Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.38296.611215.AE (Published 13 January 2005) Cite this as: BMJ 2005;330:123All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I can only talk about my experience in the female prison population
and what I do know from research undertaken in the UK into women
prisoners.
Whilst many women prisoners are mentally ill, it was mostly the
effect of incarceration and the removal from their children whilst being
many hundreds of miles from their families that caused that mental
illness, it was not the root cause of committing their crimes, that is
drug addiction, which as far as I am aware, is not classified as a mental
disorder.
Most women prisoners are convicted for non violent crime, the
majority of that relates to shop lifting.
In my own personal experience, it is the male dominated judicial
system in the UK, that is part of cause for the rise in the prison
population amongst women, the attitude being that if you are a woman you
must be punished for committing a crime of any sort as it 'is not expected
of you" particularly if you are a mother. The logic of this defies common
sense as separating mothers from their children in this manner has been
proven to contribute to reoffending. They lose their homes, jobs and in
many cases their children. The secondary factor appears to be how women in
today's society have changed in their attitudes towards alcohol and drugs.
As to the overall increase in the prison population, we have a
government that promises to "get tough on law and order" so the public
screams for punishment to be meted out, naively believing that if you lock
everyone up and throw away the key it will deter others and their lives
will be infinitely better and less crime ridden.
Prisons are so overcrowded now, that there is no realistic
possibility of any sort of rehabilitation for offending behaviour, prison
provides the public with a short break from the offenders, that is all and
if anything because of the conditions in prison, the offender will come
out with more problems than they entered with.
If just half the cost of imprisoning those with drug problems was
spent on rehabilitation we may just start to see some progress.
Sadly the reality is that not enough people care in order to bring
around the changes so desperately needed.
Competing interests:
Ex inmate at Low Newton Prison Durham, Foston Hall Derbyshire, Drake Hall Staffordshire
Competing interests: No competing interests
There could be many different reasons for the increasing general
prison population. It cannot be assumed that only the mentally ill are
responsible for this increase.
Competing interests:
None declared
Competing interests: No competing interests
Priebe et al did not fully comment on their findings in Italy. Over a
similar ten year period, both England and Italy experienced an increase in
the number of supported housing places and forensic beds. The authors
proposed that in England these increases were a consequence of the
reduction of psychiatric hospital beds. However during this period in
Italy the number of psychiatric hospital beds increased by 18%. Surely
this suggests a more complex relationship between the number of hospital
beds and the number of forensic beds and places in supporting housing.
Furthermore, it would be interesting to know the change over the ten year
period in the number of patients living in their own homes with the
support of more recently developed crisis resolution, home treatment and
assertive outreach teams.
Competing interests:
None declared
Competing interests: No competing interests
The conclusion of Priebe at al. that a process of re-
institutionalisation is taking place in the mental illness services of a
number of European countries is not born out by the data they present.
Indeed, the opposite conclusion is warranted. Even where the number of
places in ‘institutions’ has increased, the number of patients receiving
institutional care has clearly fallen markedly. An admission to a general
psychiatric bed is likely to be much shorter than that to a forensic unit
and even more so than residence in supported housing, which is intended to
provide assured, long-term homes: a single place is therefore used by many
more patients over the same time period.
For example, the extra 0.5 forensic beds and 6.4 supported housing
places per hundred thousand population provided in England between 1990
and 2001/2 will have been used by only a fraction of the several hundred
patients who might have been admitted to the 69 general psychiatric beds
that were closed over the same period, even allowing for repeated acute
admissions for some individuals.
Similar considerations apply to the figures from other countries,
including the Netherlands, where a small overall increase in places is
misleadingly presented as an example of considerable re-
institutionalisation.
There are of course also matters of principle involved, especially
the authors’ unfortunate conflation of very different milieus as simply
institutions: ‘defined by bricks and mortar’ - a particularly puzzling
definition in the case of houses. The corollary of this over-
simplification of a complex issue is that were the entire acute and
forensic hospital populations in any country to be transferred to
supported housing, no de-institutionalisation would be considered to have
occurred !
Competing interests:
None declared
Competing interests: No competing interests
Here are comparable data for Ireland. Rates are per 100,000
population and compare 1991 with 2003. Forensic beds fell from 2.2 to 1.8,
a decline of 18%, involuntary admissions dropped 24% from 89.9 to 62.2,
supported housing increased 19%, 67.5 t0 80.3, psychiatric beds went down
60% from 231.8 to 93.3 and prisoners increased 23% from 60.7 to 81.3.
Competing interests:
None declared
Competing interests: No competing interests
There is certainly a debate worth having about the changing forms of
mental health care across Europe, but more precise definition of key terms
is a prerequisite.
