, personal identification
Our case-control study was done in the Danish
number, and date of dispensing of the drug. All data
counties of North Jutland, Aarhus, Viborg, and
are transferred to a research database at Aarhus
Ringkjoebing (population 1.6 million, with 65 383
University Hospital. The data from the four counties
male births in the study period: 1989 to 2002, North
are electronically available from 1 January 1989 (North
Jutland 34 859; 1996-2002, Aarhus 20 382; and 1998-
Jutland), 1 January 1996 (Aarhus), and 1 January 1998
2002, Viborg 4148 and Ringkjoebing 5 994).
(Ringkjoebing and Viborg). We took data on all
We identified all cases of hypospadias that had a
prescriptions for clomifene during the first trimester
full prescription history in the period 1989-2003 from
and 90 days before conception. To avoid confounding,
the Danish hospital discharge registry, which contains
we also took data about prescriptions for antidiabetic
all discharges from hospitals in Denmark since 1977and includes 10 digit personal identifiers, surgical pro-cedures, and up to 20 discharge diagnoses classified
This article was posted on bmj.com on 21 December 2004:
according to ICD-8 (international classification of
http://bmj.com/cgi/doi/10.1136/bmj.38326.606979.79BMJ VOLUME 330 15 JANUARY 2005
U ϭ 4.0, P ϭ 0.028), when birds are onlymoving away from the shelf area during thefirst day of foraging. The difference wasonly due to the higher sinuosity of tracksduringHenri Weimerskirch,1,2* Francesco Bonadonna,1(0.294 Ϯ 0.084), where birds are known toFre´de´ric Bailleul,1 Ge´raldine Mabille,1 Giacomo Dell’Omo,3catch most prey ( 9 ), compared with whenbirds were over the
LIR003 – PROGRAMME NOTES The New Music Players & Five Commissions This CD is the result of a three year cycle of commissions initiated in 1999. The Foundation for Sport and the Arts was the main funder and also supported the recording. The Brighton Festival hosted the ensemble in 2000 and 2001 as part of its contemporary music weekend, and commissioned three of the works. Yorkshir