The development of de-institutionalization in Europe

Programmes that bring mental health services to primary care populations in the international setting

The last decade has witnessed an exponential growth of evidence-based care packages for mental, neurological, and substance use disorders (MNS) aimed at primary care populations; however, few have been taken to scale. Several barriers to successful integration and scale-up, such as low acceptability, poor clinical engagement process, lack of targeted resources, and poor stakeholder and policy support have been cited. This review describes and highlights common features of some of the promising programmes that deliver mental health services through primary health clinics, communities, and digital platforms, with an emphasis on those that show some evidence of complete or partial scale-up. Three distinct overarching themes and initiatives are discussed in relation to the above; primary health facilities, community (outside of primary healthcare), and digital/internet-based platforms, with a focus on how the three may interact synergistically to enhance successful integration and scale-up.

Stigma and higher rates of psychiatric re-hospitalization: São Paulo public mental health system

OBJECTIVE

The aim of this study was to assess re-hospitalization rates of individuals with psychosis and bipolar disorder and to study determinants of readmission.

METHODS

Prospective observational study, conducted in São Paulo, Brazil. One hundred-sixty-nine individuals with bipolar and psychotic disorder in need of hospitalization in the public mental health system were followed for 12 months after discharge. Their families were contacted by telephone and interviews were conducted at 1, 2, 6 and 12 months post-discharge to evaluate readmission rates and factors related.

RESULTS

One-year re-hospitalization rate was of 42.6%. Physical restraint during hospital stay was a risk factor (OR = 5.4-10.5) for readmission in most models. Not attending consultations after discharge was related to the 12-month point readmission (OR = 8.5, 95%CI 2.3-31.2) and to the survival model (OR = 3.2, 95%CI 1.5-7.2). Number of previous admissions was a risk factor for the survival model (OR = 6.6-11.9). Family's agreement with permanent hospitalization of individuals with mental illness was the predictor associated to readmission in all models (OR = 3.5-10.9) and resulted in shorter survival time to readmission; those readmitted were stereotyped as dangerous and unhealthy.

CONCLUSIONS

Family's stigma towards mental illness might contribute to the increase in readmission rates of their relatives with psychiatric disorders. More studies should be conducted to depict mechanisms by which stigma increases re-hospitalization rates.

Psychiatric inpatient expenditures and public health insurance programmes: analysis of a national database covering the entire South Korean population

BACKGROUND

Medical spending on psychiatric hospitalization has been reported to impose a tremendous socio-economic burden on many developed countries with public health insurance programmes. However, there has been no in-depth study of the factors affecting psychiatric inpatient medical expenditures and differentiated these factors across different types of public health insurance programmes. In view of this, this study attempted to explore factors affecting medical expenditures for psychiatric inpatients between two public health insurance programmes covering the entire South Korean population: National Health Insurance (NHI) and National Medical Care Aid (AID).

METHODS

This retrospective, cross-sectional study used a nationwide, population-based reimbursement claims dataset consisting of 1,131,346 claims of all 160,465 citizens institutionalized due to psychiatric diagnosis between January 2005 and June 2006 in South Korea. To adjust for possible correlation of patients characteristics within the same medical institution and a non-linearity structure, a Box-Cox transformed, multilevel regression analysis was performed.

RESULTS

Compared with inpatients 19 years old or younger, the medical expenditures of inpatients between 50 and 64 years old were 10% higher among NHI beneficiaries but 40% higher among AID beneficiaries. Males showed higher medical expenditures than did females. Expenditures on inpatients with schizophrenia as compared to expenditures on those with neurotic disorders were 120% higher among NHI beneficiaries but 83% higher among AID beneficiaries. Expenditures on inpatients of psychiatric hospitals were greater on average than expenditures on inpatients of general hospitals. Among AID beneficiaries, institutions owned by private groups treated inpatients with 32% higher costs than did government institutions. Among NHI beneficiaries, inpatients medical expenditures were positively associated with the proportion of patients diagnosed into dementia or schizophrenia categories. However, for AID beneficiaries, inpatient medical expenditures were positively associated with the proportion of all patients with a psychiatric diagnosis that were AID beneficiaries in a medical institution.