The term ‘reinstitutionalisation’ is particularly unhelpful, since
the drift of the authors’ argument, here and elsewhere (1,2), is that
‘deinstitutionalisation’ never actually occurred; the forms of
institutional care simply changed. ‘Trans-institutionalisation’ is no
better. We need a clear definition of what, in the authors’ view,
constitutes an institution or institutional care or, more important, what
does not count as such. Elsewhere, Priebe has admitted that ‘professional
mental health care is probably impossible to conceive without
institutions’ (1) and that he regards assertive outreach and early
intervention services as ‘institutional’ in nature (1-2). If that is so,
and the terms ‘mental health care’ (whether provided by statutory, private
or voluntary agencies), and ‘institutional’ are practically synonymous,
then any argument about de-, re- or trans-institutionalisation is
effectively meaningless.
________________________
1. Priebe S. Institutionalisation revisited—with and without walls.
Acta Psychiatr Scand 2004;110: 81-2.
2. Priebe S, Turner T. Reinstitutionalisation in mental health care.
BMJ 2003;326: 175-6.
Competing interests:
None declared
Competing interests: No competing interests
The wave of deinstitutionalisation of mentally ill patients has not
helped the mental health service. Managers use the magic word to reduce
beds, forgetting that the incidence and prevalence of acute mental illness
is rising.
What can we offer to patients who are very distressed, clearly
suffering and who need to be cared for in a hospital? Words and only words
of reassurance! Nursing staff making contacts three times a day to tell
the patient he will get well, and that he does not need to self harm! But
are we able to treat him this way or are we buying time for the natural
regression of an acute illness?!
Hospitals for the mentally ill need to be established with the aim of
resolving this acute phase, and then caring and treatment in the community
should be offered. But small and reducing budgets together with the magic
word, has and will continue to deny patients proper hospital care. Society
and legislation continues to look at mental illness as behavioral, rather
than as a biological illness which requires biological treatments.
Too much focus on care in the community has led to creation of
supported housing/accommodation, which is one form of low intensity
hospitalisation/institutionalisation. Yet even these are not sufficient
for the needs of growing numbers of patients.
Where will this circle stop?
Competing interests:
I am a Consultant Psychiatrist in UK struggling with the shortage of beds for acutely ill patients.
Competing interests: No competing interests
The authors have touched on some excellent points, including the
facts that supported housing is but psychiatric institutionalization in
disguise, and that the mental health field has been constantly expanding
its territory. A potential and quite plausible explanation they omitted,
is psychopharmacology's role in creating populations with CNS damage,
undermining in these populations the ability to live independently.
The authors' closing sentence, calling for professional and public
debate on the ethical basis for [medicine's] detaining and
"institutionalising" people, is somewhat surprising. Such debate is
already occurring lividly across the developed world. In particular Prof.
Dr. Thomas Szasz, often called "The Conscience of Psychiatry," has been
writing on this issue indefatigably for forty-five years.
Competing interests:
None declared
Competing interests: No competing interests
An interesting and timely study. Priebe et al bring into discussion
the historic perspective in the phenomenon of deinstitutionalisation in
mental health care throughout Western Europe. The wave of
deinstitutionalisation started in the 1950's; about 50 years on, the
authors conclude that we are witnessing the beginning of a reverse process
in the form of reinstitutionalisation or trans-institutionalisation.
It appears to me that there is a striking resemblance with the 'K-
waves' described in the field of politico-economics by Modelsky
(Washington - Political Science Department) as follows: "KONDRATIEFF WAVES
(or, for short, K-waves) may be defined as a pattern of regularity
characteristic of structural change in the modern world economy. Some 60
years in length, it consists of an alternation of periods of high sectoral
growth with others, start-up periods of slower growth. The study of this
pattern helps to trace the evolution of the global economy, and aids in
politico-economic prediction".
http://faculty.washington.edu/modelski/IPEKWAVE.html
Competing interests:
None declared
Competing interests: No competing interests
Re: Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries
Dear Editors,
1 in 20 adult Greeks, or 500,000 people, appear to be living permanently, in Psychiatric Hospitals, Mental Health Centers, Geriatric Hospitals, etc.
43% of all these mentally ill patients, appear to be treated in more than one psychiatric facility!
Thousands are registered under false social security numbers!
Thousands are nonexistent "ghost patients"!
Psychiatric Hospitals, Mental Health Centers, Geriatric Hospitals, etc, in Greece, have been claiming and receiving many more State and European Community funds than those they were supposed to, fraudulently.
Impostors, appearing as psychiatric patients, have been receiving sickness allowances.
This huge scam has managed to go undetected, even through the last 4 years of severe austerity measures and meticulous checks from European and IMF Commissioners!
References
http://translate.google.com/translate?sl=el&tl=en&js=y&prev=_t&hl=en&ie=...
http://translate.google.com/translate?sl=el&tl=en&js=y&prev=_t&hl=en&ie=...
http://translate.google.com/translate?sl=el&tl=en&js=y&prev=_t&hl=en&ie=...
http://translate.google.com/translate?sl=el&tl=en&js=y&prev=_t&hl=en&ie=...
http://translate.google.com/translate?sl=el&tl=en&js=y&prev=_t&hl=en&ie=...
http://translate.google.com/translate?sl=el&tl=en&js=y&prev=_t&hl=en&ie=...
Competing interests: No competing interests