CONCLUSIONS

This study provides evidence that patient and institutional factors are associated with psychiatric inpatient medical expenditures, and that they may have different effects for beneficiaries of different public health insurance programmes. Policy efforts to reduce psychiatric inpatient medical expenditures should be made differently across the different types of public health insurance programmes.

The "social case": Illness, psychiatry, and deinstitutionalization in postsocialist Romania

In this article, I examine the use of an ad hoc medical category--the "social case"--by psychiatrists in contemporary Romania. "Social cases" receive intensive psychiatric care, usually through long institutional stays, remaining hospitalized because psychiatrists perceive them as too poor and, thus, "unfit" to survive without the welfare assistance provided by institutionalization. The "social case" label emerges at the intersection of (1) plans by the state to deinstitutionalize public mental health care, (2) the rise of a new class of downwardly mobile and increasingly poor formerly working-class people, and (3) the desire of psychiatrists to protect their patients in the face of neoliberal assaults on Romanian welfare state support for publicly funded mental health care. Disability status, illness categories, and everyday medical practices have become battlegrounds for struggles over medical understandings of the psychological distress and illnesses that grip what I call the "New Poor" in postsocialist Romania.

Operating conditions of psychiatric hospitals and early readmission--effects of high patient turnover

OBJECTIVE

To study the association between hospitals' operating conditions and the risk of early readmission. The hypothesis was that high patient turnover might lead to a rise in the risk of readmission soon after discharge (within 30 days).

METHOD

A multivariate model including hospital and patient variables was tested using Cox's regression analysis, adjusting for clustering effects. The material included data from 20 hospitals, with 5,520 patients in the final model.

RESULTS

High patient turnover (annual discharges per bed) was significantly associated with an increased risk of readmission (hazard ratio (HR)= 3.37 (95% CI = 2.39-4.75)). In addition, being discharged from a ward with relatively low access to therapists increased the hazard further.

CONCLUSION

High patient turnover at the discharging ward was found to increase the patients' hazard of early readmission. This observation supports the hypothesis of a link between the operation conditions of the hospitals and patient outcome on a short time-scale.

[Deinstitutionalization in psychiatry: revising our principles of community psychiatry or failure of deinstitutionalization!]

OBJECTIVE

To update community psychiatry principles within the context of increased outpatient services.

METHOD

Analysis of the evolution of some community models in Italy, France, Holland, and the United States.

RESULTS

Deinstitutionalization was aimed to protect patients from the harmful effects of mental hospitals but failed to result in social integration for many of them. Success and failure of community practice shed a new light on the diversity and constancy of patients' needs.

CONCLUSIONS

Quality-of-life improvement and services integration should be guided by planning and selection of the required services.

Do we still need mental hospitals?

“The debate is over” claimed a heading in a newspaper on the 1991 Amsterdam WHO conference ‘Changing mental health care in the cities of Europe’: “After half a century of debate of the issue of deinstitutionalisation the question is not any more if we should close the large mental hospitals, but what follows the closure and how to develop adequate community mental health care which replaces the functions of the mental hospital” (Gersons & Burns, 1992).

These ‘functions’ have actually secured the long-lasting success of the mental hospital which has been in the past and, to a certain extent, still is in a number of countries, the cornerstone of psychiatric care. It incorporates all the functions of a psychiatric system in a single, usually isolated facility, including crisis intervention, evaluation, treatment, aftercare, long-term custodial care, rehabilitation, etc. In order to phase down the mental hospital these functions have to be supplemented by newly established, discrete services disseminated in the community. The process is clearly a complex one, since it implies a transition from a system of care provided only in mental hospitals under medical direction, to one that is comprehensive in scope, community-orientated, and staffed by multidisciplinary teams.